EXAM 1 NURS 1200

to consume enough vitamin a to support proper wound healing the nurse should recommend

1600 to 2000 retinol equivalents per day

which item would be required for a wound irrigation delivery system

19 gauge angiocatheter

a nurse explains the steps for adminstering a squeeze and breathe metered dose inhaler with out. a spacer to a patient the steps are in this order

1st administer the squeeze and breathe mdi canister into the holder 2nd remove the mouth piece cover from the inhaler 3rdly shake the inhaler vigorously 5 to 6 times 4th have the patient sit up take a deep breathe and exhale 5th tilt head back slightly and inhale slowly and deeply through mouth 6th remove mdi from mouth and exhale through pursed lips

how many words would the nurse ask the patient to recall when using the mini cog instrument to test the cognitive ability of a patient

3

if a patient has fair muscle strength and the muscles are at 50% normal condition which grade of muscle strength would the nurse assign

3

which nursing skill is involved in assessing a patients status after administering an intravenous med

evalution

which time frame will the nurse use for med administration if a patients prescription reads cefuroxime 1 gm intravenously TID

every 8 hours

lordosis is the

exaggeration of the anterior convex curve of the lumbar spine

gordens model is an

example of a structured database format

which assessment findng would reflect a keloid formation at the site of a previous surgery

excess scar tissue

which description is true regarding the disadvantage of med administration through the intraocular disk

expensive

after assessing the physician gives the nursing student a verbal order for a new med which action would the nursing student take first

explain to the physician that the prescription should be given to a rn

probing, leading and closed ended questions are used to

explore the history of the patinet after the assessment has started

which action by the nurse may lead to musculoskeletal injury when positioning a patient who had a syncope episode while walking

extending both legs of the patient to let them slide against the floor

the nurse is assessing a patient who reports joint pain which type of rom assessed by the nurse involves sagittal plane movement

extension dorsiflexion

Secondary intention healing

extensive tissue loss edges cant be closed repair time longer scarring greater susceptibility to infection greater

a trochanter roll prevents

external rotation of the hips when a patient is in the supine position

depression is manifested by

extreme sadness

odd is a mental health disorder seen in children who are

extremely irritable tend to lose their temper argue with adults disobey set of rules

which pain assessment tool is appropriate for a 2 yr old patient

face, legs, activity , cry and sonsolability scale

which pain assessment tool would the nurse use to evaluate the intensity of pain in a 6 yr old patient

faces pain scale

expression of feelings is a

factor related to situational context

full range of motion with gravity indicates

fair muscle strength and 50% normal condition which is considered grade 3 muscle strength

in developing a client plan of care the lpn can revise the plan if the client is not meeting expected goals

false

higher blood flow to the site

favors faster absorption of drugs

health care agencies establish individual policies to meet

federal, state and local regulations

which element of the communication process is the patient displaying when frequently nodding and saying i see as the nurse explains the steps of a dressing change

feedback

which nursing intervention would the nurse accurately measure the respiratory rate in an obese patient

feel the breaths by placing a hand on the patients abdomen

lanugo is

fine, downy hair that is present in the newborn for the first few months after birth

which part of the hand would the nurse use to assess the skin texture, swelling and the presence of lumps during palpation

fingertips

delusions are

firm, irrational and fixed false belief that occur despite real perceptions

German Measles (Rubella)

first appears on the face then spreads

athletes foot causes

fissures btwn the toes and sides of feet and soles

fibrous joints are

fixed joints the permit very little movement

a macule is a

flat circumscribed primary lesion of less than 1 cm in diameter

which primary muscle is used for the abduction of the wrist joint

flexor carpi radialis extensor carpi radialis brevis extensor carpi radialis longus

rapid skipping from 1 topic to another when the topics have recognizable associations is known as

flight of ideas

the thought process disorder in which the patient suddenly skips from one topic to another with recognizable associations to previous topics is known as

flight of ideas

which shirt term illness would explain a patients weight loss

flu

while carring for a patient with enteral feeding which precautionary measure taken by the nursing student indicates a need for correction

flushing tubes with at least 10 mL of water before and after giving one or more meds

