Nurs 341 Exam 3
The older adult client comes in for a routine visit. During the assessment, he irritably exclaims, "Speak up and quit mumbling!" How does the nurse respond? A. Apologizes and speak louder and clearer B. Asks whether the client has a hearing loss C. Offers the client a stethoscope to use D. Suggests that the client move to a soundproof examination room to improve his hearing
Apologizes and speak louder and clearer
The wife of the client with Alzheimer's disease mentions to the home health nurse that although she loves him, she is exhausted caring for her husband. What does the nurse suggest to alleviate caregiver stress? A. Arranges for respite care B. Provides positive reinforcement and support to the wife C. Restrains the client for a short time each day, to allow the wife to rest D. Teaches the client improved self-care
Arranges for respite care
A client with sleep apnea who has a new order for continuous positive airway pressure (CPAP) with a facemask returns to the outpatient clinic after 2 weeks with a report of ongoing daytime sleepiness. Which action should the nurse take first? A. Ask the client whether CPAP has been used consistently at night. B. Discuss the use of autotitrating positive airway pressure (APAP). C. Plan to teach the client about treatment with modafinil (Provigil). D. Suggest that a nasal mask be used instead of a full facemask.
Ask the client whether CPAP has been used consistently at night.
Nasal Polyps
A common cause of obstruction; Pale, shiny, gelatinous lumps or "bags" attached to the turbinates; Assess by blocking 1 naris at a time to check whether air moves through the unblocked side easily
Surgical treatment of sinusitis
A common procedure used for sinusitis that does not respond to drug therapy is functional endoscopic sinus surgery (FESS). Small endoscopes (sinoscopes) are used to first visualize the area. Instruments attached to the sinoscopes are used to open the nasal ostium and remove infected mucosa or improve the pathway for nasal drainage. A balloon catheter may also be used during FESS to change the shape of the nasal ostium to relieve obstruction and promote drainage.
When is a CBC performed?
A complete blood count (CBC) is performed when the patient's condition is severe or does not improve. Patients who need a CBC are those who have high fevers, lethargy, or manifestations of complications.
Peritonsillar abscess (PTA)
A complication of acute tonsillitis. The infection spreads from the tonsil to the surrounding tissue, which forms an abscess. The most common cause of PTA is group A beta-hemolytic Streptococcus.
Perforated Septum
A condition commonly found in cocaine users; It is present if a light shines through the perforation into the opposite nostril upon assessment
Furuncle
A furuncle is a localized external otitis caused by bacterial infection, usually Staphylococcus, of a hair follicle. Most furuncles occur on the outer half of the external canal. Treatment consists of local and systemic antibiotics and local heat application. An earwick may be used with one-half
Tuberculosis (TB)
A highly communicable disease caused by Mycobacterium tuberculosis. It is the most common bacterial infection worldwide. The organism is transmitted via aerosolization (i.e., an airborne route) Far more people are infected with the bacillus than actually develop active TB.
Pleuritic chest pain
A stabbing pain upon taking a deep breath
Where does gas exchange occur? A. Acinus B. Alveolus C. Bronchus D. Carina
Alveolus
The nurse auscultates popping, discontinuous sounds over the client's anterior chest. How does the nurse classify these sounds? A. Crackles B. Rhonchi C. Pleural friction rub D. Wheeze
Crackles
Pronator drift
Cerebral motor or brainstem integrity may also be assessed. Ask the patient to close his or her eyes and hold the arms perpendicular to the body with the palms up for 15 to 30 seconds. If there is a cerebral or brainstem reason for muscle weakness, the arm on the weak side will start to fall, or "drift," with the palm pronating (turning inward).
CONDUCTIVE HEARING LOSS - Causes
Cerumen Foreign body Perforation of the tympanic membrane Edema Infection of the external ear or middle ear Tumor Otosclerosis
What is the most common diagnostic test for pneumonia?
Chest x-ray continues to be the most common diagnostic test for pneumonia but may not show changes until 2 or more days after manifestations are present. It usually appears on chest x-ray as an area of increased density. It may involve a lung segment, a lobe, one lung, or both lungs. In the older adult, the chest x-ray is essential for early diagnosis because pneumonia symptoms are often vague.
The nurse is performing a client assessment for the client's potential employer. The client reports dyspnea when climbing stairs but is not dyspneic at rest. Which dyspnea classification does the nurse assign to this client in the report to the employer? A. Class I, can perform perform manual labor B. Class II, can perform desk job C. Class III, minimally employable D. Class IV, must remain at home
Class II, can perform desk job
The client is admitted into the emergency department with frontal-temporal pain, preceded by a visual disturbance. The client is upset and thinks it is a stroke. What does the nurse suspect may be occurring? A. Stroke B. Tension headache C. Classic migraine D. Cluster headache
Classic migraine
The RN has received report about all of these clients. Which client needs the most immediate assessment? A. Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry B. Client admitted 3 hours ago for a scheduled thoracentesis in 30 minutes C. Client with bronchogenic lung cancer who returned from bronchoscopy 3 hours ago D. Client with pleural effusion who has decreased breath sounds at the right base
Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry
Which of these clients should the charge nurse assign to the LPN/LVN working on the medical-surgical unit? A. Client with group A beta-hemolytic streptococcal pharyngitis who has stridor B. Client with pulmonary tuberculosis who is receiving multiple medications C. Client with sinusitis who has just arrived after having endoscopic sinus surgery D. Client with tonsillitis who has a thick-sounding voice and difficulty swallowing
Client with pulmonary tuberculosis who is receiving multiple medications
The nurse is caring for a client diagnosed with partial seizures after encephalitis, who is to receive carbamazepine (Tegretol). The nurse plans to monitor the client for which adverse effects? Select all that apply. A. Alopecia B. Headaches C. Dizziness D. Diplopia E. Increased blood glucose
Headaches Dizziness Diplopia
What are high-flow oxygen delivery systems?
High-flow systems include the Venturi mask, aerosol mask, face tent, tracheostomy collar, and T-piece. These devices deliver an accurate oxygen level when properly fitted.
The client is 1 day postoperative from a total laryngectomy for cancer. He has indicated to you that he is experiencing pain. Pain management for him is best achieved with which medication? A. IV ketorolac (Toradol) B. IV midazolam (Versed) C. IV morphine sulfate (Morphine) D. Oral acetaminophen (Tylenol)
IV morphine sulfate (Morphine)
Synapse
Impulses are transmitted to their eventual destination through spaces between neurons. There are two distinct types : neuron to neuron and neuron to muscle (or gland).
What happens to the pinna in a pt with chronic gout?
In chronic gout, collection of uric acid crystals results in hard, painless nodules called tophi on the pinna.
What are some indications that tracheostomy tube has become obstructed?
Indicators of obstruction include difficulty breathing; noisy respirations; difficulty inserting a suction catheter; thick, dry secretions; and unexplained peak pressures (if a mechanical ventilator is in use). Assess the patient at least hourly for tube patency. Prevent obstruction by helping the patient cough and deep breathe, providing inner cannula care, humidifying the oxygen source, and suctioning. If tube obstruction occurs as a result of cuff prolapse over the end of the tracheostomy tube, the physician or advanced practice nurse repositions or replaces the tube.
Where is an initial TB infection seen?
Initial infection is seen more often in the middle or lower lobes of the lung.
The RN assessment includes:
Inspect the entire external ear for shape, location of attachment to the head, and condition, including the condition of the visible external canal.
A nurse is providing post-mortem care to a client who has donated a cornea. Which action is appropriate for the nurse to implement? A. Applies a warm pack to the eyes B. Elevates the lower extremities C. Instills antibiotic drops into the eyes D. Contacts the recipient family
Instills antibiotic drops into the eyes
The nurse answers the client's call light and realizes that the client has an upper airway obstruction. What is the nurse's first action? A. Attempts to remove the obstruction B. Calls the Rapid Response Team to intubate immediately C. Calls the Rapid Response Team to perform an emergency cricothyroidotomy D. Determines the cause of obstruction
Determines the cause of obstruction
The nurse is assessing the client with recent changes in hearing. After taking a medication history, which drugs does the nurse identify as possible causes of the client's hearing change? Select all that apply. A. Acetaminophen B. Beta blockers C. Erythromycin D. Ibuprofen E. Insulin F. Lasix
Erythromycin Ibuprofen Lasix
Laryngopharynx
Extends from base of tongue to esophagus; it is the critical dividing point where solid food & fluids are separated from air
sclera
External layer of eye or the white stuff and transparent cornea.
Why is a Corneal ulceration considered an emergency?
because the cornea has no separate blood supply and cannot defend itself from infections that have the potential to permanently impair vision.
ophthalmic artery
brings oxygenated blood to the eye & structures in the orbit.
How we see
Light waves pass through cornea, aqueous humor, lens and vitreous humor to the retina where light waves bend (refract) and focus images.
A client with a tracheostomy is at increased risk for aspiration. Which nursing intervention(s) will reduce this risk? Select all that apply. A. Encourage frequent sipping from a cup. B. Encourage water with meals. C. Inflate the tracheostomy cuff during meals. D. Maintain the client upright for 30 minutes after eating. E. Provide small, frequent meals. F. Teach the client to "tuck" the chin down in the forward position to swallow.
Maintain the client upright for 30 minutes after eating. Provide small, frequent meals. Teach the client to "tuck" the chin down in the forward position to swallow.
Otitis Media : Nonsurgical Management
Management can be as simple as putting the patient in a quiet environment. Bedrest limits head movements that intensify the pain. Heat may be applied by using a heating pad adjusted to a low setting. Application of cold also may relieve pain. Topical antibiotics are not used to treat otitis media. Systemic antibiotic therapy decreases pain by reducing inflammation.
Closed Reduction
Manipulation during the first 24 hours of a nasal fracture. after 24 hours more difficult to manipulate bc edema and swelling.
What are clinical manifestations of pneumonia?
Many patients with pneumonia have flushed cheeks, bright eyes, and an anxious expression. The patient may have chest or pleuritic pain or discomfort, myalgia, headache, chills, fever, cough, tachycardia, dyspnea, tachypnea, hemoptysis, and sputum production. Severe chest muscle weakness also may be present from sustained coughing. Observe the patient's breathing pattern, position, and use of accessory muscles. The hypoxic patient may be uncomfortable in a lying position and will sit upright, balancing with the hands. Assess the cough and the amount, color, consistency, and odor of sputum produced. Crackles are heard with auscultation when fluid is in interstitial and alveolar areas. Wheezing may be heard if inflammation or exudate is in the airways. Bronchial breath sounds are heard over areas of density or consolidation. Fremitus is increased over areas of pneumonia, and percussion is dulled. Chest expansion may be diminished or unequal on inspiration. In evaluating vital signs, compare the results with baseline values. The patient with pneumonia is likely to be hypotensive with orthostatic changes as a result of vasodilation and dehydration, especially the older adult. A rapid, weak pulse may indicate hypoxemia, dehydration, or impending shock. Dysrhythmias may be present as a result of cardiac tissue hypoxia.
A client has returned to the postanesthesia care unit (PACU) after a bronchoscopy. Which of these nursing tasks is best for the charge nurse to delegate to the experienced nursing assistant working in PACU? A. Assess breath sounds. B. Check gag reflex. C. Determine level of consciousness. D. Monitor blood pressure and pulse.
Monitor blood pressure and pulse.
What are noninfectious causes of pneumonia?
Noninfectious causes of pneumonia include inhalation of toxic gases, chemical fumes, and smoke and aspiration of water, food, fluid, and vomitus.
Gray matter
Nonmyelinated axons have a grayish cast
Normal Pupil and Blinks
Normal pupil is 3-5 mm, blinks 5-10 times per minute
Upper Airways
Nose Sinuses Pharynx Larynx
Allergic rhinitis
Often called hay fever or allergies, is triggered by hypersensitivity reactions to airborne allergens, especially plant pollens or molds. Some episodes are "seasonal" because they recur at the same time each year and last a few weeks.
Malignant lymph nodes in neck
Often hard & are fixed to the surrounding tissue
What gene on what chromosome is linked with hearing loss?
One type of hearing loss among adults has a genetic basis with a mutation in gene GJB2 on chromosome 1.
esophageal speech
Option for total laryngectomy pt. air "burped" across esophageal pharynx to produce monotone sound which is shaped into words in the mouth; may cause intestinal bloat, strengthens respiratory and abd muscles
A client had a thoracentesis 1 day ago. He calls the home health agency and tells the nurse that he is very short of breath and anxious. What is the major concern of the nurse? A. Abscess B. Pneumonia C. Pneumothorax D. Pulmonary embolism
Pneumothorax
Vocal cord Polyps
Polypoid corditis can result from chronic laryngitis. The patient complains of chronic hoarseness but exhibits no other symptoms. Are edematous masses. occur in smokers or people with allergies or live in dry climates, cysts may also appear .
Most accurate test for pt with Sleep Apnea
Polysomnography
The nurse is reviewing the chart of a client who is scheduled for cerebral angiography. The nurse plans to report his condition to the health care provider. Which information will be most important for the nurse to communicate to the physician for a client who is scheduled for cerebral angiography? A. Allergy to penicillin B. History of bacterial meningitis C. Poor skin turgor and dry mucous membranes D. The client's dose of metformin (Glucophage) was held today.
Poor skin turgor and dry mucous membranes
The nurse is administering the intake assessment for a newly admitted client with a history of seizures. The client suddenly begins to seize. What does the nurse do next? A. Documents the length and time of the seizure B. Forces a tongue blade in the mouth C. Restrains the client D. Positions the client on the side
Positions the client on the side
What is the purpose of wearing fluoride gel trays during radiation therapy of the mouth? A. Keep the mouth moist during treatments B. Keep the teeth from turning yellow after treatment C. Prevent radiation scatter when the beam hits metal in the mouth D. Protect the taste buds on the tongue
Prevent radiation scatter when the beam hits metal in the mouth
Treatment for Methemoglobinemia
Supplemental oxygen & IV adm. of 1% methylene blue
When are surgical interventions necessary for tonsillitis?
Surgical intervention for tonsillitis may be needed for recurrent acute infections (especially group A beta-hemolytic streptococcal infections), chronic infections that do not respond to antibiotics, a peritonsillar abscess, and enlarged tonsils or adenoids that obstruct the airway.
Rhinoplasty
Surgical reconstruction of nose for cosmetic purposes and to improve airflow. Avoid forceful coughing or straining post op. laxatives and stool softeners for ease bm. avoid NASAIDs and ASA bleed risk.
Tracheostomy
The (tracheal) stoma, or opening, that results from the tracheotomy.
Pulmonary embolism
The blockage of a pulmonary artery by fat, air, tissue tumor, or a thrombus that usu. arises from a peripheral vein
Ménière's Disease - Surgical Management
The choice of the surgical procedure depends on the degree of usable hearing, the severity of the spells, and the condition of the opposite ear. The most radical procedure involves resection of the vestibular nerve or total removal of the labyrinth (labyrinthectomy), performed through the ear canal. The footplate of the stapes is moved aside, and the labyrinth is removed through the oval window. Another procedure performed early in the course of the disease is endolymphatic decompression with drainage and a shunt If an endolymphatic decompression has been performed, movement of the vestibular structures of the inner ear causes vertigo early after surgery. Reassure the patient that the vertigo is a temporary result of the surgical procedure, not the disease.
An RN from the orthopedic unit has been floated to the medical unit. Which client assignment for the floated RN is the best? A. The client with a resolving pulmonary embolus who is receiving oxygen at 6 L/min through a nasal cannula B. The client with chronic lung disease who is being evaluated for possible home oxygen use C. The client with a newly placed tracheostomy who is receiving oxygen through a tracheostomy collar D. The client with chronic bronchitis who is receiving oxygen at 60% through a Venturi mask
The client with a resolving pulmonary embolus who is receiving oxygen at 6 L/min through a nasal cannula
What is the purpose of an otoscopic examination?
The purpose of a brief otoscopic examination is to assess the patency of the external canal, identify lesions or excessive cerumen in the canal, and assess whether the tympanic membrane (eardrum) is intact or inflamed.
What is the purpose of oxygen therapy?
The purpose of oxygen therapy is to use the lowest fraction of inspired oxygen (FiO2) to have an acceptable blood oxygen level without causing harmful side effects.
When a foreign object is aspirated from the throat, where does it usually enter?
The right bronchus
Otitis Media : Pathophysiology
The three common forms of otitis media are acute otitis media, chronic otitis media, and serous otitis media. Each type affects the middle ear but has different causes and pathologic changes. If otitis progresses or is untreated, permanent conductive hearing loss may occur. Acute otitis media and chronic otitis media, also known as suppurant or purulent otitis media, are similar. An infecting agent in the middle ear causes inflammation of the mucosa, leading to swelling and irritation of the small bones (ossicles) within the middle ear, followed by purulent inflammatory exudate.
vestibule
The vestibule is a small, oval-shaped, bony chamber between the semicircular canals and the cochlea. Contains the utricle and the saccule, organs important for balance.
Sleep Apnea
a sleep disorder characterized by temporary cessations of breathing during sleep and repeated momentary awakenings Lasts 10 seconds and occurs at least 5 times an hour.
head and neck cancer begin when mucosa is chronically irritated and changes into
a tougher mucosa (squamous metaplasia).
most important nursing intervention for patients with meningitis
accurate monitoring and recording of their neurologic status, vital signs, vascular assessment
first action of pt with facial trauma
air way assessment and establish airway.
Common Triptan Drugs
almotriptan (Axert) eletriptan (Relpax) frovatriptan (Frova) naratriptan (Amerge) rizatriptan (Maxlt) sumatriptan (Imitrex)
causes of encephalitis
always caused by a viral infection elsewhere in the body (ex. west nile)
Guillain-Barre Syndrome- (GBS)
an acute autoimmune disorder characterized by varying degrees of motor weakness and paralysis. May also be called "acute idiopathic polynervitis" or "polyradiculoneuopathy"
punctum
an opening at the nasal side of the lid edges, is where tears drain into the lacrimal duct and sac, and then into the nose through the nasolacrimal duct.
Priority nursing care for pt with neck trauma is
assessing and maintaining a patent airway.
SENSORY changes in older adults
can affect their daily activities. Pupils decrease in size, which restricts the amount of light entering the eye, and adapt more slowly. Older adults need increased lighting to see. Touch sensation decreases, which may lead to falls because the older person may not feel small objects or a step underfoot. Vibration sense may be lost in the ankles and feet. Hearing also decreases, especially for high-pitched sounds.
Scala media is filled with_________.
endolymph,
Common Ergotamine drugs
ergotamine with caffeine (Cafergot, Migergot) ergotamine sublingual (Ergomar SL) medihaler ergotamine dihydroergotamin (DHE)
S.A. often diagnosed by
family member who observes person sleeping in the supine position
Tuning fork test
for hearing acuity are the Weber (top of head) and Rinne tests (mastoid process)
Near vision is tested
for patients who have difficulty reading without using glasses (Rosenbaum Pocket Vision Screener/Jaeger Card).
Meninges
form the protective covering of the brain and the spinal cord. The outside layer is the dura mater.
Vocal cord paralysis result from
injury , trauma, or disease of of larynx , laryngeal nerves or vagus nerve.
retina
innermost layer of the eye ~ a thin, delicate structure made up of sensory receptors that transmit impulses to the optic nerve.
optic fundus
inside back of the eye that can be seen with an ophthalmoscope.
termination phase
intensity of headache decreases
postprodrome phase
patient is fatigued, irritable, muscle pain
Fluorescein angiography
provides detailed image of eye circulation, the use of IV dye is injected (can cause skin staining). Assesses problems of retinal circulation or diagnosing intraocular tumors.
Ismoetheptene Combination
used when ergotamine preparations are not beneficial drugs: midrin, APAP, isometheptene, and dichloralphenazone
Communicating with a Hearing-Impaired Patient
• Position yourself directly in front of the patient. • Make sure that the room is well lighted. • Get the patient's attention before you begin to speak. • Move closer to the better-hearing ear. • Speak clearly and slowly. • Do not shout (shouting raises the frequency of the sound and often makes understanding more difficult). • Keep hands and other objects away from your mouth when talking to the patient. • Attempt to have conversations in a quiet room with minimal distractions. • Have the patient repeat your statements rather than just indicate assent. • Rephrase sentences and repeat information to aid in understanding. • Use appropriate hand motions. • Write messages on paper if the patient is able to read.
myopia
(nearsightedness) occurs when the eye overbends light; distance vision is poor; correct with biconcave lens.
Bilateral closed vocal cord paralysis causes
airway obstruction and is a medical emergency if the symptoms are severe and pt cannot compensate. stridor is major manifestation.
Epistaxis (nosebleed)
common problem bc many capillaries in the nose. Occur from trauma, hypertension, blood dyscrasia (e.g. leukemia) inflammation, tumor, decreased humidity , nose blowing picking , cocaine , ng suction. men more affected than women
Perimetry
common test to screen the visual fields. Indicate when they see flashing light in peripheral vision.
Laser imaging of the retina and optic nerve
creates 3D image of back of eye; commonly used for people with ocular hypertension or who are at risk for glaucoma.
ototoxic
damaging to the ear
Visual field tests
degree of peripheral vision.
Facial Trauma
described by specific bones e.g.. mandibular ,maxillary ,orbital, nasal fracture.
computed tomography (CT)
diagnostic tool for looking at the eyes, bony structures around the eye, and the extraocular muscles
S.A. person may have
disrupted deep sleep prevents deep sleep needed for bed rest , excessive daytime sleepiness , inability to concentrate , irritability .
ptosis
drooping eyelid
Manifestations of laryngeal trauma include
dyspnea, aphonia ( inability to produce sound), hoarseness, and subcutaneous emphysema (air present in the subcutaneous tissue), hemoptysis(bleeding from the airway).
Plexus
each nerve axon leaves the spinal cord, it joins other spinal nerves to form (clusters of nerves). continue as trunks, divisions, and cords and finally branch into individual peripheral nerves.
lesions in vocal cords are
earliest form of laryngeal cancer
how do you test for accomodation?
hold the index finger about 18 cm from the pts nose and move it toward the nose... the pts eyes normally converge during this movement & the pupils constrict equally
genes controlling cell growth are damaged allowing growth enhancement of abnormal cells which become
malignant and take the form of white patchy lesions( leukoplakia) , or red velvety patches (erythroplasia).
Most common facial fracture
mandibular ( lower jaw) can occur at any point on the mandible.
headache phase
may last a few hours to few days
Tonometry
measures intraocular pressure (IOP) (IOP varies throughout the day, always record time).
Recall memory
recent memory; can be tested during the history and checked on the medical record: The accuracy of the medical history; Dates of clinic or physician appointments; The time of admission; Health care providers seen within the past few days; Mode of transportation to the hospital or clinic.
4 eye functions that provide clear images and vision are
refraction, pupillary constriction, accommodation, and convergence.
astigmatism
refractive error caused by unevenly curved surfaces on or in the eye, especially of the cornea... these uneven surfaces distort vision.
enophthalmos
sunken appearance of the eye
ciliary arteries
supply the sclera, choroid, ciliary body, and iris.
Polypectomy
surgery to remove benign nasal polyps.
available treatment options for head and neck cancers
surgery, radiation, chemotherapy each may be used alone or in combination .
What food should be avoided with antiepleptics?
grape fruit (citrus fruits); may elevate blood levels of drugs and lead to drug toxicity
visual acuity test
measure both distance and near vision (Snellen Chart).
In POAG which eye does it effect & what are the symptoms?
this is the most common form of primary glaucoma usually affects both eyes & is asymptomatic in the early stages. IOP gradually increases
The nurse is about to administer a contrast medium to the client undergoing diagnostic testing. Which question will the nurse first ask the client? A. "Are you allergic to iodine or shellfish?" B. "Are you in pain?" C. "Are you wearing any metal?" D. "Do you know what this test is for?"
"Are you allergic to iodine or shellfish?"
The nurse is teaching the client about ear protection. Which statement by the client indicates that teaching was effective? A. "I always wear earplugs when I swim." B. "It is noisy where I work, so I listen to music with ear buds." C. "My ears ring after attending a rock concert, but it goes away." D. "The machinery is loud at work, but I get used to it."
"I always wear earplugs when I swim."
Which statement by the client with a laryngectomy indicates the need for further discharge teaching? A. "I must avoid swimming." B. "I can clean the stoma with soap and water." C. "I can project mucus when I laugh or cough." D. "I can't put anything over my stoma to cover it."
"I can't put anything over my stoma to cover it."
head and neck cancer nursing priorities and dx 1 dx = diagnosis
1 Risk for aspiration related to edema , anatomic changes , or altered protective reflexes.
Two types of sensory receptors:
1.Cones: work at low levels, provide peripheral vision. 2.Rods: active at bright light levels and provide color and central vision.
Normal IOP
10-21 mmHg
We have ____ PAIRS of cranial nerves and ____ PAIRS of spinal nerves.
12; 31
HCO3
21-28 mEq/L
Turbinates
3 bony projects that protrude into the nasal cavities from the walls of the interior portion of the nose; They increase the total surface are for filtering, heating, & humidifying inspired air
Normal amount of sputum production per day
3 ounces (90mL)
PaCO2
35-45
Which client is most in need of immediate examination by an ophthalmologist? A. 58-year old with glasses who reports an inability to see colors well and is feeling as though his or her glasses are always smudged B. 40-year-old with glasses and a reddened sclera who reports brow pain, headache, and seeing colored halos around lights C. 76-year-old with seborrhea of the eyebrows and eyelids who reports burning and itching of the eyes D. 39-year-old with contacts who reports an inability to tolerate bright lights and has visible purulent drainage on eyelids and eyelashes
40-year-old with glasses and a reddened sclera who reports brow pain, headache, and seeing colored halos around lights
pH
7.35 - 7.45
PaO2
80-100 mm Hg
SpO2
95% - 100%
What should the air temperature entering the tracheostomy be between?
98.6° and 100.4° F (37° and 38° C), and never exceed 104° F (40° C).
Empyema
A collection of pus in the pleural cavity
Pulmonary empyema
A collection of pus in the pleural space.
Surfactant
A fatty protein that reduces surface tension in the alveoli; without it, atelectasis occurs
A cough can be a side of effect of this group of prescribed drugs
ACE inhibitors
Abnormalities of the pinna include
Abnormalities of the pinna include swelling, nodules, and lesions.
Abortive Therapy for Mild Migraines
Acetaminophen, NSAIDs (Advil Migraine, Motrin Migraine, Excedrin Migraine), Antiemetics, Metoclopramide (Reglan)
Tonsillitis
An inflammation and infection of the tonsils and lymphatic tissues located on each side of the throat
Use the stick figure to test what?
Asymmetry of reflexes: 0 = absent, no response; 1(+) = weaker than normal, hypoactive; 2 (+ +) = normal; 3 (+++) = stronger or more brisk than normal; 4 (++++) = hyperactive
The nurse team leader is working with a nursing assistant in caring for a group of clients. Which task will the nurse plan to delegate to the nursing assistant? A. Prepare a client who is going to radiology for a cerebral arteriogram. B. Attend to the care needs of a client who has had a transcranial Doppler study. C. Assist the physician in performing a lumbar puncture on a confused client. D. Educate a client about what to expect during an electroencephalogram (EEG).
Attend to the care needs of a client who has had a transcranial Doppler study.
Which test best determines hearing acuity? A. Audioscopy B. Electronystagmography C. Otoscope D. Snellen test
Audioscopy
BIPAP
Bilevel positive airway pressure.
Why does caffeine help with migraines?
Caffeine blocks adenosine and adenosine causes vasodilation and inflammation
What is a main sign of lung disease?
Cough
Hypoxia
Decreased tissue oxygenation
Which type of drug therapy does the nurse anticipate giving to the client with Ménière's disease to decrease endolymph volume? A. Antihistamines B. Antipyretics C. Diuretics D. Nicotinic acid
Diuretics
Hypercarbia
Increased partial pressure of arterial carbon dioxide [PaCO2] levels
Drugs for preventing migraines
NSAIDs Beta Blockers Calcium Channel blockers (verapamil) Antiepileptic drugs (topamax)
presbyopia
Near object, reading material must be placed further away to see
Pneumothorax
Partial or complete collapse of the lung due to air or gas in the pleural space
What are infectious causes of pneumonia?
Pneumonia can be caused by bacteria, viruses, mycoplasmas, fungi, rickettsiae, protozoa, and helminths (worms).
The client has a purulent drainage in the inner canthus of the eye. Before examining the eye, what must the nurse do first? A. Administer a Snellen test. B. Obtain an informed consent. C. Instill antibiotic drops. D. Put on gloves.
Put on gloves.
What drug helps with Keratoconjuctivitis Sicca?
Restasis: helps with inflammation and helps the eye's natural ability to produce tears
Septal deviation
Some degree of it is common in most adults & appears as an S shape, tilting toward 1 side or the other
An older adult client is being discharged home with a tracheostomy. Which nursing action is an acceptable assignment for an experienced LPN/LVN? A. Complete the referral form for a home health agency. B. Suction the tracheostomy using sterile technique. C. Teach the client and spouse about tracheostomy care. D. Consult with the physician about using a fenestrated tube.
Suction the tracheostomy using sterile technique.
Alveoli
The basic units of gas exchange
What is the receptor of hearing and where is it located?
The organ of Corti and it is located on the basilar membrane of the cochlea. The cochlea contains hair cells that detect vibration from sound and stimulate the eighth cranial nerve.
The organ of Corti
The organ of Corti is the receptor of hearing located on the basilar membrane of the cochlea.
What does the mutation of GJB2 cause?
This mutation causes poor production of the protein connexin-26, which has a role in function of cochlear hair cells.
Lower Airways
Trachea Bronchi Bronchioles Alveolar ducts Alveoli
The nurse is assessing a client with a neurologic condition who is reporting difficulty chewing when eating foods. The nurse suspects that which cranial nerve has been affected? A. Abducens nerve B. Facial nerve C. Trigeminal nerve D. Trochlear nerve
Trigeminal nerve
Abortive Therapy for Severe Migraines
Triptan, Ergotamine derivatives, and Isometheptene
Rhinitis
an inflammation of the nasal mucosa
Stuporous
arousable only with vigorous or painful stimulation
Posterior nasal bleeding
is an emergency bc it cannot be easily reached pt may lose a lot of blood quickly.
During sleep
muscles relax , tongue and neck structures are displaced. result upper airway obstructed chest wall movement unimpaired.
Nasoseptlasty or submucous resection (SMR)
needed to straighten a deviated septum when chronic symtoms appear i.e. stuffy nose snoring sinusitis or discomfort occurs..
anisororia
noticeable difference in the size of pupils
What are used as a last resort for migraines?
opioids and bariturates
When obstruction is caused by tongue falling back or accumulation of secretions
slightly extend the pts head and neck and insert a nasal or oral airway.
keratomalacia
softening of the cornea
Intensity
sound is expressed in decibels (dB).
phonation
sound produced by vocal fold vibration
Broca's area
speech area located in the frontal lobe responsible for the formation of words or speech
What makes up the PNS?
spinal nerves, cranial nerves, and the ANS
The nurse is teaching the client about open-angle glaucoma management. Which statement by the client indicates a need for further instruction? A. "I must wait 10 to 15 minutes between different eyedrop medications." B. "I must press on the inside of my eye to prevent washout." C. "It is important to not skip a dose." D. "These eyedrops will not cure my glaucoma."
"I must press on the inside of my eye to prevent washout."
The female client with newly diagnosed migraine is being discharged with a prescription for sumatriptan (Imitrex). Which comment by the client indicates an understanding of the nurse's discharge instructions? A. "Sumatriptan should be taken as a last resort." B. "I must report any chest pain right away." C. "Birth control is not needed while taking sumatriptan." D. "St. John's wort can also be taken to help my symptoms."
"I must report any chest pain right away."
The nurse has taught the client about influenza infection control. Which client statement indicates the need for further teaching? A. "Handwashing is the best way to prevent transmission." B. "I should avoid kissing and shaking hands." C. "It is best to cough and sneeze into my upper sleeve." D. "The intranasal vaccine can be given to everybody in the family."
"The intranasal vaccine can be given to everybody in the family."
A client who smokes is being discharged home on oxygen. The client states, "My lungs are already damaged, so I'm not going to quit smoking." What is the discharge nurse's best response? A. "You can quit when you are ready." B. "It's never too late to quit." C. "Just turn off your oxygen when you smoke." D. "You are right, the damage has been done. But let's talk about why smoking around oxygen is dangerous."
"You are right, the damage has been done. But let's talk about why smoking around oxygen is dangerous."
Bacterial conjunctivitis
"pink-eye"
Formula for calculation of "pack years"
# of packs smoked per day X # of yrs. pt. has smoked
Which system is further divided into the sympathetic and parasympathetic fibers?
(ANS) Autonomic Nervous System; is not under "conscious" control
Fixation
(histology) the preservation and hardening of a tissue sample to retain as nearly as possible the same relations they had in the living body
Methemoglobin
-Normal blood level is less than 1% -Cyanosis occurs w/levels between 10-20% -Anxiety, tachycardia, and lethargy develop at 20-50% -Death can occur when levels reach 50-70%
Epitympanum
The middle ear consists of a compartment called the epitympanum.
What drug is commonly used for status epilepticus?
Valium
How does the process of TB infections occur?
1. The granulomatous inflammation created by the tubercle bacillus in the lung becomes surrounded by collagen, fibroblasts, and lymphocytes. 2. Caseation necrosis, which is necrotic tissue being turned into a granular mass, occurs in the center of the lesion. If this area shows on x-ray, it is called Ghon's tubercle, or the primary lesion.
Which clinical manifestation in the client with facial trauma is the nurse's first priority? A. Bleeding B. Decreased visual acuity C. Pain D. Stridor
Stridor
Adventitious sounds
Additional breath sounds superimposed on normal sounds; indicate pathologic changes in the lung
You are a charge nurse on a surgical floor. The LPN/LVN informs you that a new client who had an earlier bronchoscopy has the following vital signs: heart rate 132, respiratory rate 26, and blood pressure 98/50. The client is anxious and his skin is cyanotic. What will be your first action? A. Call the Rapid Response Team. B. Give methylene blue 1% 1 to 2 mg/kg by IV injection C. Administer oxygen. D. Notify the physician immediately.
Administer oxygen.
A client with laryngeal cancer is admitted to the medical-surgical unit the morning before a scheduled total laryngectomy. Which of these preoperative interventions can be accomplished by an LPN/LVN working on the unit? A. Administering preoperative antibiotics and anxiolytics B. Assessing the client's nutritional status and need for nutrition supplements C. Having the client sign the operative consent form D. Teaching the client about the need for tracheal suctioning after surgery
Administering preoperative antibiotics and anxiolytics
The peak pressure alarm is sounding on the ventilator of the client with a recent tracheostomy. What intervention should be done first? A. Assess the client's respiratory status. B. Decrease the sensitivity of the alarm. C. Ensure that the connecting tubing is not kinked. D. Suction the client.
Assess the client's respiratory status.
The nurse is reviewing the history of a client who has been prescribed topiramate (Topamax) for treatment of intractable partial seizures. The nurse plans to contact the health care provider if the client has which condition? A. Bipolar disorder B. Diabetes mellitus C. Glaucoma D. Hypothyroidism
Bipolar disorder
Oropharynx
Contains the palatine tonsils
Hyperactive reflexes indicate
possible upper motor neuron disease, tetanus, or hypocalcemia.
Hypoxemia
Low levels of oxygen in the blood
What are the main components of the CNS?
brain and spinal cord
Trachoma
a chronic, bilateral scarring form of conjunctivitis caused by Chlamydia trachomatis
Used to rule out esophageal perforation injury
barium or meglumine ditrizoate (Gastrografin) swallow.
ocular melanoma
cancer of the eye
The tougher mucosa occurs by
increasing the mucosal thickness( acanthosis or hyperplasia )or by developing a a keratin layer (keratosis),
atypical migraines
less common and include menstrual and cluster migraines
Scala tympani and scala vestibuli are filled with _______.
perilymph.
bacterial meningitis (outcome) is...
potentially life threatening
injury to the carotid artery may
result in death, stroke, or paralysis from disruption of blood.
The major nursing priority with disorders of the upper respiratory tract is
to promote oxygenation by ensuring a patent airway
head and neck cancer is curable when
treated early.
refract
when light waves bend
laser surgery description
tumor reduced or destroyed by laser beam through laryngoscope. result voice quality normal / hoarse.
These disorders push the trachea AWAY from the affected area
*Tension pneumothorax *Large pleural effusion *Mediastinal mass *Neck tumors
seizure
abnormal, sudden, excessive, uncontrolled electrical discharge of neurons within th ebrain that may result in a change in LOC, motor or sensory ability, and or behavior
The client admitted for sleep apnea asks the nurse, "Why does it seem like I wake up every 5 minutes?" What is the nurse's best response? A. "Because your body isn't getting rid of carbon dioxide. This is what stimulates your body to wake up and breathe." B. "Because your body isn't getting enough oxygen. Not getting enough oxygen is what stimulates you to wake up and breathe." C. "Because your tongue may be blocking your throat, and you wake up because you are choking." D. "It isn't really that often. It just feels that way."
"Because your body isn't getting rid of carbon dioxide. This is what stimulates your body to wake up and breathe."
The nurse is performing preoperative teaching for the older adult client who will be having a cataract removed. Which instructions does the nurse include? Select all that apply. A. "Cataracts are an opacity of the lens that can be caused by aging, sunlight, or trauma." B. "You will need to wear a patch on your eye for several weeks after the surgery." C. "Several different types of eyedrops are requested after surgery, and they have to be taken several times a day for up to 4 weeks." D. "You will receive a medication to help you relax. Then you will receive some different eyedrops to dilate your pupils and paralyze the lens." E. "Bring sunglasses with you on the day of your procedure." F. "Can you show me how to put these natural tear drops in your eyes?" G. "You might experience a lot of bruising and swelling around the eye."
"Cataracts are an opacity of the lens that can be caused by aging, sunlight, or trauma." "Several different types of eyedrops are requested after surgery, and they have to be taken several times a day for up to 4 weeks." "You will receive a medication to help you relax. Then you will receive some different eyedrops to dilate your pupils and paralyze the lens." "Bring sunglasses with you on the day of your procedure." "Can you show me how to put these natural tear drops in your eyes?"
The client who is concerned about getting a tracheostomy says, "I will be ugly, with a hole in my neck." What is the nurse's best response? A. "But you know you need this to breathe, right?" B. "Do you have a pretty scarf or a large loose collar that you could place over it?" C. "Your family and friends probably won't even care." D. "It won't take you long to learn to manage."
"Do you have a pretty scarf or a large loose collar that you could place over it?"
The spouse of the client with Alzheimer's disease (AD) is listening to the hospice nurse explaining the client's drug regimen. Which statement by the spouse indicates an understanding of the nurse's instruction? A. "Donepezil (Aricept) will treat the symptoms of Alzheimer's disease." B. "Memantine (Namenda)is indicated for treatment of early symptoms of Alzheimer's disease. C. "Rivastigmine (Excelon) is used to treat depression." D. "Sertraline (Zoloft) will treat the symptoms of Alzheimer's disease.''
"Donepezil (Aricept) will treat the symptoms of Alzheimer's disease."
The client has received contrast medium. Which teaching will the nurse provide to avoid any neurologic health problems after the procedure? A. "Practice memory drills this afternoon." B. "Drink at least 1000 to 1500 mL of water today." C. "Avoid sunlight." D. "Rest in bed for 24 hours."
"Drink at least 1000 to 1500 mL of water today."
The client has received packing for a posterior nosebleed. In reviewing the client's orders, which order does the nurse question? A. "Give ibuprofen 800 mg every 8 hours as needed for pain." B. "Encourage bed rest, with the head of the bed elevated 45 to 60 degrees." C. "Provide humidified air." D. "Suction at the bedside."