Nursing Assessment

focus on the patient's response to health problems

according to maslows heirarchy of needs basic physical needs must be met first such as

food air and water

volume controlled infusions allow

for administration of meds that are stable for a limited time in solution

a propellant is used

for effective dispersion of the drug in the canister

transdermal routes are used

for prolonged systemic effects with limited side effects buy may not provide rapid relief

shaking an insulin vial can

form bubbles that can interefere with correct dosage

tinea corporis

form multiple circular lesions with clear centers on the abdomen chest and back of arms

a capsule is a

form of med that is encased in a gelatin shell this med is meant to be swallowed whole

which info regarding synovial joints would be correct

freely movable and lined with synovial membranes

synovial joints are

freely movable joints

eversion and inversion occur in the

frontal plane

abduction is a

frontal plane movement

which alteration in mental status would the nurse assess for in an older adult patient who has age related hearing loss

frustration social isolation suspicion

stage 4 pressure injury

full thickness tissue loss exposing bone tendon muscle

keratin has no

function un skin pigmentation

which exam visualizes neurochemical changes in the brain caused by nociception

functional magnetic resonance imaging

which observation would be considered correct when assessing the mobility of a patient walking across the room

gait

a patient should be adminstered o2 at a rate of 2 l/min via nasal cannula if the patient has impaired

gas exchange related to decreased cardiac output

which fluids if exposed to the skin pose the highest risk of skin breakdown

gastric secretions

which items would be required for wound irrigation

gauze dressing supplies

hydrogel dressings are

gauze or sheet dressings impregnated with water or glycerin based amorphous gells

the patient with class 2 obesity

generally has a bmi of 35-39

which assessment tool would the nurse use to assess the level of consciousness of an older adult with confusion

glasgow coma

which piece of equipment measures the rom of a shoulder joint

goniometer

the wider the base of the support the

greater the stability of the nurse

the lower the center of gravity the

greater the stanility of the nurse

which skin finding in a newborn would alert the nirse to fetal distress

greenish brown discoloration of the nails and cord

when a patient diagnosed with onychomycosis presents with nail clubbing and loosening of the nail plate for which additional finding would the nurse assess

greenish discoloration around the nail plate

based on the medical record of a patient diagnosed with gigantism which laboratory value would the nurse reviewq

growth hormone

which abnormal mental health finding would the patient be experiencing when they tell the nurse i often heat my dead grandfathers voice

hallucinations

which condition would involve the distal part of the great toe being directed away from the bodys midline

hallux valgus

intrapersonal communication

happens within the person

tympanic percussion note

has a loud intensity, high pitch and a drumlike musical quality

intramuscular and intravenous routes

have higher absorption rates

meds placed under the tounge

have quick absorption

patients with trigeminal neuralgia

have severe stabbing or piercing pain in the facial area

which nursing action is appropriate when the nurse only administers a partial dose of a narcotic

having a second nurse sign for the waste in the patients record disposing of the unused part of the narcotic in the presence of another nurse

to determine if a child has increased intracranial pressure which assessment would the nurse perform on a 7 month old infant who sustained a fall

head circumference

agility training may

help prevent falls

a wood light

helps to find scalp infections

intramuscular injections are preferred for meds such as

hep b, tetanus, diphtheria and pertussis immunizations

which condition would the nurse expect in a patient who after sustaining a fall reports severe back pain that shoots down to the legs and who is unable to perform hip flexion or extension during an assessment

herniated lumbar disc

a patient is lying supine with the leg relaxed the nurse slowly raises the foot keeping the knee straight until the patient complains of pain and then dorsiflexes the foot the nurse would be assessing for which condition

herniated nucleus pulposus

thigh bp is

higher than that of the arm

cell membrane has a lipid layer

highly lipid soluble meds cross cell membranes easily and are absorbed quickly

which activity is least appropriate for an older adult patients exercise program

hiit training

the presence of excessive hair growth on a females chest and face indicates

hirsutism

which neurotransmitter is released at the site of injury

histamine bradykinin prostaglandin

probing explores the

history of the patient without controlling the direction of the story and is meant to bring out as much info as the patient can give

while assessing a patient the nurse observes raised irregularly shaped skin eruptions with red margins which mild reaction does the nurse document in the medical record

hives or urticaria

Insulin syringe

hold 0.3 mL to 1 mL

a patient using a breath activated metered dose inhaler which action made by the patient ensures full med distribution