"Give ibuprofen 800 mg every 8 hours as needed for pain."
The nurse's friend fears that his mother is getting old, saying that she is becoming extremely forgetful and disoriented and is beginning to wander. What is the nurse's best response? A. "Have you taken her for a checkup?" B. "She has Alzheimer's disease." C. "That is a normal part of aging." D. "You should look into respite care."
"Have you taken her for a checkup?"
A 70-year-old client has a complicated medical history including chronic obstructive pulmonary disease (COPD). Which client statement indicates the need for further teaching about the disease? A. "I am here to receive the yearly pneumonia shot again." B. "I am here to get my yearly flu shot again." C. "I should avoid large gatherings during cold and flu season." D. "I should cough into my upper sleeve instead of my hand."
"I am here to receive the yearly pneumonia shot again."
The client is being discharged home with a tracheostomy. Which statement by the client indicates the need for further teaching about correct tracheostomy care? A. "I can only take baths, no showers." B. "I can put normal saline in my tracheostomy to keep the secretions from getting thick." C. "I should put cotton or foam over the tracheostomy hole." D. "I will have to learn to suction myself."
"I can only take baths, no showers."
The nurse is preparing the client for electronystagmography. Which statement by the client indicates that teaching was effective? A. "I can't drink caffeine 24 to 48 hours before the test." B. "I should drink more fluids 4 hours before the test." C. "I'll be placed in a soundproof booth for the test." D. "I'll be sedated for the test."
"I can't drink caffeine 24 to 48 hours before the test."
The client has a bilateral corneal disorder and must instill anti-infective eyedrops every hour for the first 24 hours. Which comment by the client indicates a need for further instruction by the nurse? A. "I have two bottles of eyedrops because I will require a lot of medication." B. "I won't be able to wear my contacts for a while." C. "I must apply the drops throughout the night." D. "I must wash my hands before and between eye applications and after putting the drops in.''
"I have two bottles of eyedrops because I will require a lot of medication."
The nurse is teaching the client newly diagnosed with migraine about trigger control. Which statement made by the client demonstrates good understanding of the teaching plan? A. "I can still eat Chinese food." B. "I must not miss meals." C. "It is okay to drink a few wine coolers." D. "I need to use fake sugar in my coffee."
"I must not miss meals."
The client is scheduled for a total laryngectomy. Which statement by the client indicates the need for further teaching about the procedure? A. "I hope I can learn esophageal speech." B. "I really will miss the taste of my favorite food." C. "I won't be able to breathe through my nose anymore." D. "It is hard to believe that I will never hear my own voice again."
"I really will miss the taste of my favorite food."
The nurse is talking to the client about ear hygiene safety. Which statement by the client indicates a need for further teaching? A. "After I shower, I dry my ears using my fingertip and a towel." B. "I irrigate my ears with tap water." C. "I never clean my ears with a cotton swab." D. "I use a bobby pin to remove ear wax."
"I use a bobby pin to remove ear wax."
The nurse is reviewing postoperative instructions with the client undergoing stapedectomy. Which statement by the client indicates a need for further teaching? A. "I may have problems with vertigo after the surgery." B. "I should not drink from a straw for several weeks." C. "I will have to take antibiotics after the surgery." D. "I will be able to hear as soon as my dressing is removed."
"I will be able to hear as soon as my dressing is removed."
The nurse is instructing a client for whom a position emission tomography (PET) scan has been requested. Which statement indicates to the nurse that the client understands the instructions? A. "It's okay to have a cup of coffee before the test." B. "Because I am diabetic, I will take my insulin just before the test." C. "I can continue to smoke cigarettes up to 2 hours before the test." D. "I will drink plenty of fluids after the test."
"I will drink plenty of fluids after the test."
The nurse is teaching the mother of a teenage client with conjunctivitis how to administer eye ointment. Which statement by the mother indicates correct understanding of the nurse's instruction? A. "My child should look down at the floor during instillation." B. "I will place the ointment in the lower lid." C. "My child should rub the eye gently after instillation to increase absorption." D. "I will press gently on the inner canthus for 1 minute."
"I will place the ointment in the lower lid."
The client is returning home after cataract surgery with a patch over the affected eye. Which statement by the client's spouse indicates a need for further instruction on providing a safe home environment? A. "I will get some books on tape for entertainment." B. "I will be sure to pick up all clutter and loose carpets from the floor." C. "I will rearrange the furniture for better flow before my spouse gets home." D. "I will place a nonskid mat in the bathtub."
"I will rearrange the furniture for better flow before my spouse gets home."
The nurse is teaching the client about audiometric testing. Which statement by the nurse effectively communicates information about the procedure to the client? A. "Here is a picture of how the test is done. See how your bad ear will be tested first? You will be alone in the soundproof booth, so you will need to watch for lights flashing on and off as your cues." B. "Here is a video of the procedure. Please watch and feel free to ask me any questions." C. "I will sit right in front of you in the soundproof booth and give you instructions on what types of sounds you will hear and how you'll need to respond." D. "You will be in a soundproof booth and the sounds will be piped in. When you first hear the loudest sound, put your hand down. When you stop hearing the sound, put your hand up to stop."
"I will sit right in front of you in the soundproof booth and give you instructions on what types of sounds you will hear and how you'll need to respond."
The nurse is teaching the client who is scheduled for an ultrasonography of the eye. Which statement by the client indicates a need for further instruction? A. "I'll have to wear a bandage over my eye after the test." B. "I will be awake during this test." C. "I won't hear the high-frequency sound waves." D. "This test will help determine whether my retina is detached."
"I'll have to wear a bandage over my eye after the test."
The nursing instructor asks the student nurse caring for a client with Alzheimer's disease who has been prescribed donepezil (Aricept) how the drug works. Which response by the nursing student best explains the action of donepezil? A. "The reuptake of serotonin is blocked." B. "Donepezil prevents the increase in the protein beta amyloid." C. "It delays the destruction of acetylcholine by acetylcholinesterase." D. "Dopamine levels are increased."
"It delays the destruction of acetylcholine by acetylcholinesterase."
The nurse is teaching the client about visual changes that occur with age. Which statement does the nurse include? A. "It may take your eyes longer to adjust in a darkened room." B. "Most visual changes occur before age 40." C. "When the sclera starts to turn yellow, this means you might have problems with your liver.'' D. "You probably will have to move reading materials closer to your eyes."
"It may take your eyes longer to adjust in a darkened room."
The older adult client expresses concern about the ability to instill over-the-counter eyedrops, saying, "My vision is getting so bad, I can't even see my own eyes." What is the nurse's best response? A. "Don't worry about the eyedrops." B. "Getting old isn't fun, is it?" C. "Can your daughter help you do it?" D. "Let's find a way that will work for you."
"Let's find a way that will work for you."
The nurse is teaching the client who will soon be fitted for a hearing aid about proper care and use. Which statement by the client indicates that teaching was effective? A. "Background noises will be difficult for me to hear." B. "I should wear my hearing aid only to work at first." C. "I should just get a smaller hearing aid because I don't have much money." D. "Listening to the radio and television will help me get used to new sounds."
"Listening to the radio and television will help me get used to new sounds."
A client's mother asks what is the most important thing she will need to know to care for her son who is having an inner maxillary fixation (IMF) completed as an outpatient. What does the RN tell her? A. "Give him Phenergan (promethazine) by rectum around the clock so he does not vomit." B. "He can only drink milk and eat ice cream until the wires come off." C. "He must brush his teeth every 2 hours." D. "Make sure he always has wire cutters with him."
"Make sure he always has wire cutters with him."
The home health nurse is checking in on the client with dementia and the client's spouse. The spouse confides to the nurse, "I am so tired and worn out." What is the nurse's best response? A. "Can't you take care of your spouse?" B. "Establishing goals and a daily plan can help." C. "Make sure you take some time off and take care of yourself too." D. "That's not a very nice thing to say."
"Make sure you take some time off and take care of yourself too."
The client has undergone single-photon emission computed tomography (SPECT). Which instruction does the nurse give the client? A. "Continue to use the ice pack." B. "Call me if you have any itching." C. "Keep the head of the bed flat." D. "Return to your usual activity."
"Return to your usual activity."
The nurse is teaching the client with vertigo about safety precautions for fall prevention. Which statement by the client indicates a further need for instruction? A. "I may need to use a cane." B. "I should keep my grandkids' toys out of the hallway." C. "Moving more slowly may help the vertigo subside." D. "Taking my medication will allow me to drive my car again."
"Taking my medication will allow me to drive my car again."
When performing an eye or vision assessment, which comment by the client alerts the nurse that immediate care by an ophthalmologist is needed? A. "One eye is green and the other eye is blue." B. "My eyes are red and itchy." C. "My vision has been getting worse gradually." D. "The redness appeared this morning, without any cause."
"The redness appeared this morning, without any cause."
The client is being discharged home with active tuberculosis. Which information does the nurse include in the discharge teaching plan? A. "You are not contagious unless you stop taking your medication." B. "You will not be contagious to the people you have been living with." C. "You will have to take these medications for at least 1 year." D. "Your sputum may turn a rust color as your condition gets better."
"You will not be contagious to the people you have been living with."
most head and neck cancers (80%) are
squamous cell carcinomas of the mucosa that are slow growing , taking several years to develop. often appear as deep ulcerations.
Inhalation anthrax
(respiratory anthrax) is a bacterial infection caused by the gram-positive organism Bacillus anthracis, which lives as a spore in contaminated soil. Infection with this organism occurs through the skin, the intestinal tract, or the lungs. Inhalation anthrax is a rare natural occurrence in the United States and is nearly 100% fatal without treatment. It is not spread by person-to-person contact.
Purposes of breathing
* Provides O2 for tissue perfusion so that cells have enough O2 to take part in metabolism * Removes CO2, the major waste product of metabolism
These disorders pull the trachea TOWARD the affected area
**Pneumonectomy **Fibrosis **Atelectasis
Lobar bronchi
*Cartilage is ring-shaped and RESISTS collapse *Lined with a ciliated, mucus-secreting membrane
Right Lung
*Responsible for about 60-65% of respiratory function *Any problem with this lung inteferes with oxygenation to a greater degree than a problem in the other lung
Acute viral rhinitis
(coryza, or the common cold) is caused by any of over 200 viruses. It spreads from person to person by droplets from sneezing or coughing and by direct contact. Colds are most contagious in the first 2 to 3 days after symptoms appear.
hyperopia
(farsighted ness of hypermetropia) occurs when the eye does not refract light enough; near vision is poor; correct with convex lens
circle of Willis
(has to do with circulation in the brain); The anterior, middle, and posterior cerebral arteries are joined together by small communicating arteries to form a ring at the base of the brain known as the
Six voluntary muscles
(medial rectus muscle; superior rectus muscle; superior oblique muscle; lateral rectus muscle; inferior rectus muscle; and inferior oblique muscle) rotate the eye and coordinate eye movements.
Priority problems for patients requiring tracheostomy include(5):
1. Reduced oxygenation related to weak chest muscles, obstruction, or other physical problems 2. Inadequate communication related to tracheostomy or intubation 3. Inadequate nutrition related to presence of endotracheal tube 4. Potential for infection related to invasive procedures 5. Damaged oral mucosa related to mechanical factors (endotracheal tube)
Total Lung Capacity
A PFT to determine the amount of air in the lungs at the end of MAXIMUM INhalation
Functional Residual Capacity
A PFT to determine the amount of air remaining in the lungs after NORMAL EXpiration
Residual Volume
A PFT to determine the amount of air remaining in the lungs at the end of a full, FORCED EXhalation
An older client presents to the emergency department (ED) with a 2-day history of cough, pain on inspiration, shortness of breath, and dyspnea. The client never had a pneumococcal vaccine. The client's chest x-ray shows density in both bases. The client has wheezing upon auscultation of both lungs. Would a bronchodilator be beneficial for this client? A. A bronchodilator would not be beneficial for this client. B. A bronchodilator would help decrease the bronchospasm. C. It would clear up the density in the bases of the client's lungs. D. It would decrease the client's pain on inspiration.
A bronchodilator would help decrease the bronchospasm.
The nurse has just received change-of-shift report about these clients. Which client needs to be assessed first? A. A client with Ménière's disease who is reporting severe nausea and is requesting an antiemetic B. A client who has had removal of an acoustic neuroma and has complete hearing loss on the surgical side C. A client with labyrinthitis who has a temperature of 102.4° F (39.1° C) and a headache D. A client who has acute otitis media and is reporting drainage from the affected ear
A client with labyrinthitis who has a temperature of 102.4° F (39.1° C) and a headache
Lung Abscess
A lung abscess is a localized area of destruction caused by liquefaction necrosis, which is usually related to pyogenic bacteria. Patients with an abscess often have a history of pneumonia, aspiration of stomach contents, or obstruction as a result of a tumor or foreign body. Multiple abscesses and cavities form in patients with tuberculosis (TB) or fungal infections of the lung.
Describe Mixed conductive-sensorineural hearing loss
A profound hearing loss resulting from both conductive and sensorineural hearing loss.
Benzocaine spray
A topical anesthetic to numb the oropharynx that is used cautiously, if at all, because it can induce methemoglobinemia
Tactile (vocal) fremitus
A vibration of the chest wall produced with the pt. speaks; This vibration is increased w/pneumonia & abscesses
Conditions Affecting the External Ear : atresia, cauliflower, or boxer's ear
Abnormalities of the external ear range from crumpling or falling forward of the pinna to complete absence (atresia) of the auditory canal. Trauma can damage or destroy the auricle and external canal. Surgical reconstruction can re-form the pinna with skin grafts and plastic prostheses. Trauma to the auricle resulting in a hematoma requires the removal of blood via needle aspiration to prevent calcification and hardening, which is often referred to as a cauliflower or boxer's ear.
The parents of a young child report that their child sometimes stares blankly into space for just a few seconds and then gets very tired. The nurse anticipates that the child will be assessed for which seizure disorder? A. Absence B. Myoclonic C. Simple partial D. Tonic
Absence
A client with chronic obstructive pulmonary disease has a physician's prescription stating, "Adjust oxygen to keep SpO2 at 90% to 92%." Which nursing action can be delegated to a nursing assistant working under the supervision of an RN? A. Adjust the position of the oxygen tubing. B. Assess for signs and symptoms of hypoventilation. C. Change the O2 flow rate to keep SpO2 as prescribed. D. Choose which O2 delivery device should be used for the client.
Adjust the position of the oxygen tubing.
The nurse has just received report on a group of clients. Which client will the nurse assess first? A. Young adult who was in a car accident and has a 13 Glasgow Coma Scale score B. Adult who had a cerebral arteriogram and has a cool, pale right leg C. Middle-aged adult who has a headache after undergoing a lumbar puncture D. Older adult who has expressive aphasia after a left-sided stroke
Adult who had a cerebral arteriogram and has a cool, pale right leg
A client with asthma reports shortness of breath. What is the nurse assessing when auscultating this client's chest? A. Adventitious breath sounds B. Fremitus C. Oxygenation status D. Respiratory excursion
Adventitious breath sounds
Is air or bone conductions more sensitive?
Air conduction of sound is normally more sensitive than bone conduction.
Crepitus
Air trapped in & under the skin aka as subcutaneous emphysema; it is FELT as a crackling sensation beneath the fingertips
Which clients are at high risk for developing hearing problems? Select all that apply. A. Airline mechanic B. Client with Down syndrome C. Drummer in a rock band D. Teenager listening to music using ear buds E. Telephone operator
Airline mechanic Client with Down syndrome Drummer in a rock band Teenager listening to music using ear buds
The nurse is providing discharge instructions to the client with glaucoma. Which actions does the nurse instruct the client to avoid? Select all that apply. A. Bending over to tie shoes B. Sitting with legs elevated C. Sleeping on more than two pillows D. Blowing the nose frequently E. Lifting a 5-pound bag of flour
Bending over to tie shoes Blowing the nose frequently Lifting a 5-pound bag of flour
Which two factors in combination are the greatest risk factors for head and neck cancer? A. Alcohol and tobacco use B. Chronic laryngitis and voice abuse C. Marijuana use and exposure to industrial chemicals D. Poor oral hygiene and use of chewing tobacco
Alcohol and tobacco use
The client with a migraine is lying in a darkened room with a wet cloth on the head after receiving analgesic drugs. What will the nurse do next? A. Allow the client to remain undisturbed. B. Assess the client's vital signs. C. Remove the cloth because it can harbor microorganisms. D. Turn on the lights for a neurologic assessment.
Allow the client to remain undisturbed.
What are some advantages/disadvantages of noninvasive positive-pressure ventilation (NPPV)?
Although NPPV prevents the complications associated with intubation, including ventilator-associated pneumonia (VAP), some risks and complications are associated with this type of therapy. Masks must fit tightly in order to form a proper seal. This can lead to skin breakdown over the bridge of the nose or other areas of the face. Leaks can cause uncomfortable pressure around the eyes, and gastric insufflation can lead to vomiting and the potential for aspiration. Thus NPPV should be used only on patients with an intact mental status and the ability to protect their airway, although a nasogastric (NG) tube may still be required for safety.
Which is the greater threat to life: oxygen-induced hypoventilation or hypoxemia?
Although oxygen-induced hypoventilation is a serious concern, untreated or inadequately treated hypoxemia is a greater threat to life.
Acoustic Neuroma
An acoustic neuroma is a benign tumor of cranial nerve VIII that often damages other structures as it grows. Depending on the size and exact location of the tumor, damage to hearing, facial movements, and sensation can occur. Manifestations begin with tinnitus and progress to gradual sensorineural hearing loss in most patients. Later, patients have constant mild to moderate vertigo. As the tumor enlarges, nearby cranial nerves are damaged. Acoustic neuromas are diagnosed with computed tomography (CT) scanning and magnetic resonance imaging (MRI). Audiograms show sensorineural hearing loss. Cerebrospinal fluid assays show increased pressure and protein. Surgical removal through a craniotomy is performed, and the remaining hearing is lost.
Which client will the neurologic unit charge nurse assign to a registered nurse who has floated from the labor/delivery unit for the shift? A. An older adult client who was just admitted with a stroke and needs an admission assessment B. A young adult client who has had a lumbar puncture and reports, "Light hurts my eyes." C. An adult client who has just returned from having a cerebral arteriogram and needs vital sign checks every 15 minutes. D. A middle-aged client who has a possible brain tumor and has questions about the scheduled magnetic resonance imaging.
An adult client who has just returned from having a cerebral arteriogram and needs vital sign checks every 15 minutes.
Severe acute respiratory syndrome (SARS)
An easily spread respiratory infection first identified in China in November 2002. At first appearing as an atypical pneumonia, it is caused by a new, more virulent form of coronavirus, and there is no known effective treatment. It infects cells of the respiratory tract, triggering inflammatory responses, and stays in the respiratory passageways rather than spreading into the blood. The virus is easily spread by airborne droplets from infected people through sneezing, coughing, and talking. People at greatest risk for SARS are those in close direct contact with an infected person. The portals of entry are the mucous membranes of the eyes, nose, and mouth.
Pneumonia
An excess of fluid in the lungs resulting from an inflammatory process.
Laryngitis
An inflammation of the mucous membranes lining the larynx and may or may not include edema of the vocal cords.
Sinusitis
An inflammation of the mucous membranes of one or more of the sinuses. Swelling can obstruct the flow of secretions from the sinuses, which may then become infected. The disorder often follows rhinitis. Other conditions leading to sinusitis include deviated nasal septum, nasal polyps or tumors, inhaled air pollutants or cocaine, facial trauma, nasal intubation, dental infection, or decreased immune function.