holding the breath for 5 to 10 seconds during inhalation

the 3 point technique involves

holding the thumb at the mouthpiece with the index and middle fingers at the top

the primary function of the pituitary gland is

hormone secretion and doesnt help thermoregulation

which type of dressing is provided to the patient that developed a deep pressure injury that has the presence of exudates

hydrogel

which dressing would the nurse use to protect and absorb moisture when providing care to a patient with a pressure injury

hydrogel covered with foam

which contributing factor of delirium would the nurse check for while collecting the medical history on a patient who has delirium

hypoglycemia hypotension head injury

excessive sweating in infants is associated with

hypoglycemia heart disease hyperthyroidism

which organ would be considered the thermostat of the human bosy

hypothalamus

which assessment finding indicates atelectasis that may result from immobility

hypoventilation

the registered nurse is teaching a nursing student about home care considerations to prevent the risk of pressure injuries which statment by the nursing student indicates effective learning

i should educate the patient about the signs of wound infection i should dicuss reactive surfaces that may increase pressure to the wound

which statement made by the nursing student indicates effective learning regarding methods to prevent aspiration

i will instruct the patient to hold and drink from a cup if possible i will crush and mix some meds with pureed foods for easy administration i will assess a patient for signs of dysphagia before administering meds

stretching is

ideal for enhancing circulation

thigh pressure should

ideally be measured in adolescents or young adults

pain originating from the musculoskeletal tissues or the body surface is

identified as somatic pain

which adverse effect involves overreaction or underreaction to a med effect (unpredictable)

idiosyncratic reaction

when preparing to measure a patients waist circumference which landmark would the nurse use when placing the measuring tape

iliac crest

the bones comprising nonsynovial joints are

immovable

protein quickens fibroplasia and acts as

immune function

t lymphocytes are cells that play an

important role in immunity

hirsutism is caused by

improper functioning of the endocrine glands or metabolic dysfunction

the effect of exercise on the musculoskeletal system includes

improved muscle tolerance to physical exercise

the effect of exercise on the cardiovascular system includes

improved mycardial contraction which strengthens the cardiac muscle

the human body absorbs meds

in a liquid state more readily than tabs and capsules

skin infection may result

in acute pain because of inflammation and tissure damage

the oral route of administration is contraindicated

in patients with gi disorders and motility

that patient with coronary disease experiences pain

in the neck then that patient indicates referred pain

which additional finding would the nurse monitor for in a child with attention deficit hyperactivity disorder who presents with excessive talking

inability to complete tasks

which nursing sensitive patient outcome is a component of quality health care

incidences of pressure injuries number of falls

isometric contraction causes an

increase in muscle tension or muscle work but no shortening or active movement of the. muscle

hyperemia is the

increased blood flow thorugh engorged arterioles skin changes to red or bright pink

kyphosis is the

increased convexity in the curvature of the thoracic spine which may be caused by rickets osteoprosis or tb of the spine

the reliability of a patients bmi would be afffected by which factors

increased muscular tone loss of muscle mass

the effect of exercise on the pulmonary system is an

increased respiratory rate and depth followed by a quicker return to the resting state

the patient with unilateral weakness may have an

increased risk of aspiration because of impaired swallowing

a patient is advised to be in supported fowler position which trouble area can cause the patients discomfort in this position

increased shearing force on the back and heels unprotected pressure points at the sacrum and heels pressure on the posterior aspects of the knees decreasing circulation to the feet

jaundice after 2 weeks of age may

indicate biliary tract obstruction

serum transferrin levels also

indicate protein status in the body

grade 2 muscle strenght is

indicated by full range of passive motion

daily

indicated that the med should be given every day

prn

indicated that the med should be given whenever it is needed

bmi of 37

indicates class 2 obesity

if thigh pressure is lower than the arm pressure it

indicates coarctation of the aorta

the question what aggravates the pain

indicates provocation/palliation criterion because the nurse is assessing the trigger for the pain

the question do you feel like that pain travels around

indicates the region/radiation criterion because the nurse is assessing radiation of the pain

the question does pain interfere with your activites

indicates the severity scale criterion because the nurse is assessing the severity of the pain

silver impregnated dressings are used for

infected wounds and should be discontinued when wounds are clean

scabies is an

infection caused by mites that cause elevated pruritic burrows on the fingers

objective data

information that is seen, heard, felt, or smelled by an observer; signs

which initial step would the nurse take if lateral violence occurs in the workplace

informing the manager to obtain support

which route of administration mainly uses meds in the form of aerosol sprays

inhalation

which route of drug administration may provide rapid relief to the patient with difficulty breathing

inhalation

which type of med is often described as a rescue or maintenance med

inhalational

maintenance meds are

inhaled and their effects last for long periods of time

gamma aminobuytric acid

inhibits and blocks the pain impulses through descending pathways from the brainstem to the spinal cord and prodcue an analgesic effect

which route is generally preferred for the administration of anesthetic agents during abdominal surgery

inhilation

Tertiary intention healing

initally left open edema, infection or exudare resolves then closed

parenteral administration

injecting a medication into body tissues

intramuscular

injection into a muscle

intravenous

injection into a vein

intradermal

injection into the dermis just under the epidermis

Subcuataneous

injection into tissues just below the dermis of the skin

which outcome is desired when the head of the bed is elevated to 60 degrees in the supported fowler position

inproves ventilation

which assessment technique includes looking at the patient in a well lighted room

inspection

patients using breath actuated metered dose inhalers are

instructed to coordinate the puffs with inhalation for an effective outocme

patients using dry powder inhalers are

instructed to inspire fast enough to administer the entire dose of meds

which action made by the nursing student may cause the patient to experience aspiration

instructing the patient to use straws while taking the liquid med positioning the patient in a relaxed sleeping position during administration

which action performed by the nurse would require correction when obtaining a patients height

instructs the patient to stand facing the wall

loudness or softness of sounds indicates the

intensity or amplitude of the sound

public communication is

interaction with an audience

which form of communication is appropriate to assess understanding and clarify misinterpretations when the nurse is teaching a patient about health concer

interpersonal

which injection is given to a patient receiving a tuberculin screening test

intradermal

which route of administration involves inserting a needle at a 5-15 degree angle from the surface of the skin without puncturing the patients subcuatenous tissue

intradermal

which injection is preferred for allergy skin testing

intradermal injection

which parenteral route of administration uses the z track method

intramuscular route because it will minimize local skin irritation by sealing the med in the the muscle tissue

the needle is inserted at an angle of 90 degrees from the skin surface when the

intramuscular route is used

which route if administration is beneficial in an emergency situation for an infant with poor access to intravascular space

intraossesous

the health care provider prescribed a med to be administered in the subarachnoid space of the patient ( or one of the ventricles of the brain). which route of administration is the health care provider prescribing for the patient

intrathecal

which action will the nurse take when conducting the reconcile phase of the med reconciliation process

investigate any discrepancies after comparing the new med prescription with the current list

buccal route of med administration

involves placing the med agains the mucous membrane of the cheek until the med dissolves

percussion

involves tapping the patients skin with short sharp strokes to assess the underlying structures

suppository for of a med

involves the insertion of pellets of meds in body cavities such as the vagina and rectum

the presence of concave shaped spoon like nails indicates

iron decficiency anemia

delusions are a patients

irrational and fixed false belief

a 35 ml syringe is used for

irrigating an open wound

Which mood and affect abnormality would be observed in a child with oppositional defiant disorder (ODD)?

irritability

a health promotion nursing diagnosis

is a clinical judgment of a person's, family's, or community's motivation, desire, and readiness to increase well-being and actualize human health potential as expressed in their readiness to enhance specific health behaviors such as nutrition and exercise

cheilosis

is a condition in which fissures occur at the corners of the mouth from excess moisture

achondroplastic dwarfism

is a genetic disorder causing a shortened height

the third korotkoff sound

is a knocking sound of longer duration of blood flow through the artery

troche

is a lozenge that is given orally

the visual analogue scale

is a pain assessment tool that helps identify the patients level of pain

aphasia

is a speech disorder in which the patient has difficulty understanding or producing language

the second sound of korotkoff sounds

is a swooshing sound of turbulent blood flow through a still partially occluded artery

loosening of assoications

is a thought process disorder in which the patient shifts from topic to topic while communicating and the topics are unrelated

incident pain

is a type of acute pain caused by certain body movments

malignant pain

is a type of chronic pain

a pulse that is 0

is absent

pain caused by kidney stones

is acute pain

insulin

is administered through intraperitoneal route

the brief pain inventory scale

is an assessment that uses graduated scales from 0-10

blanchable erythema

is an early indication of pressure in pressure ulcers

the modulation phase

is associated with alleviation of the pain stimulus because there is no release of bradykinin and prostaglandins from injured tissues