Thoracentesis
An invasive diagnostic assessment involving the aspiration of pleural fluid or air from the pleural space; Can be used for diagnosis or treatment
Bronchoscopy
An invasive diagnostic assessment; Used to diagnose & manage pulmonary diseases
Which client has the most urgent need for frequent nursing assessment? A. An older adult client who was admitted 2 hours ago with emphysema and dyspnea and has a 45-year 2-pack-per-day smoking history, and is receiving 50% oxygen through a Venturi mask B. A young client who has had a tracheostomy for 1 week, who is on room air with SpO2 at percents in the upper 90's, who has been receiving antibiotic therapy for 16 hours, and who has foul-smelling drainage on the tracheostomy ties C. An older adult client who is anxious to go home with her new tank of oxygen and supply of nasal cannulas and is being discharged with a new prescription for home oxygen therapy D. A middle-aged client who was admitted yesterday with pneumonia and is receiving oxygen at 2 L/min through a nasal cannula
An older adult client who was admitted 2 hours ago with emphysema and dyspnea and has a 45-year 2-pack-per-day smoking history, and is receiving 50% oxygen through a Venturi mask
The bedridden client with reduced vision has been admitted. Which nursing interventions will ease the client's hospital stay? Select all that apply. A. Announce name and purpose when entering the client's room. B. Explain food positions on the tray using a compass as the example. C. Orient the client to the location of the call light, and keep it in that place. D. Orient the client to the room surroundings and equipment. E. Speak in a loud, clear voice.
Announce name and purpose when entering the client's room. Explain food positions on the tray using a compass as the example. Orient the client to the location of the call light, and keep it in that place. Orient the client to the room surroundings and equipment.
The community health nurse is planning tuberculosis treatment for a client who is homeless and heroin addicted. Which action will be most effective in ensuring that the client completes treatment? A. Arrange for a health care worker to watch the client take the medication. B. Give the client written instructions about how to take prescribed medications. C. Have the client repeat medication names and side effects. D. Instruct the client about the possible consequences of nonadherence.
Arrange for a health care worker to watch the client take the medication.
Cancer of the nose and sinuses
Are rare, may be benign or malignant. can occur any age. peak incidence for men 40-45 , women 60-65. Onset is slow resembles sinusitis. pt may have advanced disease at diagnosis.
When do you need to assess for oxygen-induced hypoventilation?
Assess for oxygen-induced hypoventilation in the patient whose main respiratory drive is hypoxia (hypoxic drive), such as in the patient with chronic lung disease who also has carbon dioxide retention (hypercarbia). The arterial carbon dioxide (PaCO2) level for these patients gradually rises over time. Manifestations of hypoventilation are seen during the first 30 minutes of oxygen therapy. The patient's color improves (from ashen or gray to pink) because of an increase in the PaO2 level before the apnea or respiratory arrest occurs from slower and shallow respirations. Therefore carefully monitor the level of consciousness, respiratory pattern and rate, and pulse oximetry for those at risk for oxygen-induced hypoventilation, apnea, and respiratory arrest.
The client admitted with cerebral edema suddenly begins to have a seizure while the nurse is in the room. What will the nurse do first? A. Administer phenytoin (Dilantin) B. Draw blood C. Assess the need for additional support D. Start an intravenous (IV) line
Assess the need for additional support
When would an Auditory brainstem-evoked response (ABR) test be used?
Assesses hearing in patients who are unable to indicate or are unreliable in indicating their recognition of sound stimuli during standard hearing tests, which require cognition. This test helps diagnose both conductive and sensorineural hearing losses.
The client is admitted with bacterial meningitis. Which nursing intervention is the highest priority for this client? A. Assessing neurologic status at least every 2 to 4 hours B. Decreasing environmental stimuli C. Managing pain through drug and nondrug methods D. Strict monitoring of hourly intake and output
Assessing neurologic status at least every 2 to 4 hours
The client is being discharged to home with progressing stage I Alzheimer's disease. The family expresses concern to the nurse about caring for their parent. What is the priority for best continuity of care? A. Assigning a case manager B. Ensuring that all family questions are answered before discharge C. Providing a safe environment D. Referring the family to the Alzheimer's Association
Assigning a case manager
The nurse is caring for the client with advanced Alzheimer's disease. Which communication technique is best to use with this client? A. Providing the client with several choices to choose from B. Assuming that the client is not totally confused C. Waiting for the client to express a need D. Writing down instructions for the client
Assuming that the client is not totally confused
The nurse is performing a rapid neurologic assessment on a trauma client. Which assessment finding is normal? A. Decerebrate posturing B. Increased lethargy C. Minimal response to stimulation D. Constriction of pupils
Constriction of pupils
Nasopharynx
Contains the adenoids & the opening of the eustachian tube
The older adult client reports ear pain. Otoscopic examination by the nurse practitioner (NP) reveals a dull and retracted membrane. What does the NP do next? A. Continues further assessment B. Irrigates the ear C. Prescribes antibiotics for probable otitis media D. Tests hearing acuity
Continues further assessment
People involved in which occupations or activities are encouraged to wear masks and to have adequate ventilations? Select all that apply. A. Bakers B. Coal miners C. Electricians D. Furniture refinishers E. Plumbers F. Potters
Bakers Coal miners Furniture refinishers Potters
The client has just returned from a cerebral angiography. Which symptom does the client display that causes the nurse to act immediately? A. Bleeding B. Increased temperature C. Severe headache D. Urge to void
Bleeding
Hemoptysis
Blood in the sputum; Most often seen in patients with chronic bronchitis or lung cancer
When suctioning a client with an endotracheal tube for the first time, what does the nurse do first? A. Briefly explains the procedure B. Preoxygenates the client C. Sets up a sterile field D. Suctions for 10 to 15 seconds
Briefly explains the procedure
The nursing assistant has taken vital signs of the ventilated postoperative client who has had radical neck surgery. What does the nurse tell the assistant to be especially vigilant for? A. Bright red blood rapidly seeping through the dressing B. Decreased level of consciousness C. Effective pain management D. Heart rate and blood pressure trending up over several hours
Bright red blood rapidly seeping through the dressing
Which of these assessment findings will be of greatest concern when the nurse is assessing a client with emphysema? A. Barrel-shaped chest B. Bronchial breath sounds heard at the bases C. Hyperresonance to percussion of the chest D. Ribs lying horizontal
Bronchial breath sounds heard at the bases
Which of the components of a client's family history are of particular importance to the home health nurse who is assessing a new client with asthma? A. Brother is allergic to peanuts. B. Father is obese. C. Mother is diabetic. D. Sister is pregnant.
Brother is allergic to peanuts.
The client with new-onset diminished vision is being discharged and is concerned about living independently. Which technique best facilitates independent self-care for the client? A. Building on the remaining vision B. Keeping the floor free of clutter C. Suggesting a seeing eye animal companion D. Teaching Braille
Building on the remaining vision
The client is admitted to the hospital for chronic obstructive pulmonary disease (COPD), and the physician requests a nasal cannula at 2 L/min. Within 30 minutes, the client's color improves. What does the nurse continue to monitor that may require immediate attention? A. Increasing carbon dioxide levels B. Decreasing respiratory rate C. Increasing adventitious breath sounds D. Increased coughing
Decreasing respiratory rate
The medical-surgical unit has one negative airflow room. Which of these four clients who have just arrived on the unit should the charge nurse admit to this room? A. Client with bacterial pneumonia and a cough productive of green sputum B. Client with neutropenia and pneumonia caused by Candida albicans C. Client with possible pulmonary tuberculosis who currently has hemoptysis D. Client with right empyema who has a chest tube and a fever of 103.2° F
Client with possible pulmonary tuberculosis who currently has hemoptysis
Cerumen or Foreign Bodies : Pathophysiology
Cerumen (wax) is the most common cause of an impacted canal. A canal can also become impacted as a result of foreign bodies that can enter or be placed in the external ear canal, such as vegetables, beads, pencil erasers, and insects.
What do hair follicles and cerumen do for the middle ear?
Cerumen helps protect and lubricate the ear canal. The hair follicles and cerumen protect the eardrum and the middle ear.
What age related change happens to cerumen?
Cerumen is dryer and impacts more easily, reducing hearing function.
An older adult resident in a long-term care facility becomes confused and agitated, telling the nurse "Get out of here! You're going to kill me!" Which action will the nurse take first? A. Check the resident's oxygen saturation. B. Do a complete neurologic assessment. C. Give the prescribed PRN lorazepam (Ativan). D. Notify the resident's primary care provider.
Check the resident's oxygen saturation.
A client receiving sumatriptan (Imitrex) for migraine headaches is experiencing adverse effects after taking the drug. Which adverse effect is of greatest concern to the nurse? A. Chest tightness B. Skin flushing C. Tingling feelings D. Warm sensation
Chest tightness
Four clients arrive in the emergency department simultaneously with chest pain. The client with which type of chest pain requires immediate attention by the nurse? A. Client with pain on deep inspiration B. Client with pain on palpation C. Client with pain radiating to the shoulder D. Client with pain that is rubbing in nature
Client with pain radiating to the shoulder
Which of these clients will the charge nurse on the medical unit assign to an RN who has floated from the postanesthesia care unit (PACU)? A. Client with allergic rhinitis scheduled for skin testing B. Client with emphysema who needs teaching about pulmonary function testing C. Client with pancreatitis who needs a preoperative chest x-ray D. Client with pleural effusion who has had 1200 mL removed by thoracentesis
Client with pleural effusion who has had 1200 mL removed by thoracentesis
A local hunter is admitted to the intensive care unit with a diagnosis of inhalational anthrax. Which of the following medications will the RN anticipate as a physician request? A. Amoxicillin (Amoxil, Triamox) 500 mg orally every 8 hours B. Ceftriaxone (Rocephin) 2 g IV every 8 hours C. Ciprofloxacin (Cipro) 400 mg IV every 12 hours D. Pyrazinamide (PZA) 1000 to 2000 mg orally every day
Ciprofloxacin (Cipro) 400 mg IV every 12 hours
The nurse is working in an urgent clinic. Which of these four clients needs to be evaluated first by the nurse? A. Client who is short of breath after walking up two flights of stairs B. Client with soreness of the arm after receiving purified protein derivative (PPD) (Mantoux) skin test C. Client with sore throat and fever of 39° C oral D. Client who is speaking in three-word sentences and has SaO2 of 90% by pulse oximetry
Client who is speaking in three-word sentences and has SaO2 of 90% by pulse oximetry
Four clients are sent back to the emergency department from triage at the same time. Which client requires the nurse's immediate attention? A. Client with acute allergic reaction B. Client with dyspnea on exertion C. Client with lung cancer with cough D. Client with sinus infection with fever
Client with acute allergic reaction
The home health nurse is assigned to visit all of these clients when a change in agency staffing requires that one of the clients should be rescheduled for a visit on the following day. Which of these clients would be best to reschedule? A. Client with emphysema who has been on home oxygen for a month and has SPO2 levels of 91% to 93% B. Client with history of a cough, weight loss, and night sweats who has just had a positive Mantoux test C. Client with newly diagnosed pleural effusion who needs an admission visit and an initial intake assessment D. Client with percutaneous lung biopsy yesterday who called in to report increased dyspnea
Client with emphysema who has been on home oxygen for a month and has SPO2 levels of 91% to 93%
A newly hired RN with no previous emergency department (ED) experience has just completed a 1-month orientation. Which of these clients would be most appropriate to assign to this nurse? A. Client with epistaxis with profuse bleeding on warfarin (Coumadin) B. Client with facial burns caused by a mattress fire while sleeping C. Client with possible facial fractures after a motor vehicle collision (MVC) D. Client with suspected bilateral vocal cord paralysis and stridor
Client with epistaxis with profuse bleeding on warfarin (Coumadin)
Which change in the cerebrospinal fluid (CSF) indicates to the nurse that the client may have bacterial meningitis? A. Cloudy, turbid CSF B. Decreased white blood cells C. Decreased protein D. Increased glucose
Cloudy, turbid CSF
The client is homeless and has been living in shelters for the past 6 months. The client asks the nurse why he must take so many medications. What information will the nurse provide in answering this question? Select all that apply. A. Combination drug therapy is effective in preventing transmission. B. Combination drug therapy is the most effective method of treating tuberculosis (TB). C. Combination drug therapy will decrease the length of required treatment to 2 months. D. Multiple drug regimens destroy organisms as quickly as possible. E. The use of multiple drugs reduces the emergence of drug-resistant organisms.
Combination drug therapy is effective in preventing transmission. Combination drug therapy is the most effective method of treating tuberculosis (TB). Multiple drug regimens destroy organisms as quickly as possible. The use of multiple drugs reduces the emergence of drug-resistant organisms.
What causes laryngitis?
Common causes include exposure to irritating inhalants (e.g., chemical fumes, tobacco, alcohol, smoke), voice overuse, inhalation of fumes (e.g., glue, paint thinner, butane), or intubation. Recurrent laryngitis may be caused by gastroesophageal reflux disease (GERD).
Your client is the football coach at a local high school. His chief problem is hoarseness. Which of the following is the best recommendation the nurse can make regarding his care? A. Complete voice rest B. Drinking hot tea with lemon C. Prescription for antibiotics D. Whispering instead of using full voice
Complete voice rest
Home oxygen therapy is provided in one of three ways: compressed gas in a tank or a cylinder, liquid oxygen in a reservoir, or an oxygen concentrator. Describe each.
Compressed gas in an oxygen tank (green) is the most often used oxygen source. Liquid oxygen for home use is oxygen gas that has been liquefied. A concentrated amount of oxygen is available in a lightweight and easy-to-carry container similar to a Thermos bottle. The oxygen concentrator or oxygen extractor is a machine that removes nitrogen, water vapor, and hydrocarbons from room air. Oxygen is concentrated from room air to more than 90%. The concentrator, although noisy and large, is the least expensive system and does not need to be filled.
A client is admitted to the surgical floor with chest pain, shortness of breath, and hypoxemia after having a knee replacement. What diagnostic test will the nurse teach the client about to help confirm the diagnosis? A. Bronchoscopy B. Chest x-ray C. Computed tomography (CT) scan D. Thoracoscopy
Computed tomography (CT) scan
Hearing Loss - Etiology and Genetic Risk - Conductive hearing loss
Conductive hearing loss can be caused by any inflammation or obstruction of the external or middle ear by cerumen or foreign objects. Changes in the eardrum such as bulging, retraction, and perforations may indicate damage to middle ear structures, which leads to conductive hearing loss. Tumors, scar tissue, and overgrowth of soft bony tissue (otosclerosis) on the ossicles from previous middle ear surgery also lead to conductive hearing loss.
Which components belong to the ventilator bundle approach to prevent ventilator-associated pneumonia (VAP)? Select all that apply. A. Administering antibiotic prophylaxis B. Continuous removal of subglottic secretions C. Elevating the head of the bed at least 30 degrees whenever possible D. Handwashing before and after contact with the client E. Placing a nasogastric tube F. Placing the client in a negative airflow room
Continuous removal of subglottic secretions Elevating the head of the bed at least 30 degrees whenever possible Handwashing before and after contact with the client
Assess for and record these problems:
Furuncles, large amounts of cerumen, scaliness, redness, swelling of or drainage from the ear associated with a foreign object (insects or other substances), trauma, or infection, Drainage such as blood, cerebrospinal fluid, pus, or serous fluid, and its character
macula lutea
it is on one side of the optic disc; small, yellowish pink area.
pruritus
itching
The nurse is performing a neurologic assessment on an 81-year-old client. Which physiologic change does the nurse expect to find because of the client's age? A. Decreased coordination B. Increased sleeping during the night C. Increased touch sensation D. Stability in pain perception
Decreased coordination
Which systemic disorders may affect the eye and vision and require yearly eye examination by an ophthalmologist? Select all that apply. A. Anemia B. Diabetes mellitus C. Hepatitis D. Hypertension E. Multiple sclerosis (MS)
Diabetes mellitus Hypertension Multiple sclerosis (MS)
The nurse is performing an otoscopic examination of the client's ear and sees a greenish white drainage. What does the nurse do next? A. Disposes of the otoscope tip and washes his or her hands before examining the other ear B. Reports the finding to the physician immediately C. Sends a specimen for culture D. Suctions out the drainage
Disposes of the otoscope tip and washes his or her hands before examining the other ear
A new graduate RN discovers that her client, who had a tracheostomy placed the previous day, has completely dislodged both the obturator and the tracheostomy tube. Which action should the nurse take first? A. Auscultate the client's breath sounds while applying a nasal cannula. B. Direct someone to call the Rapid Response Team while using a resuscitation bag and facemask. C. Apply a 100% non-rebreather mask while administering high-flow oxygen. D. Replace the obturator while reinserting the tracheostomy tube.
Direct someone to call the Rapid Response Team while using a resuscitation bag and facemask.
Categories of Migraines
migraines with aura, migraines without aura, atypical migraines
Cerumen Action Alert
Do not irrigate an ear with an eardrum perforation or otitis media because this may spread the infection to the inner ear. Also, do not irrigate the ear when the foreign object is vegetable matter, because this material expands when wet, making the impaction worse. For vegetable matter, the object needs to be physically removed by an experienced health care professional. Discourage the use of cotton swabs and ear candles (hollow tubes coated in wax inserted into the ear and then lighted at the far end) to clean the ears or remove cerumen.
A client with pneumonia caused by aspiration after alcohol intoxication has just been admitted. The client is febrile and agitated. Which physician order should the nurse implement first? A. Administer levofloxacin (Levaquin) 500 mg IV. B. Draw aerobic and anaerobic blood cultures. C. Give lorazepam (Ativan) as needed for agitation. D. Refer to social worker for alcohol counseling.
Draw aerobic and anaerobic blood cultures.
Patients gender is important
otosclerosis more common in women; Ménière's disease common men.
Polysomnography (PSG)
the diagnostic measurement of physiological activity during sleep; also known as a sleep apnea study. pt observed with EEG , ECG, pulse ox, and EEG. Pt observed for depth of sleep , type of sleep and respiratory effort, 02 saturation, muscle movement.
A client is admitted to the medical floor with a new diagnosis of lung cancer. How can the nurse assist the client initially with the anxiety associated with the new diagnosis? A. Encourage client to ask questions and verbalize concerns. B. Leave client alone to deal with his own feelings. C. Medicate client with diazepam (Valium) for anxiety every 8 hours. D. Provide journals about cancer treatment.
Encourage client to ask questions and verbalize concerns.
Hearing Loss - Nonsurgical Management
Early detection helps correct the problem causing the hearing loss. Drug therapy is focused on either correcting the underlying pathologic change or reducing the side effects of problems occurring with hearing loss. Assistive devices are useful for patients with permanent, progressive hearing loss. Portable amplifiers can be used while watching television to avoid increasing the volume and disturbing others.
Which method is the best way to prevent outbreaks of pandemic influenza? A. Avoiding public gatherings at all times B. Early recognition and quarantine C. Vaccinating everyone with pneumonia vaccine D. Widespread distribution of antiviral drugs
Early recognition and quarantine
In assessing the client's respiratory status, blood gas test results reveal pH of 7.50, PaO2 of 99, PaCO2 of 29, and HCO of 22. What action does the nurse need to take first? A. Call the physician. B. Encourage the client to slow his breathing rate. C. Nothing. These results are within the normal range. D. Provide oxygen support.
Encourage the client to slow his breathing rate.
What is the action of miotics in the client with glaucoma? A. Decrease the inflammatory process B. Enhance aqueous outflow C. Increase the production of vitreous humor D. Vasoconstrict the blood vessels in the eye
Enhance aqueous outflow
Which nursing intervention is the priority in preparing the client for pulmonary function testing (PFT)? A. Administer bronchodilator medication on call. B. Encourage clear fluid intake 12 hours before the procedure. C. Ensure no smoking 6 hours before the test. D. Provide supplemental oxygen as testing begins.
Ensure no smoking 6 hours before the test.
The oxygen saturation monitor of the client recovering from an empyema indicates periodic decreased perfusion, yet the client is talking and laughing with a visitor. The client's respirations are even and unlabored, and the nail beds are pink. What does the nurse do first? A. Auscultates breath sounds B. Calls Respiratory Therapy C. Ensures that the pulse oximetry probe is in place D. Instructs the client to breathe deeply
Ensures that the pulse oximetry probe is in place
A "Do not resuscitate" (DNR) client has a non-rebreather oxygen mask, and breathing appears to be labored. What does the nurse do first? A. Ensures that the tubing is patent and that oxygen flow is high B. Notifies the chaplain and the family member of record C. Calls the Rapid Response Team and prepares to intubate D. Comforts the client and confirms that signed DNR orders are in the chart.