Cushing's syndrome

is caused by an overproduction of ACTH

which statement is true regarding piggybacks

is connected to a short tubing line the connects upper y port of a primary infusion line or to an intermittent venous access 25-250 mL of fluid

Meatcommunication

is factors that influence communication

auscultation

is listening to the sounds produced by body such as the heart, bvs, lungs and abdomen

a pulse that is 2+

is normal

Chronic nonmalignant pain

is often associated with musculoskeletal conditions such as arthritis and fibromyalgia

which characteristic behavior would the nurse find in a patient who is diagnosed with agoraphobia

is reluctant to leave home

postoperative pain

is somatic damage that causes nociceptive pain

tendinitis

is the inflammation of tendons which causes deep somatic pain

the brainstem

is the posterior part of the brain that regulates heartbeat, breathing and sleeping

liver metastasis

is visceral damage that results in nociceptive pain

a pulse that is 1+

is weak

vernix caseosa

is. a thick cheesy substance made of sebum and epithelial cellss

which characteristic of stage 2 pressure injry is the nurse likely to find during a wound assessment

it has reddish pink wound bed without slough

if the patient has pain resulting from damage to the skin surface

it indicates that the patient has cutaneous pain

if the patient has an injury at a particual site but experiences pain elsewhere

it indicates that the patient is having reffered pain

the nurse would use an adherent film dressing because

it will facilitate softening of the eschar to allow for debridement

which clinical sign or symptom is indicative of pruritus

itching of skin

the nurse has to adminster an alkaline med to a patient which route of med administration is preferred

iv

alkaline and other irritant meds are usually administer through

iv routes because they cause less discomfort

the nurse explains that exercises increases

joint mobility, cardiac output and basal metabolic rate

which nursing intervention would be appropriate for a patient who is at risk of skin break down because of moisture

keep the skin dry and free of maceration

which skin disease would the nurse consider when assessing patients with dark skin

keloids melasma pseudofolliculitis

the basal cell layer of the epidermis is mainlymade of

keratin

serum creatinine levels indicate

kidney function

collateral ligaments connect the

knee joint at both sides and prevents dislocation by giving medial and lateral stability

persistent repetition of words and actions is

knowns as perseveration

which term describes snide remarks or put downs btwn colleagues

lateral violence

which description would best illustrate the tripod position

leans forward with the arms braced on the arms of the chair

in which position would the nurse place the patient to admminister a rectal suppository

left side lying position

thomas test is

leg raising test that involves flexion of the hip joint

which complication would occur when the blood supply to the femoral epiphysis is decreased

legg calve perthes syndrome

duration refers to the

length of time the produced sound

confluent indicates the

lesions have run together

range of motion test would be used to test

limitations

zosteriform is a

linear arrangement along a unilateral nerve route

which topical med contains a soapy emollient

liniment

which topical med contains alcohol

liniment

which therapeutic communication technique would the nurse apply in attending to an agitated patient

listen actively share empathy ask relevant questions

topical routes primarily provide

local effects mainly related to skin problems

oral routes often produce

local or systemic effects but may not provide rapid relief for local respiratory problems as effectively as the inhalational route

hypperresonant

louder booming longer

enoxaparin

low molecular weight heparin that is administered in subcutaneous tissue of the abdomen at least 2 inched away from the umbilicus

which sound is auscultated with the bell of the stethoscope

low pitched

the health care provider advises a patient to dissolve the prescribed drug in his mouth for a long time without swallowing which form of a med is prescribed for this patient

lozenge

which blood cells are known as garbage cells

macrophages because they ingest bacteria, dead cells and debris from wounds

the epidermis or the outer layer is

made of tough fibrous protein called keratin

interview is used

mainly while taking the nursing health history

which action is a principle of proper body mechanics when lifting or carrying objects