Ensures that the tubing is patent and that oxygen flow is high
The client with visual limitations has been admitted to the intensive care unit (ICU). Which action is most important to implement for this client? A. Allowing the client's seeing eye dog in the unit B. Ensuring that all health care team members are aware of the client's visual limitations C. Keeping the client bedridden for safety D. Addressing the client in a loud, clear voice
Ensuring that all health care team members are aware of the client's visual limitations
total laryngectomy
Entire larynx , hyoid bone , strap muscles , one or two tracheal rings removed. Nodal neck dissection if nodes involved. result: no natural voice.
The standard laryngectomy plan of care for a client admitted with laryngeal cancer includes these interventions. Which intervention will be most important for the nurse to accomplish before the surgery? A. Educate the client about ways to avoid aspiration when swallowing after the surgery. B. Establish a means for communication during the immediate postoperative period, such as a Magic Slate or an alphabet board. C. Discuss appropriate clothing to wear that will help cover the laryngectomy stoma and decrease social isolation after surgery. D. Teach the client and significant others about how to suction and do wound care of the stoma.
Establish a means for communication during the immediate postoperative period, such as a Magic Slate or an alphabet board.
A client is taking INH, rifampin, pyrazinamide, and ethambutol for tuberculosis. The client calls to report visual changes, including blurred vision and reduced visual fields. Which medication may be causing these changes? A. Ethambutol B. INH C. Pyrazinamide D. Rifampin
Ethambutol
A client has just been admitted to the emergency department and requires high-flow oxygen therapy after suffering facial burns and smoke inhalation. Which oxygen delivery device should the nurse use initially? A. Face tent B. Venturi mask C. Nasal cannula D. Non-rebreather mask
Face tent
Which finding in the postoperative client after nasoseptoplasty requires immediate intervention by the nurse? A. Ecchymosis B. Edema C. Excessive swallowing D. Sore throat
Excessive swallowing
CPAP
For CPAP, the effect is to open collapsed alveoli. Patients who may benefit from this form of oxygen or air delivery include those with atelectasis after surgery or cardiac-induced pulmonary edema or those with COPD. It is not beneficial for patients with respiratory failure following extubation. NPPV is also being used in palliative care for alleviating dyspnea, including for those patients with "do-not-intubate" orders. However, this practice is controversial. The Society of Critical Care Medicine (SCCM) recommends that goals of therapy and expected outcomes be discussed with the patient and family before initiating therapy.
Which symptom of pneumonia may present differently in the older adult than in the younger adult? A. Crackles on auscultation B. Fever C. Headache D. Wheezing
Fever
How is a patient weaned from a tracheostomy tube?
First, the cuff is deflated as soon as the patient can manage secretions and does not need mechanical ventilation. This change allows him or her to breathe through the tube and through the upper airway. Next, the tube is changed to an uncuffed tube. If this is tolerated, the size of the tube is gradually decreased. When a small fenestrated tube is placed (No. 4 or 6, depending on the size of the airway), the tube is capped so that all air passes through the upper airway and the fenestra, with none passing through the tube. Assess the patient to ensure adequate airflow around the tube when it is capped. The tube may be removed after he or she tolerates more than 24 hours of capping. Place a dry dressing over the stoma (which gradually heals on its own).
Which eye procedure requires informed consent from the client? A. Eyedrop instillation B. Fluorescein angiography C. Ophthalmoscopy D. Snellen test
Fluorescein angiography
BiPAP
For BiPAP, a cycling machine delivers a set inspiratory positive airway pressure each time the patient begins to inspire. As he or she begins to exhale, the machine delivers a lower set end-expiratory pressure. Together, these two pressures improve tidal volume, can reduce respiratory rate, and may relieve dyspnea.
When will Medicare cover the cost of home oxygen therapy?
For Medicare to cover the cost of home oxygen therapy, the patient must have severe hypoxemia defined as a partial pressure of arterial oxygen (PaO2) level of less than 55 mm Hg or an arterial oxygen saturation (SpO2) of less than 88% on room air and at rest. The criteria vary when hypoxemia is caused by cardiac rather than pulmonary problems or when oxygen is needed only at night or with exercise.
When is a cuffed tube required for a tracheostomy?
For patients receiving mechanical ventilation, a cuffed tube is used in acute care settings. A noncuffed tube is used when mechanical ventilation is not required.
Histoplasmosis and Coccidioidomycosis
Fungal diseases
Which is the most effective way for the college student to minimize the risk for bacterial meningitis? A. Avoiding large crowds B. Getting the meningitis polysaccharide vaccine C. Taking a daily vitamin D. Taking prophylactic antibiotics
Getting the meningitis polysaccharide vaccine
Clients with a family history of which eye disorder may have problems with increased intraocular pressure (IOP), requiring additional assessment? A. Anisocoria B. Cataracts C. Diabetic retinopathy D. Glaucoma
Glaucoma
A client is having surgery. He asks his nurse, "When they put that tube in my throat, where does it really go?" What is the name of the opening of the vocal cords? A. Arytenoid cartilage B. Epiglottis C. Glottis D. Palatine tonsils
Glottis
A client with glaucoma is being assessed for new symptoms. Which symptom indicates a high priority need for reassessment of intraocular pressure in the client with glaucoma? A. Burning in the eye B. Inability to differentiate colors C. Increased sensitivity to light D. Gradual vision changes
Gradual vision changes
manifestations of open bilateral vocal cord paralysis include
Hoarseness , a breathy weak voice, and aspiration of food.
The nurse is providing medication instructions for a client for whom phenytoin (Dilantin) has been requested for treatment of epilepsy. The nurse plans to instruct the client to avoid which beverage? A. Apple juice B. Grape juice C. Grapefruit juice D. Milk
Grapefruit juice
Bronchioles
Have no cartilage and depend entirely on the elastic recoil of the lung to remain patent
Hearing Loss - Pathophysiology
Hearing loss is a common handicap worldwide. It may be conductive, sensorineural, or a combination of the two. Conductive hearing loss occurs when sound waves are blocked from contact with inner ear nerve fibers because of external ear or middle ear disorders. If the inner ear sensory nerve fibers that lead to the cerebral cortex are damaged, the hearing loss is sensorineural. Combined hearing loss is mixed conductive-sensorineural.
Securing a patent airway is a primary intervention. place the patient in
High Fowlers position to aid breathing and proper alignment of airway structures. Assess for upper air way obstruction. Immediately notify Rapid Response Team if dyspnea or stridor occurs. Emergency endotracheal intubation or tracheostomy may be needed.
Which way do you pull the ear for an adult pt?
Hold the otoscope in your dominant hand, and gently pull the pinna up and back with your nondominant hand to straighten the canal.
When does a peritonsillar abscess become of concern?
Hospitalization is required when the airway is in jeopardy or when the infection does not respond to antibiotic therapy. Incision and drainage of the abscess and additional antibiotic therapy may be needed. A tonsillectomy may be performed to prevent recurrence.
For client safety and quality care, which technique is best for the nurse to use when suctioning the client with a tracheostomy tube? A. Hyperoxygenate before and after suctioning. B. Repeat suctioning until the tube is clear. C. Apply suction during insertion of the tube. D. Suction for 30 seconds.
Hyperoxygenate before and after suctioning.
The client has sustained damage to cranial nerve II after a traumatic injury. Which intervention does the nurse anticipate to accommodate for this injury? A. Artificial tears B. Identifying food on the client's plate using the clock method C. Daily eye assessment using the six cardinal positions of gaze D. Ensuring that the client wears sunglasses when the curtains are open or when the room light is on
Identifying food on the client's plate using the clock method
Otitis Media : Surgical Management
If pain persists after antibiotic therapy and the eardrum continues to bulge, a myringotomy (surgical opening of the pars tensa of the eardrum) is performed. This procedure drains middle ear fluids and immediately relieves pain. Preoperative care includes reassuring the patient that the myringotomy will relieve pain and is usually performed without anesthesia. Postoperative care priorities include teaching the patient to keep the external ear and canal free of other substances while the incision is healing. Instruct him or her to keep the head dry by not washing the hair or showering for several days.
When to suspect methemoglobinemia?
If patient becomes cyanotic after receiving a topical anesthetic, does not respond to supplemental O2, & blood is a characteristic chocolate brown in color
A client who has fallen off a roof arrives in the emergency department with possible head, neck, and chest trauma. All of these physician requests are received. Which action will the nurse take first? A. Give oxygen to keep O2 saturation greater than 93%. B. Immobilize the neck with a cervical collar. C. Infuse normal saline by large-bore IV catheter. D. Obtain CT scan of head, neck, and chest.
Immobilize the neck with a cervical collar.
The client returns to the medical unit after a therapeutic bronchoscopy. Which intervention does the nurse apply first? A. Assess the puncture site for drainage. B. Implement NPO (nothing by mouth) status. C. Monitor for signs of anaphylaxis. D. Perform aggressive chest physiotherapy
Implement NPO (nothing by mouth) status.
What are some important assessment findings regarding pulmonary empyema?
Important history findings include recent febrile illness (including pneumonia), chest pain, dyspnea, cough, and trauma. Observe and document the character of the sputum. Chest wall motion may be reduced on physical examination. If a pleural effusion is present, fremitus may be decreased or absent on palpation, percussion may sound flat, and breath sounds are decreased on auscultation. With compression of lung tissue near the effusion, abnormal breath sounds include bronchial breath sounds, egophony, and whispered pectoriloquy. Ask about fever, chills, night sweats, and weight loss. The patient may be hypotensive because of a mediastinal deviation placing pressure on the heart. Palpate the point of maximal impulse (PMI) because it may be displaced.
In the older adult client, which respiratory change does not require further assessment by the nurse? A. Increased anteroposterior (AP) diameter B. Increased respiratory rate C. Shortness of breath D. Sputum production
Increased anteroposterior (AP) diameter
What are the stages of inhalation anthrax illness?
Inhalation anthrax is a two-stage illness—prodromal and fulminant. The prodromal stage is early and difficult to distinguish from influenza or pneumonia. Manifestations include fever, fatigue, mild chest pain, and a dry, harsh cough. A special feature of inhalation anthrax is that it is not accompanied by upper respiratory manifestations of sore throat or rhinitis. Usually the patient starts to feel better and symptoms improve in 2 to 4 days. The fulminant stage begins after the patient feels a little better. Usually there is a sudden onset of breathlessness. This sensation rapidly progresses to severe respiratory distress, dyspnea, diaphoresis, stridor, and cyanosis. The patient has a high fever. Mediastinitis and pleural effusions develop. As the disease spreads through the blood, causing septic shock and meningitis, death often occurs within 24 to 36 hours even if antibiotics are started in this stage.
Paroxysmal nocturnal dyspnea
Intermittent dyspnea sleep; The pt. has a sudden onset of breathing difficulty severe enough to awaken them from sleep; Often occurs with chronic lung disease & left-sided heart failure
The client has been admitted with new-onset status epilepticus. Which seizure precautions does the nurse put in place? Select all that apply. A. Bite block at the bedside B. Intravenous access C. Continuous sedation D. Suction equipment at the bedside E. Siderails up
Intravenous access Suction equipment at the bedside Siderails up
Your client has been homeless and has spent the past 6 months living in shelters. The client has been diagnosed with confirmed tuberculosis (TB). You are completing your medication teaching with this client. About which medications will the nurse teach the client? A. Isoniazid (INH), rifampin (Rifadin), pyrazinamide (Tebrazid), ethambutol (Myambutol) B. Metronidazole (Flagyl), acyclovir (Zovirax), flunisolide (AeroBid), rifampin (Rifadin) C. Prednisone (Prednisone), guaifenesin (Organidin), ketorolac (Toradol), pyrazinamide (Trabrazide) D. Salmeterol (Serevent), cromolyn sodium (Intal), dexamethasone (Decadron), isoniazid (INH)
Isoniazid (INH), rifampin (Rifadin), pyrazinamide (Tebrazid), ethambutol (Myambutol)
complex partial seizure
LOC or "black out" for 1-3 minutes. the patient is unaware of environment and may wander at the start of seizure. after seizure patient may experience amnesia. temporal lobe is most involved
The RN is caring for a client with severe acute respiratory syndrome (SARS) who is receiving mechanical ventilation. Which nursing action should the nurse delegate to a nursing assistant? A. Keeping the head of the bed elevated 30 to 45 degrees B. Monitoring the impact of the ventilator on the client's oxygenation C. Performing oral care with disinfecting rinses every 12 hours D. Suctioning the client's endotracheal tube as needed
Keeping the head of the bed elevated 30 to 45 degrees
Labyrinthitis
Labyrinthitis is an infection of the labyrinth, which may occur as a complication of acute or chronic otitis media. Infection results from an erosion of the bony capsule, allowing organisms to invade the inner ear. Labyrinthitis often results from the growth of a cholesteatoma (benign overgrowth of squamous cell epithelium) from the middle ear into the semicircular canal. Manifestations include hearing loss, tinnitus, nystagmus to the affected side, and vertigo with nausea and vomiting. Meningitis (infection of the brain covering) is a common complication of labyrinthitis.
Angle-closure glaucoma (closed-angle glaucoma, narrow-angle glaucoma, or acute glaucoma.
Less common, sudden onset, & is an emergency. Narrowed angle & forward displacement of the iris. This obstructs the outflow of aqueous humor because of the movement of the iris against the cornea narrowing or closing the chamber angle.
A nurse providing education on eye protection should include which of the following as suggesting high need for protective eyewear? Select all that apply. A. Cab driver B. College student C. Lifeguard D. Racquetball player E. Registered nurse
Lifeguard Racquetball player
A client who has had a recent laryngectomy continues to report pain. Which of the following medications would be best used as an adjunct to a narcotic once he can take oral nutrition? A. Liquid NSAIDs B. Liquid steroids C. Opioid antagonists D. Oral diazepam
Liquid NSAIDs
A client has just arrived in the postanesthesia care unit (PACU) following a successful tracheostomy procedure. Which nursing action must be taken first? A. Suction as needed. B. Clean the tracheostomy inner cannula and stoma. C. Listen to lung sounds. D. Change the tracheostomy dressing as needed.
Listen to lung sounds.
Motor cortex
Located in the frontal lobe, controls voluntary movement.
Your client has been diagnosed with oral and laryngeal cancer. He completed a course of radiation, and it is 2 days since he underwent a total laryngectomy. The client had been very anxious about his surgery. Which of the following medications would you expect to find on his home medication list? A. Amitriptyline (Elavil) B. Diazepam (Valium) C. Ketorolac (Toradol) D. Lorazepam (Ativan)
Lorazepam (Ativan)
CO2 Narcosis
Loss of sensitivity to high levels of PaCO2
What are low-flow delivery systems?
Low-flow delivery systems include the nasal cannula, simple facemask, partial rebreather mask, and non-rebreather mask.
The client with respiratory failure has been intubated and placed on a ventilator and is requiring 100% oxygen delivery to maintain adequate oxygenation. Twenty-four hours later, the nurse notes new-onset crackles and decreased breath sounds, and the most recent arterial blood gases (ABGs) show a PaO2 level of 95 mm Hg. The ventilator is not set to provide positive end-expiratory pressure (PEEP). Why is the nurse concerned? A. The low PaO2 level may result in oxygen toxicity. B. The 100% oxygen delivery requirement indicates immediate extubation. C. Lung sounds may indicate absorption atelectasis. D. The level of oxygen delivery may indicate absorption atelectasis.
Lung sounds may indicate absorption atelectasis.
The client is admitted to the emergency department with metal shards in the right eye. Which test is contraindicated for this client? A. Magnetic resonance imaging (MRI) B. Ophthalmoscopy C. Radioisotope scanning D. Snellen chart
Magnetic resonance imaging (MRI)
The nurse is caring for a client who is scheduled to have a brain biopsy. The nurse anticipates that the health care provider will request which test before the brain biopsy is performed? A. Lumbar puncture (LP) B. Magnetic resonance imaging (MRI) C. Skull x-ray D. Transcranial Doppler ultrasonography (TCD)
Magnetic resonance imaging (MRI)
uvea
Middle layer of eye is heavily pigmented and consists of the choroid (dark brown membrane between sclera and retina lines most of sclera; many blood vessels), the ciliary body, and the iris.
The nurse has just received change-of-shift report about a group of clients on the neurosurgical unit. Which client will the nurse attend to first? A. Young adult post-motor vehicle accident client who is yelling obscenities at the nursing staff B. Adult postoperative left craniotomy client whose hand grips are weaker on the right C. Middle-aged adult post-cerebral aneurysm clipping client who is increasingly stuporous D. Older adult-old post-carotid endarterectomy client who is unable to state the day of the week
Middle-aged adult post-cerebral aneurysm clipping client who is increasingly stuporous
The nurse plans discharge teaching for the client who is recovering from pneumonia. When is the best time to accomplish this? A. After the client has had his bath B. In the evening C. Midmorning or midafternoon D. When visitors are present
Midmorning or midafternoon
Drug approved to help manage daytime sleepiness associated with sleep apnea and narcolepsy.
Modafinil ( Attenace, Provigil), does not treat cause of S.A. or narcolepsy.
White matter
Myelinated axons appear whitish
SENSORINEURAL HEARING LOSS - Assessment Findings
Normal appearance of external canal and tympanic membrane Tinnitus common Occasional dizziness Speaking loudly Hearing poorly in loud environment Rinne test: air conduction less than bone conduction Weber test: lateralization to unaffected ear
Ménière's Disease - Pathophysiology
Ménière's disease has three features: tinnitus, one-sided sensorineural hearing loss, and vertigo, occurring in attacks that can last for several days. (Some patients have continuous manifestations of varying intensity rather than intermittent attacks.) Patients are almost totally incapacitated during an attack, and full recovery often takes several days. The pathology of Ménière's disease is an excess of endolymphatic fluid that distorts the entire inner-canal system. This distortion decreases hearing by dilating the cochlear duct, causes vertigo because of damage to the vestibular system, and stimulates tinnitus
Manifestations of sinusitis
Nasal swelling and congestion, headache, facial pressure, and pain (usually worse when the head is tilted forward or is in a dependent position). Other manifestations include tenderness to touch over the involved area, low-grade fever, cough, and purulent or bloody nasal drainage.
Sleep Apnea blood gas changes stimulate
Neural centers sleeper awakens after 10 seconds or longer of apnea and corrects the obstruction respiration resumes . pt sleeps again cycle can resume again in 5 minutes
Absorption Atelectasis
Nitrogen in the air helps maintain patent airways and alveoli. Making up 79% of room air, nitrogen prevents alveolar collapse because it does not cross the alveolar-capillary membranes and remains in the airways and alveoli. When high oxygen levels are delivered, nitrogen is diluted, oxygen diffuses from the alveoli into the circulation, and the alveoli collapse. Collapsed alveoli cause atelectasis (called absorption atelectasis), which is detected by auscultation. Monitor the patient receiving high levels of oxygen closely for indications of absorption atelectasis (new onset of crackles and decreased breath sounds) every 1 to 2 hours when oxygen therapy is started and as often as needed thereafter.
laryngofissure
No cord removed ( early lesion) result: normal ( high cure rate)
Non-rebreather Masks
Non-rebreather masks provide the highest oxygen level of the low-flow systems and can deliver an Fio2 greater than 90%, depending on the patient's breathing pattern. This mask is often used with patients whose respiratory status is unstable and who may require intubation. The non-rebreather mask has a one-way valve between the mask and the reservoir and two flaps over the exhalation ports (Fig. 30-6). The valve allows the patient to draw all needed oxygen from the reservoir bag, and the flaps prevent room air from entering through the exhalation ports (room air would dilute the oxygen concentration). During exhalation, air leaves through these exhalation ports while the one-way valve prevents exhaled air from re-entering the reservoir bag. The flow rate is kept high (10 to 15 L/min) to keep the bag inflated during inhalation. Assess for this safety feature at least hourly. Ensure that the valve and flaps on a non-rebreather mask are intact and functional during each breath. If the oxygen source should fail or be depleted when both flaps are in place, the patient would not be able to inhale room air.
Noninvasive positive-pressure ventilation (NPPV)
Noninvasive positive-pressure ventilation (NPPV) is a technique using positive pressure to keep alveoli open and improve gas exchange without the need for airway intubation. NPPV is now being used to manage dyspnea, hypercarbia and acute exacerbations of chronic obstructive pulmonary disease (COPD), cardiogenic pulmonary edema, and acute asthma attacks.
What happens if the pressure becomes too high inside the eye?
the extra pressure presses on blood vessels in the eye & prevents blood from flowing through them.... Condition known as glaucoma
The client has recently been released from prison and has just tested positive for tuberculosis (TB). What teaching points does the community health nurse want to stress for this client regarding medications? Select all that apply. A. Not taking the medication could lead to an infection that is difficult to treat or to total drug resistance. B. The medications may cause nausea. The client should take them at bedtime. C. The client is generally not contagious after 2 to 3 consecutive weeks of treatment. D. These medications must be taken for 2 years. E. These medications may cause renal failure.
Not taking the medication could lead to an infection that is difficult to treat or to total drug resistance. The medications may cause nausea. The client should take them at bedtime.
While reading the client's optical chart, the nurse notices that the client has emmetropia. Which corrective equipment does the nurse expect to see this client wearing? A. Bilateral eye patches B. Contact lenses C. Nothing. This is normal. D. Reading glasses
Nothing. This is normal.
When is oxygen therapy prescribed?
Oxygen therapy is prescribed when the oxygen needs of the patient cannot be met by atmospheric or "room air" alone. It is used for both acute and chronic breathing problems that cause decreased blood and tissue oxygen levels as indicated by decreased partial pressure of arterial oxygen (PaO2) levels or by decreased arterial oxygen saturation (SaO2).
At what oxygen level are the lungs at risk for injury?
Oxygen toxicity is related to the concentration of oxygen delivered, duration of oxygen therapy, and degree of lung disease present. In general, an oxygen level greater than 50% given continuously for more than 24 to 48 hours may damage the lungs.
Frequency
the highness or lowness of tones (expressed in hertz).
hyperacusis
the intolerance for sound levels that do not bother other people
ectropion
the lower eyelid may relax and fall away from the eye
Which value indicates clinical hypoxemia and the need to increase oxygen delivery? A. Hemoglobin of 22 g/dL B. PaCO2 of 30 mm Hg C. PaO2 of 65 mm Hg D. Oxygen saturation of 88%
PaO2 of 65 mm Hg
Appearance of nasal mucous membrane in patient with Allergic Rhinitis
Pale, engorged, and bluish gray
Threshold
the lowest level of intensity at which pure tones and speech are heard by a patient about 50% of the time.
The nurse prepares to assess a client with diabetes mellitus for sensory loss. Which equipment will the nurse need to perform this assessment? A. Glucometer B. Hammer C. Nothing; the client is asked to walk D. Paper clip
Paper clip
Partial Rebreather Masks
Partial rebreather masks provide oxygen concentrations of 60% to 75% with flow rates of 6 to 11 L/min. It is a mask with a reservoir bag but no flaps. With each breath, the patient rebreathes one third of the exhaled tidal volume, which is high in oxygen and provides a higher fraction of inspired oxygen (FiO2). Be sure that the bag remains slightly inflated at the end of inspiration; otherwise, the desired amount of oxygen is not delivered. If needed, call the respiratory therapist for assistance.
conjunctivae
the mucous membranes of the eye
At what age do people with the genetic osteogenesis imperfecta display bilat. Hearing loss?
People with the genetic disorder osteogenesis imperfecta have bilateral and progressive hearing loss by their 30s.
Perichondritis
Perichondritis is an infection of the perichondrium, a tough, fibrous tissue layer that surrounds the cartilage and shapes the pinna. This tissue supplies blood to the ear cartilage. Infection can be caused by opening an area of pus or localized infection, insect bites, trauma, postoperative complication of tympanoplasty, and cartilage ear piercing.
The nurse is planning care for the non-English-speaking client who is on complete voice rest. What alternative method of communication does the nurse implement? A. Alphabet board B. Picture board C. Translator at the bedside D. Word board
Picture board
The older adult client with degenerative arthritis is admitted for tracheostomy surgery. What is the best communication method for this client during the postoperative period? A. Computer keyboard B. Magic Slate C. Picture board D. Pen and paper
Picture board
A client comes to the emergency department with a productive cough. Which symptom does the nurse look for that will require immediate attention? A. Blood in the sputum B. Mucoid sputum C. Pink frothy sputum D. Yellow sputum
Pink frothy sputum
A client is admitted to the emergency department (ED) with a possible diagnosis of avian influenza ("bird flu"). Which of these actions included in the hospital protocol for avian influenza will the nurse take first? A. Ensure that ED staff members receive oseltamivir (Tamiflu). B. Obtain specimens for the H5 polymerase chain reaction test. C. Place the client in a negative air pressure room. D. Start an IV line and administer rehydration therapy.
Place the client in a negative air pressure room.
A client who has recently traveled to Vietnam comes to the emergency department with fatigue, lethargy, night sweats, and a low-grade fever. What is the nurse's first action? A. Contacts the health care provider for tuberculosis (TB) medications B. Performs a TB skin test C. Places a respiratory mask on the client D. Tests all family members for TB
Places a respiratory mask on the client
Which is a correct step in the proper technique for eyedrop instillation? A. Instilling the drops into the inner canthus B. Opening the eye by raising the upper eyelid C. Placing the eyedrop in the lower lid pocket D. Touching the bottle tip to the eyeball
Placing the eyedrop in the lower lid pocket
Which technique is the correct way to instill eardrops? A. Maintaining the head in the same position for 2 minutes after instillation B. Placing the medication bottle in a bowl of warm water before instillation C. Rinsing the ear canal with hydrogen peroxide before instillation D. Checking to see whether the eardrum is intact before instillation
Placing the medication bottle in a bowl of warm water before instillation
An RN and an LPN/LVN are working together to provide care for a client hospitalized with dyspnea who requires all of these nursing actions. Which of these actions is best accomplished by the RN? A. Administer the purified protein derivative (PPD) for tuberculosis testing. B. Assess vital signs and the puncture site after thoracentesis. C. Monitor oxygen saturation using pulse oximetry every 4 hours. D. Plan client and family teaching regarding upcoming pulmonary function testing.
Plan client and family teaching regarding upcoming pulmonary function testing.
viral meningitis (outcome) is ..
usually self-limiting and the patient has a complete recovery
The client with a new tracheostomy has a soiled dressing. What is the best nursing intervention? A. Cut sterile 4 × 4 gauze to fit around the tracheostomy tube. B. Reinforce the dressing with sterile 4 × 4 gauze. C. Replace the dressing with clean, folded 4 × 4 gauze. D. Replace the dressing with sterile, folded 4 × 4 gauze.
Replace the dressing with sterile, folded 4 × 4 gauze.
The client with early-stage Alzheimer's disease is admitted to the surgical unit for a biopsy. Which client problem is the priority? A. Potential for injury related to chronic confusion and physical deficits B. Risk for reduced mobility related to progression of disability C. Potential for skin breakdown related to immobility and/or impaired nutritional status D. Lack of social contact related to personality and behavior changes
Potential for injury related to chronic confusion and physical deficits
Hearing Loss - Etiology and Genetic Risk - Presbycusis
Presbycusis is a sensorineural hearing loss that occurs as a result of aging . It is caused by breakdown or atrophy of cochlear nerve cells, loss of elasticity of the basilar membrane, or a decreased blood supply to the inner ear. Deficiencies of vitamin B12 and folic acid may play a role in presbycusis. Other causes include atherosclerosis, hypertension, infections, fever, Ménière's disease, diabetes, and ear surgery. Each disorder accelerates degenerative changes of the cochlea . Trauma to the ear also contributes to sensorineural hearing loss.
How do you prevent hypoxia while suctioning a client?
Prevent hypoxia by hyperoxygenating the patient with 100% oxygen with a manual resuscitation bag attached to an oxygen source. If the patient can take deep breaths, instruct him or her to do so three or four times with the existing oxygen delivery system before suctioning. If possible, monitor the heart rate or use a pulse oximeter while suctioning to assess tolerance of the procedure. Assess for hypoxia (e.g., increased heart rate and blood pressure, oxygen desaturation, cyanosis, restlessness, anxiety, dysrhythmias). Oxygen saturation below 90% by pulse oximetry indicates hypoxemia. If hypoxia occurs, stop the suctioning procedure. Using the 100% oxygen delivery system, reoxygenate the patient until baseline parameters return.
What are priority problems for the patient with pneumonia?
Priority problems for the patient with pneumonia are: 1. Hypoxemia related to decreased diffusion at the alveolar-capillary membrane 2. Potential for airway obstruction related to excessive tracheobronchial secretions, fatigue, chest discomfort, muscle weakness 3. Potential for sepsis related to the presence of microorganisms in a very vascular area
Community health nurses are tasked with providing education on prevention of respiratory infection for diseases such as the flu. Which target audience is given the highest priority? A. Homeless people B. Hospital staff C. Politicians D. Prison staff and inmates
Prison staff and inmates
SENSORINEURAL HEARING LOSS - Causes
Prolonged exposure to noise Presbycusis Ototoxic substance Ménière's disease Acoustic neuroma Diabetes mellitus Labyrinthitis Infection Myxedema
The nurse notices a visitor walking into the room of a client on airborne isolation with no protective gear. What does the nurse do? A. Ensures that the client is wearing a mask B. Tells the visitor that the client cannot receive visitors at this time C. Provides a particulate air respirator to the visitor D. Provides a mask to the visitor
Provides a mask to the visitor
What is the proper technique for assessing the adult client's ear with an otoscope? A. Hold the otoscope right side up when inserting it into the ear canal. B. Maintain distance between the otoscope and the client's head. C. Place the otoscope in the nondominant hand. D. Pull the pinna up and back with the nondominant hand.
Pull the pinna up and back with the nondominant hand.
Treatment for nose and sinus cancer
Radiation is main treatment. Surgery if radiation not successful. Problems post op change in body image, speech and altered nutrition. pt may lose sense of taste or smell.
Blood or clear fluid (cerebral spinal fluid)
Rarely drains from one or both nares as a result of a simple nasal fracture. CSF drainage can indicate a skull fracture CSF will test positive for glucose in a dipstick test. CSF dries on a piece of filter paper yellow halo appears as ring on the dried edge of fluid.
The client has recently had cataract surgery. About which symptom does the nurse instruct the client to notify the physician? A. Increased tearing B. Itching of the eye C. Reduction in vision D. Swollen eyelid
Reduction in vision
The client recently diagnosed with Ménière's disease is struggling with tinnitus. How does the nurse provide support to this client? A. Provides further assessment B. Suggests a quiet environment C. Suggests temporary removal of a hearing aid D. Refers the client to the American Tinnitus Association
Refers the client to the American Tinnitus Association
The older adult client with a new diagnosis of hearing loss is deeply concerned about not being able to hear at her neighborhood council meetings. Which nursing intervention best addresses the client's concern? A. Suggests that the client discuss with the chairperson about asking everyone speaking at the meeting to speak louder B. Refers the client to the Center for the Visually Impaired for support C. Arranges for a sign language specialist to attend the meetings to teach everyone how to communicate with the hearing impaired member D. Refers the client to the Hearing Loss Association of America
Refers the client to the Hearing Loss Association of America
The client has recently been diagnosed with 20/200 vision bilaterally. How does the nurse best offer increased support? A. Provides instructions in a loud, clear voice B. Refers the family to local services for the blind C. Tells the client to find a support group D. Writes instructions down in very large print
Refers the family to local services for the blind
light reflex
Reflection of the otoscope's light from the normal eardrum is the light reflex, and it appears as a clearly outlined triangle of light.
Describe Sensorineural hearing loss
Results from a defect in the cochlea, the eighth cranial nerve, or the brain itself. Exposure to loud noise and music may cause this type of hearing loss as a result of damage to the cochlear hair cells.
Describe Conductive hearing loss
Results from physical obstruction of sound wave transmission such as a foreign body in the external canal, a retracted or bulging tympanic membrane, or fused bony ossicles.
The client with dementia and Alzheimer's disease is discharged to home. The client's daughter says, "He wanders so much, I am afraid he'll slip away from me." What resource does the nurse suggest? A. Alzheimer's Wandering Association B. National Alzheimer's Group C. Safe Return Program D. Lost Family Members Tracking Association
Safe Return Program
What is secondary TB?
Secondary TB is a reactivation of the disease in a previously infected person. It is more likely when defenses are lowered, such as with older adults and people with HIV disease. The upper lobes are the most common site of reactivation and are referred to as Simon's foci.
Hearing Loss - Etiology and Genetic Risk - Sensorineural hearing loss
Sensorineural hearing loss occurs when the inner ear or auditory nerve (cranial nerve VIII) is damaged. Prolonged exposure to loud noise can damage the hair cells of the cochlea. Many drugs are toxic to the inner ear structures, and their effects on hearing can be transient or permanent, dose related or non- dose related, and affect one or both ears. When ototoxic drugs are given to patients with reduced kidney function, increased ototoxicity can result because drug elimination is slower. Older patients are especially at risk for ototoxicity because of reduced kidney function.
Triptan
Serotonin receptor agonist (reverses vasodilation) Few side effects Contraindicated in pts with ischemic heart disease, cerebrovascular ischemia, HTN, PVD, Prinzmetal's agina
Orthopnea
Shortness of breath that occurs when lying down but is relieved by sitting up; Often occurs with chronic lung disease & left-sided heart failure
Simple Facemasks
Simple facemasks are used to deliver oxygen concentrations of 40% to 60% for short-term oxygen therapy or in an emergency. A minimum flow rate of 5 L/min is needed to prevent the rebreathing of exhaled air. Ensure the mask fits well to maintain inspired oxygen levels. Care for the skin under the mask and strap to prevent skin breakdown.
Cancer on the pinna could look like ____
Small, crusted, ulcerated, or indurated lesions on the pinna that fail to heal could be squamous cell carcinoma.
The client says, "I have problems reading the signs when I am driving." Which test does the nurse use to assess this client's problem? A. Confrontation test B. Ishihara chart C. Rosenbaum Pocket Vision Screener or a Jaeger card D. Snellen chart
Snellen chart
Name two methods by which sound is conducted.
Sound is transmitted by air conduction and bone conduction.
Cochlea
Spiral organ of hearing, filled with fluid to protect the cochlea and semicircular canals by allowing structures to float in the fluids; contains hair cells that detect vibration and stimulate 8th cranial nerve
The older adult client reports nausea during removal of impacted cerumen from the ear canal. What does the nurse do next? A. Administers an antiemetic B. Calls the physician C. Stops irrigation immediately D. Uses less water to irrigate
Stops irrigation immediately
What assessments signal the need for suctioning?
Suctioning is needed when secretions are audible or noisy, when crackles or wheezes are heard on auscultation, or when restlessness, increased pulse or respiratory rates, or mucus in the artificial airway is present. Other indications include patient requests for suctioning or an increase in the peak airway pressure on the ventilator.
Respirations of the sedated client with a new tracheostomy have become noisy, and the ventilator alarms indicate high peak pressures. The ventilator tube is clear. What is the best immediate action by the nurse? A. Humidifying the oxygen source B. Increasing oxygenation C. Removing the inner cannula of the tracheostomy D. Suctioning the client
Suctioning the client
Painful methods to employ with the GCS are
Supraorbital (over eyes) pressure; Trapezius muscle squeeze; Mandibular (jaw) pressure; Sternal (breastbone) rub
Which clinical manifestation requires immediate action by the nurse for the client with laryngeal trauma? A. Aphonia B. Hemoptysis C. Hoarseness D. Tachypnea
Tachypnea
Ménière's Disease - Nonsurgical Management
Teach patients to move the head slowly to prevent worsening of the vertigo. Nutrition and lifestyle changes can reduce the amount of endolymphatic fluid. Encourage patients to stop smoking because of the blood vessel- constricting effects. Nutrition therapy with a hydrops diet may stabilize body fluid levels to prevent excess endolymph accumulation. The basic structure of this diet involves: • Distributing food and fluid intake evenly throughout the day and from day to day • Avoiding foods or fluids that have a high salt content • Drinking adequate amounts of fluids (low in sugar) daily • Avoiding caffeine-containing fluids and foods • Limiting alcohol intake to one glass of beer or wine each day • Avoiding foods containing monosodium glutamate (MSG)
What should you teach the patient regarding laryngitis?
Teach the patient and family about relief measures, infection prevention, and avoidance of alcohol, tobacco, and pollutants, which can irritate the larynx. Teach about preventive strategies such as reducing tobacco and alcohol use. Emphasize the need to avoid activities that place an added strain on the larynx, such as singing, cheering, public speaking, heavy lifting, and whispering. Speech-language therapy is used when vocal cord injury occurs with laryngitis. Further evaluation is needed for recurrent bouts of laryngitis.
Calmette-Guérin (BCG) vaccine
The BCG vaccine contains attenuated tubercle bacilli and is used in many countries to produce increased resistance to TB. Anyone who has received BCG vaccine within the previous 10 years will have a positive skin test that can complicate interpretation. Usually the size of the skin response decreases each year after BCG vaccination. These patients should be evaluated for TB with a chest x-ray or the QuantiFERON-TB Gold test. The effectiveness of BCG vaccine in preventing TB is controversial, and it is not used widely for this purpose in the United States or Canada.
Which hearing frequency is lost first?
The ability to hear high-frequency sounds is lost first. Older adults may have particular problems hearing the f, s, sh, and pa sounds.
What happens to sound wave vibrations after they become action potentials?
The action potentials are conducted to the brain as nerve impulses by the cochlear portion of the eighth cranial (auditory) nerve. The nerve impulses are processed and interpreted as sound by the brain in the auditory cortex of the temporal lobe.
What are the causes and manifestations of lung injury from oxygen toxicity?
The causes and manifestations of lung injury from oxygen toxicity are the same as those for acute respiratory distress syndrome (ARDS). Initial symptoms include dyspnea, nonproductive cough, chest pain beneath the sternum, and GI upset. As exposure to high levels of oxygen continues, the symptoms become more severe with decreased vital capacity, decreased compliance, crackles, and hypoxemia. Prolonged exposure to high oxygen levels damages lung tissues. Atelectasis, pulmonary edema, hemorrhage, and hyaline membrane formation result. Surviving this critical condition depends on correcting the underlying disease process and decreasing the oxygen amount delivered.
A client who has experienced a panic attack is being transferred to the medical-surgical ward. The transfer nurse reports that the client is doing much better after receiving bronchodilators via nebulizer and a small dose of oral Valium 4 hours ago in the emergency department. Vital signs are stable with oxygen delivered at 4 L/min via simple facemask. Why is this client at high risk for subsequent respiratory distress? A. The client is not being treated for asthma. B. The client has a mental disorder. C. The client received a dose of Valium. D. The client is receiving oxygen at 4 L/min
The client is receiving oxygen at 4 L/min (this is based on flow rates for the simple facemask)
A client is being admitted for pneumonia. The sputum culture is positive for Streptococcus. The client asks about the length of the treatment. On what does the nurse base the answer? A. The client may be switched from IV to oral antibiotics in 2 to 3 days. B. Usually anti-infectives are used for 7 to 10 days. C. When the client has completed 6 days of therapy D. When the client is afebrile for 24 hours
The client may be switched from IV to oral antibiotics in 2 to 3 days.
The nurse is caring for a client who is admitted with mastoiditis. Which of these assessment data obtained by the nurse requires the most immediate action? A. The eardrum is red, thick appearing, and immobile. B. The lymph nodes are swollen and painful to touch. C. The client reports a headache and a stiff neck. D. The client's oral temperature is 100.1° F (37.8° C).
The client reports a headache and a stiff neck.
Methemoglobinemia
The conversion of normal hemoglobin to methemoglobin, an altered iron state that does not carry O2 resulting in tissue hypoxia
transoral cordectomy
Tumor (early lesion) resected through laryngoscope . result : normal / hoarse (high cure rate)
lethargic
drowsy or sleepy but easily awakened
Neoplasms
Tumors of the middle ear are rare, and the most common type is the glomus jugulare, a benign lesion arising from the jugular vein. Malignant ear tumors also can occur. The growth of any lesion within the middle ear area disrupts conductive hearing, erodes the ossicles, and may spread to the inner ear and nearby cranial nerves.
corneal staining
dye outlines irregularities of corneal surface (used for corneal trauma, problems caused by contacts, or presence of foreign bodies, abrasions, ulcers, or other corneal disorders).
What is the distance from the ear canal to the eardrum?
The distance from the opening of the ear canal to the eardrum in an adult is 1 to 1½ inches
Supratentorial/Infratentorial
The dura also lies between the cerebral hemispheres and the cerebellum and is called the tentorium. It helps decrease or prevent the transmission of force from one hemisphere to another and protect the lower brainstem when head trauma occurs.
What does the eardrum look like and what makes it move?
The eardrum, a thick sheet of tissue, is transparent, opaque, or pearly gray and moves when air is injected into the external canal.
Ratings on the GCS
The higher the number means you're getting response; Lower response = lower number; Highest possible not intubatedis 15; Highest for intubated is 11t; Comatose = 7
How often should oxygen delivery equipment be changed?
The humidifier or nebulizer may be a source of bacteria, especially if it is heated. Pseudomonas aeruginosa is often the organism involved. Oxygen delivery equipment such as cannulas and masks can also harbor organisms. Change equipment as per policy or protocol, which ranges from every 24 hours for humidification systems to every 7 days or whenever necessary for cannulas and masks.
How does pneumonia affect the body?
The inflammation occurs in the interstitial spaces, the alveoli, and often the bronchioles. The process begins when organisms penetrate the airway mucosa and multiply in the alveoli. White blood cells (WBCs) migrate to the area of infection, causing local capillary leak, edema, and exudate. These fluids collect in and around the alveoli, and the alveolar walls thicken. Both events seriously reduce gas exchange and lead to hypoxemia, interfering with oxygenation and possibly leading to death. Red blood cells (RBCs) and fibrin also move into the alveoli. The capillary leak spreads the infection to other areas of the lung. If the organisms move into the bloodstream, sepsis results; if the infection extends into the pleural cavity, empyema (a collection of pus in the pleural cavity) results. The fibrin and edema of inflammation stiffen the lung, reducing compliance and decreasing the vital capacity. Alveolar collapse (atelectasis) further reduces the ability of the lung to oxygenate the blood moving through it. As a result, arterial oxygen levels fall, causing hypoxemia
Mastoiditis - Pathophysiology
The lining of the middle ear is continuous with the lining of the mastoid air cells, which are embedded in the temporal bone. Mastoiditis is an infection of the mastoid air cells caused by untreated or inadequately treated otitis media.
What are possible causes of pulmonary empyema?
The most common cause of empyema is pulmonary infection, lung abscess, or infected pleural effusion. Pneumonia or lung abscess can spread across the pleura. Lymph node obstruction can cause a retrograde (backward) flood of infected lymph into the pleural space. A liver abscess or abdominal abscess can spread through the lymphatic system into the lungs. Chest surgery or trauma can introduce bacteria directly into the pleural space, leading to empyema. Blood from trauma may collect in the pleural space, promoting infection.
At what flow rates and oxygen concentrations can you use nasal cannula?
The nasal cannula, or nasal prongs, is used at flow rates of 1 to 6 L/min. Oxygen concentrations of 24% (at 1 L/min) to 44% (at 6 L/min) can be achieved. Flow rates greater than 6 L/min do not increase oxygenation because the anatomic dead space (places where air flows but the structures are too thick for gas exchange) is full. In addition, high flow rates increase mucosal irritation.
Home care preparation for oxygen therapy
The nurse or respiratory therapist teaches the patient about the equipment needed for home oxygen therapy, including the oxygen source, delivery devices, humidity sources, and safety aspects of using and maintaining the equipment.
What are some considerations for older adults when assessing for pneumonia?
The older adult with pneumonia has weakness, fatigue, lethargy, confusion, and poor appetite. Fever and cough may be absent, but hypoxemia is often present. The most common manifestation of pneumonia in the older adult patient is acute confusion from hypoxia. The WBC count may not be elevated until the infection is severe. Waiting to treat the disease until more typical manifestations appear greatly increases the risk for sepsis and death.
What is the oxygen content of air?
The oxygen content of atmospheric air is about 21%.
Pars Flaccida
The pars flaccida is that portion of the eardrum above the short process of the malleus.
Pars Tensa
The pars tensa is that portion surrounding the long process of the malleus.
When should the patient be re-evaluated regarding bacterial pharyngitis?
The patient should be re-evaluated if there is no improvement in 3 days or if manifestations are still present after completion of the antibiotic course. Persistent bacterial pharyngitis may occur with immunosuppression. Any patient whose bacterial pharyngitis does not improve with antibiotics should consider human immune deficiency virus (HIV) testing.
Which patients shouldn't receive oxygen at rates higher than 2 to 3 L/min?
The patient who retains carbon dioxide is rarely prescribed to receive oxygen at a rate higher than 2 to 3 L/min because of the risk for losing the drive to breathe, thereby increasing the risk for apnea or respiratory arrest.
What are some signs of the flu?
The patient with influenza often has a severe headache, muscle aches, fever, chills, fatigue, and weakness. Adults are contagious from 24 hours before symptoms occur and up to 5 days after they begin. Patients who are immunosuppressed may be contagious for several weeks. Sore throat, cough, and watery nasal discharge generally follow the initial symptoms for a week or longer. Most patients feel fatigued for 1 to 2 weeks after the acute episode has resolved.
Cricothyroid membrane
The site used in an emergency for access to the lower airways (aka a tracheostomy)
Tracheotomy
The surgical incision into the trachea to create an airway.
What are the 3 most common modes of delivery for noninvasive positive-pressure ventilation NPPV?
The three most common modes of delivery for NPPV are (1) CPAP, which delivers a set positive airway pressure throughout each cycle of inhalation and exhalation; (2) volume-limited or flow-limited, which delivers a set tidal volume with the patient's inspiratory effort; and (3) pressure-limited, which includes pressure support, pressure control, and bi-level positive airway pressure (BiPAP), which cycles different pressures at inspiration and at expiration.
What can be a problem with tracheostomy patients?
The tracheostomy tube sometimes tethers the larynx in place, making it unable to move effectively. The result is difficulty in swallowing. Also, when the tracheostomy tube cuff is inflated, it can balloon backwards and interfere with the passage of food through the esophagus. The wall between the back of the trachea and the front of the esophagus is very thin, allowing this pushing problem. Instruct the patient to keep the head of the bed elevated for at least 30 minutes after eating.
Several rapid and simple tests for hearing can be performed at the patient's bedside.
The voice test, watch test, audioscopy testing , tuning fork tests
Carbon Dioxide (CO2)
The waste gas created in the tissues that moves from the blood into the alveoli so that it can be exhaled
Tinnitus
Tinnitus (continuous ringing or noise perception in the ear) is a common hearing problem. Diagnostic testing cannot confirm tinnitus, nor can the disorder be observed. Testing is performed, however, to assess hearing and rule out other disorders. When patients report tinnitus, consider the many factors that cause tinnitus: presbycusis, otosclerosis (irregular bone growth around ossicles), Ménière's disease, certain drugs, exposure to loud noise, and other inner ear problems When no cause can be found or the disorder is untreatable, therapy focuses on ways to mask the tinnitus with background sound, noisemakers, and music during sleeping hours. Ear mold hearing aids can amplify sounds to drown out the tinnitus during the day.
What are low-flow delivery systems advantages and disadvantages?
These systems are inexpensive, easy to use, and fairly comfortable. A disadvantage is that the actual amount of oxygen delivered varies and depends on the patient's breathing pattern. The oxygen is diluted with room air (21% oxygen), which lowers the amount of oxygen actually inspired.
Pulmonary Function Tests (PFTs)
These tests evaluate lung function & breathing problems; During these tests the patient breaths through the mouth only
Coronaviruses
These viruses have ribonucleic acid (RNA) as their genetic material and have many projections that look like a halo or "corona." This family of viruses causes many forms of the common cold.
Why are the turbinates important? A. They decrease the weight of the skull on the neck. B. They increase the surface area of the nose for heating and filtering. C. They move inspired particles from nose to throat for removal. D. They separate two nasal passages down the middle.
They increase the surface area of the nose for heating and filtering.
How do you obtain a specimen for a throat culture?
To obtain a specimen, rub a sterile cotton swab from a throat culture kit first over the right tonsillar area, moving across the right arch, the uvula, and then across the left arch to the left tonsillar area. Remove the swab without touching the patient's teeth, tongue, or gums. Place the swab back into the tube, cap it, and then crush the glass ampule in the culture tube. Send it to the laboratory as quickly as possible.
Tissue damage can occur at the point where the inflated cuff presses against the tracheal mucosa. At what pressure should the cuff be inflated?
To reduce the risk for tracheal damage, keep the cuff pressure between 14 and 20 mm Hg or 20 and 30 cm H2O (ideally, 25 cm H2O or less)
The client has a fever of 40° C. In which direction, if any, will this shift the oxyhemoglobin dissociation curve? A. Down B. To the left C. To the right D. Will not shift
To the right
seizure precautions
be sure oxygen and suctioning equipment with an airway are readily available, maintain iv acess, siderails up at all times
Descending tracts
begin in the brain and end in the spinal cord.
Speech and language therapy is used for
behavior voice changes and helps pt learn to reduce speech intensity. this therapy may make surgery unnecessary.
Transtracheal oxygen (TTO)
Transtracheal oxygen (TTO) is a long-term method of delivering oxygen directly into the lungs. A small, flexible catheter is passed into the trachea through a small incision with the patient under local anesthesia. TTO avoids the irritation that nasal prongs cause. Patients also report it to be more cosmetically acceptable. TTO flow rates are prescribed for rest and for activity. A flow rate also is prescribed for the nasal cannula, which is used when the TTO catheter is being cleaned. Most patients using this delivery method have a 55% reduction in required oxygen flow at rest and a 30% decrease with activity.
Nasal polyps
benign grape like clusters of mucous and connective tissue . often occur bilaterally. Cause: irritation on nasal mucosa or sinuses allergies, infections (chronic sinusitis). Become to large airway obstruction. treated with steroids or surgery.
Ear Trauma - Pathophysiology
Trauma and damage may occur to the eardrum and ossicles by infection, by direct damage, or through rapid changes in the middle ear pressure. Foreign objects placed in the external canal exert pressure on the eardrum and cause perforation. Excessive nose blowing and rapid changes of pressure that occur with nonpressurized air flight (barotrauma) can increase pressure within the middle ear. High pressure damages the ossicles and can perforate the eardrum.
How often should clients receive the pneumococcal polysaccharide vaccine (PPV23)?
This vaccine is usually given once; however, some experts believe that older adults and those with chronic health problems could benefit from a second vaccination if more than 5 years have passed since the first vaccination.Especially encourage people older than 65 years and those with a chronic health problem to receive the PPV23.
The client comes to the emergency department with a sore throat. Examination reveals redness and swelling of the pharyngeal mucous membranes. Which diagnostic test does the nurse expect will be requested first? A. Chest x-ray B. Complete blood count C. Tuberculosis (TB) skin test D. Throat culture
Throat culture
Causes of upper airway obstructions include
Tongue edema, occlusion by the tongue, laryngeal edema, peritonsillar and pharyngeal abscess, head and neck cancer, thick secretions , stroke and cerebral edema, smoke inhalation edema,facial tracheal or laryngeal trauma, foreign body aspiration, burns of the neck and head area, anaphylaxis.
Nonsurgical treatment of sinusitis
Treatment includes the use of broad-spectrum antibiotics, analgesics for pain and fever, decongestants, steam humidification, hot and wet packs over the sinus area, and nasal saline irrigations. Teach the patient to increase fluid intake unless another medical problem requires fluid restriction. If this treatment plan is not successful, he or she may need to be evaluated with sinus x-rays and CT scans. Surgical intervention may be needed if nonsurgical management fails to provide relief.
Hearing Loss - Surgical Management
Tympanoplasty reconstructs the middle ear to improve conductive hearing loss. The procedures vary from simple reconstruction of the eardrum (myringoplasty) to replacement of the ossicles within the middle ear (ossiculoplasty). A type I tympanoplasty is used for a myringoplasty; a type II tympanoplasty is used in cases of greater damage, and it provides more extensive reconstruction
A new client arrives in the medical-surgical unit with a flap. The flap appears dusky in color. What is the nurse's first action? A. Apply a hot pack over the flap site. B. Massage the flap site vigorously. C. Place a tight dressing over the flap. D. Use a Doppler to assess flow to the area.
Use a Doppler to assess flow to the area.
Tender lymph nodes in neck
Usu. movable & suggest inflammation
What are common manifestations of SARS?
Usually, the patient has a fever higher than 100.4° F (38.0° C), a headache, and general body aches. Mild cold symptoms of a runny nose, sore throat, and watery eyes may also be present. Within 2 to 7 days, the patient develops a dry cough and has difficulty breathing. Hypoxia, with cyanosis, low oxygen saturation, and a feeling of breathlessness, indicates more severe illness. Chest x-rays show a pattern similar to pneumonia. Diagnosis is made by the manifestations and the use of a rapid SARS test that detects SARS-CoV RNA in the blood within 2 days after symptoms begin.
The nurse is aware that which cranial nerve allows a person to feel a light breeze on the face? A. I (olfactory) B. III (oculomotor) C. V (trigeminal) D. VII (facial)
V (trigeminal)
The nurse has just received report on a group of clients on the neurosurgical unit. Which client will be the nurse's first priority? A. Young adult client whose Glasgow Coma Scale (GCS) rating has changed from 15 to 10 B. Adult client whose deep tendon reflexes have become hyperactive C. Middle-aged client who displays plantar flexion when the bottom of the foot is stroked D. Older adult client who consistently demonstrates decortication when stimulated
Young adult client whose Glasgow Coma Scale (GCS) rating has changed from 15 to 10
Venturi Mask
Venturi masks (commonly called Venti masks) deliver the most accurate oxygen concentration without intubation. It works by pulling in a proportional amount of room air for each liter flow of oxygen. An adaptor is located between the bottom of the mask and the oxygen source (Fig. 30-7). Adaptors with holes of different sizes allow specific amounts of air to mix with the oxygen. More precise delivery of oxygen results. Each adaptor uses a different flow rate. Humidification is not needed with the Venturi mask.
Which oxygen delivery system is best for patients with chronic lung disease?
Venturis masks are best for the patient with chronic lung disease because it delivers a more precise oxygen concentration.
The older adult client reports ear pain. To differentiate the cause, which clinical manifestation is more indicative of otitis media? A. Dry, flaky cerumen B. Pain on movement of the tragus C. Ringing in the ears D. Vertigo
Vertigo
Vertigo and Dizziness
Vertigo and dizziness are common manifestations of many ear disorders. Dizziness is a disturbed sense of a person's relationship to space. True vertigo is a real sense of whirling or turning in space. The visual system, the vestibular system (cochlea, semicircular canals), and the proprioceptive system (muscles and nerve endings) combine to give input to the brain about balance. Problems in any of these areas lead to a disturbed sense of balance and motion. Problems that cause vertigo include Ménière's disease, labyrinthitis, acoustic neuromas, motion sickness, and drug or alcohol ingestion. Manifestations of vertigo include nausea, vomiting, falling, nystagmus, hearing loss, and tinnitus. Until the cause of the vertigo can be identified, each manifestation is treated.
The results of a client's lumbar puncture indicate that the client's protein level is 150 mg/dL. The nurse suspects that the client may have which condition? A. Guillain-Barré syndrome B. Meningismus C. Paraventricular tumor D. Viral infection
Viral infection
The nurse has received report on a group of clients. Which client requires the nurse's attention first? A. Adult who is lethargic after a generalized tonic-clonic seizure B. Young adult who has experienced four tonic-clonic seizures within the past 30 minutes C. Middle-aged adult with absence seizures who is staring at a wall and does not respond to questions D. Older adult with a seizure disorder who has a temperature of 101.9° F (38.8° C)
Young adult who has experienced four tonic-clonic seizures within the past 30 minutes
The nurse understands that which client diagnosed with neurologic injury is typically at highest risk for depression? A. Young man with a spinal cord injury B. Young woman with a spinal cord injury C. Older man with a mild stroke D. Older woman with a mild stroke
Young man with a spinal cord injury
The client reports "something scratching on the inside of my eyelid." Before examining the eyelid, what does the nurse do first? A. Administers a Snellen test B. Obtains an informed consent C. Washes hands D. Wears sterile gloves
Washes hands
The nurse manager at a long-term care facility is planning care for a client who is receiving radiation therapy for laryngeal cancer. Which of these tasks will be best to delegate to a nursing assistant? A. Administering throat-numbing lozenges B. Assessing the mouth for inflammation and infection C. Teaching about skin care while receiving radiation D. Washing the skin with soap and water
Washing the skin with soap and water
When preparing to examine an ear with drainage, what does the nurse do first? A. Begins testing at 1000 Hz B. Reassures the client that the ear drainage is normal C. Tilts the client's head away slightly D. Wears clean gloves
Wears clean gloves
Which of these client assessment findings warrants further investigation by the nurse in the ophthalmology clinic? A. Snellen eye examination result is 20/50 for the client who normally wears corrective lenses but does not have them at the time of the examination. B. When six cardinal positions of gaze of the left eye are assessed, the client exhibits nystagmus when looking to the left lower and upper fields. C. The pupil exhibits miosis when exposed to light from the ophthalmoscope during examination and mydriasis when the light is removed from the pupil. D. When assessing the cornea, the nurse notes cloudiness and the client reports pain when the ophthalmoscope light shines into the pupil.
When assessing the cornea, the nurse notes cloudiness and the client reports pain when the ophthalmoscope light shines into the pupil.
At what rate do you humidify the oxygen delivery system?
When the prescribed oxygen flow rate is higher than 4 L/min, humidify the delivery system. For the patient to receive properly humidified oxygen, the humidifier or nebulizer must have a sufficient amount of sterile water and the flow rate must be adequate.
intraocular pressure or IOP
When the vitreous humor & aqueous humor is present in set amounts that apply pressure inside the eye to keep it inflated
Decrotication
abnormal posturing seen in the patient with lesions that interrupt the CORTICOSPINAL PATHWAYS. The patient's arms, wrists, and fingers are flexed with internal rotation and plantar flexion of the legs.
The client is in the immediate postoperative period after tympanoplasty. How does the nurse position the client? A. On the affected side B. Supine, with eyes toward the ceiling C. With the head elevated 60 degrees D. With the affected ear facing up
With the affected ear facing up
The client is having a stapedectomy. Which form of postoperative communication is most effective for the nurse to use? A. Gesturing B. Sign language C. Speaking D. Writing
Writing
What is the first indication that central neuro function has declined?
a change in the LOC (responsiveness and mental status)
neurotransmitter
a chemical that is released by a neuron for the purpose of carrying information across the gaps (synapses) between neurons; Each neuron produces a specific substance, or chemical (e.g., acetylcholine or serotonin), that can either enhance or inhibit the impulse but cannot do both.
lens
a circular, conves structure that lies behind the iris & in front of the viteous body. bends light entering through pupil
vitreous body
a clear, thick gel that fills the vitreous chamber
optic disc
a creamy pink to white depressed area in the retina where the optic nerve enters and exits the eyeball.
corneal ulceration
a deeper disruption of the corneal epithelium extending into the stromal layer
Glaucoma
a group of ocular diseases resulting in increased IOP...
Upper airway obstruction is
a life threatening emergency in which airflow is interrupted through the nose, mouth,pharynx or larynx.
corneal abrasion
a scrape or scratch of the cornea that disrupts the integrity of this structure
Myelin sheath
a white, lipid covering of the axons (the "tail" of a neuron);
Decerebration
abnormal posturing and rigidity characterized by extension of the arms and legs, pronation of the arms, plantar flexion, and opisthotonos (body spasm in which body is bowed forward). Decerebration is usually associated with dysfunction in the BRAINSTEM area.
Surgical intervention of pts. with S.A.
adenoidectomy , uvalectomy .or remodeling of entire oropharnyx (uvulopalatopharyngoplasty UPP ),
keratoconjunctivitis sicca
aka... dry-eye syndrome, results from changes in tear composition, lacrimal gland malfunction, or altered tear distribution
Ophthalmoscopy
allows viewing of eyes external and interior structures with an instrument called an ophthalmoscope - examine fundus, optic disc, optic vessel, and macula. As you guide the ophthalmoscope at the pupil, a red glare (red reflex) should be seen in the pupil as a reflection of the light on the retina.
hordeolum (stye)
an infection of the sweat glands in the eyelid at the place where the eyelashes exit from the eyelid... can be internal or external.
conjunctivitis
an inflammation of infection of the conjunctiva.
chalazion
an inflammation of the sebaceous gland in the eyelid... begins with redness & tenderness (similar to the hordeolum.
arcus senilis
an opaque, bluish white ring within the outer edge of the cornea, caused by fat deposits
Cricothyroidectomy
an opening is made between the thyroid and cricoid cartiliage and results in a tracheostomy. used in an emergency for access to the lower airways.
Tracheotomy
an opperation cutting into the trachea or breathing tube. In emergency can be performed in under 2 minutes.
Vocal cord Nodules
are enlarged fibrous tissue caused by infectious process of overuse of the voice. affects people who speak loudly.
"battle sign "
area behind ears in mastoid area are extensively bruises.
Assessing ATTENTION
ask the patient to repeat a series of three numbers, such as 4, 7, and 3. The series is increased by one number with each successful repetition until seven or eight digits are achieved. If the patient has difficulty at any level (cannot repeat the series), repeat the numbers. If the patient cannot repeat, stop the procedure. Next, ask the patient to repeat the numbers backward, starting again with three digits and increasing by one each time. Normally, a person should be able to repeat five to eight digits forward and four to six backward. Education, occupation, interest, culture, anxiety, and depression affect mental status, and what is considered "normal" may not be so for a particular patient.
The pt with open vocal paralysis is at risk for
aspiration because the airway may not close during swallowing .
Extraocular muscle function
assessed using the corneal light reflex and the 6 cardinal positions - tests eye smoothness and movement, and cranial nerves.
Auditory brainstem-evoked response (ABR)
assesses hearing in patients who are unable to indicate or are unreliable in indicating their recognition of sound stimuli during standard hearing tests, which require cognition.
APAP
auto titrating positive air way pressure machine adjusts continually resetting pressure throughout breathing cycle to meet pts needs.
Alert
awake and responsive
proprioreception
awareness of position of movements of body parts
deep tendon reflexes (DTRs)
biceps, triceps, brachioradialis, and quadriceps muscles and of the Achilles tendon can be tested as part of the routine neurologic assessment. Striking the tendon with the reflex hammer should cause contraction of the muscle.
sleep apnea increases
blood co2, and decreases ph,
Head and neck cancer can disrupt
breathing, eating , facial appearance , self image, speech, and communication.
myoclonic seizure
brief jerking or stiffening of the extremities that may occur singly or in groups, lasting for just a few seconds
absence seizure
brief periods of loss of consciousness and blank staring as though the person is daydreaming, the person's eyes may flutter
Testing for recent memory
can be tested during history and checked on med records. EX. Appts, time of admin, transportation to hosp.
Ergotamine Preparations
causes vasocontriction; sometimes combines with caffeine; should not be used concurrently with several other meds; taken when headache begins and need to follow directions for additional dosages during same headache
Health care personnel must take great care not to make these injuries worse by
causing movement in cervical spine injuries by establishing an airway using the jaw thrust maneuver.
key features is patient's with meningitis
change in LOC, disorientated to person, place, time, abnormal eye movements, shortened attention span, behavior/personality changes, severe headaches, generalized muscle aches, fever and chills, nausea, vomiting, tachycardia, red macular rash
Esophagus injury may occur with neck trauma assess for
chest pain, tenderness, oral bleeding, crepitus ( crackling sounds when palpating the skin),
aqueous humor
clear watery fluid that fills the anterior and posterior chambers of the eyee.
consensual response
constriction of the left pupil when the light is shined at the right pupil
CPAP
continuous positive airway pressure
Reticular activating system (RAS)
controls awareness and alertness. For example, this tissue awakens a person from sleep when presented with a stimulus like loud noise, when there is pain, or when it is time to awaken.
SPINAL CORD
controls body movement (mobility); regulates organ function; processes sensory information from the extremities, trunk, and many internal organs (sensation); and transmits information to and from the brain. It contains H-shaped gray matter (neuron cell bodies) that is surrounded by white matter (myelinated axons). The white matter is divided into posterior, lateral, and anterior columns. Groups of cells in the white matter (ascending and descending tracts) have been fairly well identified.
Central Nervous System (CNS)
controls mobility, sensation, and cognition
surgery for laryngeal cancer include
cord stripping , removal of vocal cord( cordectomy) partial laryngectomy and or total laryngectomy .
Keratoplasty
corneal transplant
PERRLA
cranial nerve 3; To test for pupil constriction, ask the patient to close his or her eyes. Bring a penlight in from the side of the patient's head, and shine the light in the eye being tested as soon as the patient opens his or her eyes. The pupil being tested should constrict (direct response). The other pupil should also constrict slightly (consensual response). To test accommodation, ask the patient to focus on a distant object and then immediately look at an object 4 to 5 inches from the nose. The eyes should converge, and the pupils should constrict.
touch discrimination
for testing, the patient closes his or her eyes. The practitioner touches him or her with a finger and asks that he or she point to the area touched. This procedure is repeated on each extremity at random rather than at sequential points. Next, the practitioner touches the patient on each side of the body on corresponding sites at the same time. The patient should be able to point to both sites.
COGNITIVE changes in older adults
functions of perceiving, registering, storing, and using information often change as a normal part of aging. Therefore it is important to differentiate between these expected findings and those of dementia, depression, and delirium (3Ds). Failure to correctly diagnosis pathologic cognitive problems may lead to a poor patient outcome.
aura phase
generally involves visual changes, flashing lights, or diplopia (double vision)
External otitis
is a painful condition caused when irritating or infective agents come into contact with the skin of the external ear. The result is either an allergic response or inflammation with or without infection. Affected skin becomes red, swollen, and tender to touch or movement. Swelling of the ear canal can lead to temporary hearing loss due to obstruction. Occurs more often in hot, humid environments, especially in the summer, and is known as swimmer's ear because it occurs most often in people involved in water sports.
Subdural space
is located between the dura mater and the middle layer, the arachnoid.
seborrhea
greasy, itchy scaling (occurs on the eyebrows and eyelids in Blepharitis)
Magnetic Resonance Imaging (MRI)
has replaced CT in many settings for looking at the orbits and the optic nerves... also evaluates ocular tumors
Pandemic
having the potential to spread globally
clinical manifestations of encephalitis
high fever, changes in mental status, motor dysfunction, focal neurological deficits, phototopias, fatigue, symptoms of increasing ICP
Subarachnoid space
is situated between the arachnoid and pia mater, where CSF circulates.
Thalamus
is the major "relay station," or "central switchboard," for the CNS.
emmetropia
is the perfect refraction of the eye
Glasgow Coma Scale (GCS)
is used to help describe the patient's level of consciousness (LOC); establishes baseline data in each of these areas: eye opening, motor response, and verbal response. The patient is assessed and assigned a numerical score for each of these areas. A score of 15 represents normal neurologic functioning. A score of 7 represents a comatose state. Thus the lower the score, the lower the patient's LOC. For patients who are intubated and cannot talk, record their score with a "t" after the number. The best possible score for this patient would be 11t.
Radioisotope scanning
is used to locate tumors and lesions.
encephalitis
inflammation of brain tissue and often the surrounding meninges, affectin gthe cerebrum, brainstem, and cerebellum
Blepharitis
inflammation of the eyelid edges...occurs most often in older adult & those with dry-eye syndrome
meningitis
inflammation of the meninges that surround the brain and spinal cord
Autonomic nervous system (ANS)
innervates many body systems to make them function; ex. the sacral spinal nerves stimulate the detrusor muscle to contract when the urinary bladder is full; is considered "thoracolumbar" b/c of its anatomic location.
management of cord polyps and nodules
instruct pt about tabacco use hazards, smoking cessation and voice rest.
Nystagmus
involuntary and rapid twitching of the eyeball, is a normal finding for the far lateral gaze
nystagmus
involuntary eye movements
refraction
involves bending light rays from the outside world into the eye.
Audioscopy testing
involves the use of a handheld device to generate tones of varying intensities to test hearing.
entropion
inward turning of the eyelid will end up causing the lashes to rub against the eye.
Reflex arc
is a closed circuit of spinal and peripheral nerves and therefore requires no control by the brain.
fovea centralis
it is at the center of the macula & where vision is most acute.
Wernicke's area
language area located in the temporal lobe allows processing of words into coherent thought and understanding of written or spoken words
tonic-clonic seizure
lasts 2-5 minutes beginning with a tonic phase that causes stiffening or rigidity of the muscles, and immediate loss of consciousness, clonic or rhythmic jerking of all extremities follows
spondee
lists of two-syllable words used in Speech reception threshold testing
Remote memory
long term memory; can be tested by asking patients about their birth date, schools attended, the city of birth, or anything from the past that can be verified. Nurses often ask the maiden name of the patient's mother, which is sometimes listed on the admission form and can be checked.
Testing for remote memory- long term
long term- ask about birthday, schools attended, city of birth, anything in the past you can verify.
Hypoactive reflexes may result from
lower motor neuron disease (damage to the spinal cord), disease of the neuromuscular junction, muscle disease, or health problems such as diabetes mellitus, hypothyroidism, or hypokalemia.
slit-lamp examination
magnifies the anterior eye structures, - helps to locate any abnormality in the cornea, lens, or anterior vitreous humor.
Nursing intervention for encephalitis
maintain a patent airway to prevent the development of atelectasis or pneumonia which can lead to further brain hypoxia
Nose and sinus cancer post op care
maintain patent airway, monitor hemorrhage , provide wound care asses nutritional status, perform trach care. perform careful mouth care use water pik or sonicare or saline irrigation.
electrolarynges
maybe used for pt who cannot attain esophageal speech, vibrates air inside mouth and throat to produce robot-like sound for speech.
Bacterial meningitis
medical emergency with mortality rate of 25%, occurs in areas of high population density in fall or winter, causes formation of exudate
Who gets depressed more often in response to having had a stroke? men or women
men
cluster headache
most common chronic short-duration headache with pain lasting less than 4 hours
Fungal meningitis
most common in AIDS patients.
tension headaches
most common type of chronic long-duration headache with pain lastine more than 4 hours
Viral meningitis
most common type, results from measles, mumps, herpes simplex, and herpes zoster, and other viral infections. No organisms are obtained in the CSF, clinical manifestations include: fever, phototopia, headache, myalgias, nausea
Immediate memory
new memory; is tested by giving the patient two or three unrelated words, such as "apple," "street," and "chair," and asking him or her to repeat the words to make sure they were heard. After about 5 minutes, while continuing with the examination, ask the patient to repeat the words. An alternative to this method is to give a three-step command and observe whether it is carried out correctly. For example, "Pick up the paper, fold it in half, and draw a square on it."
Treatment of cord polyps and nodules
not speaking, especially not whispering, avoid heavy lifting, stool softeners used to avoid bearing down during elimination which could cause glottis to close, humidify air.
Smoking history cigarette pack years is
number of packs smoked per day times number of years pt has smoked.
Factors in sleep apnea
obesity, large uvula, short neck, smoking , enlarged tonsils or adenoids, oropharyngeal edema. men more affected than women. risk increases with age.
unclassified/idiopathic seizure
occur for no reason and do not fit into general classifications
Perennial rhinitis
occurs either intermittently with no seasonal pattern or continuously whenever the person is exposed to an offending allergen such as dust, animal dander, wool, or foods
Contralateral
opposite side of the body
What is the nerve of sight?
optic nerve (CN II)
Ascending tracts
originate in the spinal cord and end in the brain.
priority for care of patient having migraines is...
pain management
Warning signs of head and neck cancer
pain, lump in mouth throat or neck, difficulty swallowing, color changes in the mouth or tongue to red white gray dark brown or black, oral lesions or sores that do not heal in 2 weeks,persistent unexplained oral bleeding, numbness in mouth lips or face, change in denture fit, burning sensation when drinking citrus juice or hot liquids , persistent unilateral ear pain, hoarseness or change in voice quality, persistent or recurrent sore throat, S.O.B., anorexia or weight loss.
atonic (akinetic) seizure
patient has a sudden loss of muscle tone, lasting for seconds, followed by postictal (after the seizure) confusion. in most cases, these seizures cause the patient to fall, which may result in injury.
prodrome phase
patient has specific symptoms such as food cravings or mood changes
manifestations of nose and sinus cancer
persistant obstruction, drainage, bloody discharge, pain that does not improve with after treatment of sinusitis. Local lymph node enlargement on side with tumor mass.
Hypothalamus
plays a major role in autonomic nervous system control (controlling temperature and other functions) and intellectual function (cognition).
Methods to stop posterior nose bleed
posterior packing epitaxis cath (nasal pressure tubes ) gel tampon.
photophobia
sensitivity to light
Electroretinography
process of graphing the retina's response to light simulation. Helpful detecting and evaluating blood vessel changes from disease or drugs.
Mixed conductive-sensorineural hearing loss
profound hearing loss resulting from both conductive and sensorineural hearing loss.
exophthalmos proptosis
protrusion of the eye
Neurolglial cells
provide protection, structure, and nutrition for the neurons. They are classified into four types: astroglial cells, ependymal cells, oligodendrocytes, and microglial cells. These cells are also part of the blood-brain barrier and help regulate cerebrospinal fluid (CSF).
Sleep apnea assessment
pt unaware they have it, suspected for person that wakes up tired particularly if they snore heavily. causes irritability personality changes
miosis
pupillary constriction
mydriasis
pupillary dilation
simple partial seizure
remains conscious throughout the episode. patient often reports an aura before seizure. patient may have one-sided movement of an extremity, change in heart rate, skin flushing, and epigastric discomfort
Dermatomes
represent sensory input from spinal nerves to specific areas of the skin. For example, the patient with an injury to cervical spinal nerves C6 and C7 has sensory changes in the thumb, index finger, middle finger, middle of the palm, and back of the hand.
Sensorineural hearing loss
results from a defect in the cochlea, the eighth cranial nerve, or the brain itself.
Conductive hearing loss,
results from physical obstruction of sound wave transmission such as a foreign body in the external canal, a retracted or bulging tympanic membrane, or fused bony ossicles.
BoneSource
shaping plates used during surgery to repair facial fractures. They hold bone fragments together until new bone growth occurs. The plates may remain in place, or may be removed.
Ipsilateral
situated on the same side
manifestations of pt with airway obstruction
stridor, s.o.b., dyspnea, anxiety, restlessness, hypoxia, hypercarbia ( elevated blood co2),decreased o2 sat,cyanosis , LOC.
Drugs for seizures
tegertol, phenytoin, klonipin, depakote, neutrotin, topamax, kepra
spinal fluid through ears and nose indicates
temporal bone or basilar skull fracture
Aphonia
temporary voice loss
Gonioscopy
test performed when a high IOP is found and determines whether open angle glaucoma is present.
Larynx
the "voice box"; located above the trachea
convergence
the ability to turn both eyes inward toward the nose to ensure only a single image of close objects is seen
cornea
the clear layer that forms the external coat on the front of the eye
What is the "blind spot" & why is it called that?
the optic disc is called this because it contains only nerve fibers & no photoreceptors
ectropion
the outward turning & sagging of the eyelid, which often occurs with aging.
canthus
the place where the two eyelids meet at the corner of the eye.
accommodation
the process of maintaining a clear visual image when the gaze is shifted from a distant to a near object
red reflex
the red glare that occurs when you direct the ophthalmoscope at the pupil
vitreous chamber
the space between the lens and the retina... this gel transmits light & maintains eye shape.
Primary open-angle glaucoma (POAG)
the structures involved in circulation & reabsorption of the aqueous humor undergo direct pathologic change.
Clonus
the sudden, brief, jerking contraction of a muscle or muscle group often seen in seizures.
Two most important risk factors in neck and head cancer
tobacco and alcohol use especially in combination.
priority action to establish air way
tracheotomy , cricothyroidotomy ( opening between thyroid cartilage and cricoid cartilage)
Endotracheal intubation
tube is placed through the mouth to the trachea to establish an airway
Semicircular Canals
tubes made of cartilage and contain fluid and hair cells (helps maintain balance).
epilepsy
two or more seizure experienced by a person, it is a chronic disorderin which repeated unprovoked seizure activity occurs
Comatose
unconscious and cannot be aroused
typical migraine symptoms
unilateral, fronto-temporal, throbbing pain in head often is worse behing one eye or ear. accompanies by sensitive scalp, anorexia, photophobia, phonophobia, and nausea with or without vomiting.
Non surgical measures for Sleep apnea
use of positive pressure ventilation nasal mask or full face mask. weight loss, portion fixing fixing devices that prevent subluxation of the tongue and neck structures.
Ultrasonography
used to examine the orbit and eye with high-frequency sound waves. Noninvasive test, aids in diagnosis of trauma, intraorbital tumors, proptosis, and choroidal or retinal detachment.
Romberg sign
used to test equilibrium; ask the patient to stand with arms at the sides, feet and knees close together, and eyes open. Check for swaying, and then ask him or her to close his or her eyes and maintain position. The examiner should be close enough to prevent falling if the patient cannot stay erect. If he or she sways with the eyes closed but not when the eyes are open (the _____ _____), the problem is probably proprioceptive (awareness of body position). If the patient sways with the eyes both open and closed, the neurologic disturbance is probably cerebellar in origin.
cutaneous (superficial) reflexes (+ other terms associated)
usually tested are the plantar reflexes and sometimes the abdominal reflexes. The plantar reflex is tested with a pointed (but not sharp) object, such as the handle end of the reflex hammer or the rounded end of bandage scissors. The normal response is plantar flexion of all toes. Dorsiflexion of the great toe and fanning of the other toes (Babinski's sign) is abnormal in anyone older than 2 years and represents the presence of central nervous system (CNS) disease. The term "positive Babinski's sign" (abnormal response) and "negative Babinski's sign" (normal response) are clinically used terms but are not correct. Babinski's sign is a pathologic, or abnormal, reflex. Health care providers may also use the terms "upgoing" or "downgoing" to refer to the toes of the stimulated foot. "Upgoing" toes is an abnormal response that indicates the presence of pathology in the CNS. Babinski's sign can occur with drug and alcohol intoxication, after a seizure, or in patients with multiple sclerosis or liver disease.
patho of encephalitis
virus infades brain tissue via bloodstream. inflammation extends over cerebral cortex causing degeneration of neurons of the cortex. demyelination of axons occurs, this leads to hemmorhage, edema, necrosis, and development of cavities in cerebral hemispheres
What drug should not be taken with phenytoin?
warfarin
signs and symptoms of ICP
widened pulse pressure, bradycardia, and irregular respirations
fixed occlusion
wiring the jaws together in the mouth closed position time 6 to 10 weeks anti biotic therapy recommend to prevent oral wound contamination. delay of treatment or poor oral care may cause mandibular infection.
How is color vision tested?
with the Ishihara chart