maintain a wide base support

muscle tone helps

maintain functional positions such as sitting or standing without excess muscle fatigue

the inner ear helps in

maintaining balance by allowing a person to change positions suddenly without losing balance

oral, buccal and parenteral meds can be

maintenance meds used on a daily schedule they arent typically considered rescue meds as they take longer to absorb

the equilibrium of an object is

maintianed as long as the line of gravity passes through its base of support

examining is the

major method used in the physical health assessment

according to erikson establishing trust is the

major rask of an infant during development

developing a sense of industry is a

major task in a school age child because at this age the child develops basic competency

intraarterial med administration

managed by the nurse who continuously infuses the clot dissolving agent and carefully monitors the integrity of the infusion

a nurse finds that a patient who has urinary incontinence scores 11 on the braden scale which nursing action is most appropriate to prevent from developing pressure injuries

managing moisture

during the mental status exam which finding is expected when the nurse is assessing a patient with parkinsons disease

masklike expressin monotonous speech

stage 1 pressure injury

may be discoloration of skin warmth edema hardness pain

a drug with a slow onset of action

may show a delayed effect

the nurse instructs the patient ro flex the knee joint while performming the

mcmurray test to determine the presence of a torn meniscus

a leading question is

meant to control the direction of the story

an electronic thermometer with a blue tipped probe

measures oral temp

ac indicates

med should be taken before meals

qh indicates

med should be taken every hr

bid indicates

med should be taken twice a day

federal medication laws control

medication sales and distribution

which route causes meds to be absorbed slowly after administration

meds placed on the skin

time critical meds are

meds that should be administered with in 30 minutes before or after the scheduled time

feedback is the

message the receiver returns that indicates understanding

which clinical manisfestation would the nurse expect when assessing a patient diagnosed with achondroplastic dwarfism

midface hyplasia thoracic kyphosis lumbar lordosis

the nurse would develop a care plan focused on which medical condition if a patient scores a 12 on the patient health questionnaire 9

minor depression

insulin glargine should nit be

mixed with any other insulin

which finding from a mental status exam of an adolescent patient is considered normal

moderate pace of convo clear articulation abstract thinking ability

hydrocolloid gauze provides a

moist environment for the wound to heal

which equipment is used to test the loss of protective sensation in a patients foot

monofilament

according to the circular transactional model the referent

motivates one person to communicate with another initiating the communication process

which area would the nurse inspect for the presence of koplik spots in a child with suspected measles

mouth

which instruction would the nurse provide the patient to assess the trigeminal nerve

move the jaw forward and laterally

adduction involves

moving a limb toward the midline of the body

Isometric exercises are activities that involve

muscle contraction without body movement

hydralazine is a

muscle relaxant indicated in emergency conditions

arthritis, fibromyalgia and low back pain are all

musculoskeletal disorders associated with severe nerve and tissue damage which may result in chronic nonmalignant pain

Somatic pain originates from

musculoskeletal tissues or body surface

rapid acting insulin mixed with NPH insulin

must be given 15 mins nefore meals and for max benefit

a cuff size that is too

narrow for the patient yields a false high bp because it takes extra pressure to compress the brachial artery

proprioceptors present in the

nerve endings of muscles joints and tendons monitor proprioception

which type of pain does the nurse document in the medical record for a patient with herpes zoster who reports a pain level 10/10

neuropathic

which type of pain is being experienced by a patient who states i have numbness and tingling and occasionally shooting pain when asked what hteir pain feels like

neuropathic

which landmarks would the nurse use to ensure accuarate chest circumference of a 12 month old infant

nipple line

normal saline is a

noncytotoxic topical fluid that can be used to clean a pressure ulcer

about which condition would the nurse educate a patient wanting a tattoo

nontuberculous mycobacterial infections

cartilage is

nonvascular and it supports ct that sustain weight and serve as a shock absorber btwn articulating bones

cartilage is

nonvasculat supporting ct

muscle tone is the

normal state of balanced muscle tension

bmi of 18.5 to 24.9 indicates

normal weight

pitch or frequency indicates the

number of vibrations per second low or high

during the consider and compare phase

nurse reviews what the patient was taking at home or preadmission and makes sure that the lise of meds, dosages and frequencies is accurate and then compares this list to the current ordered meds and treatment plan

serum prealbumin is the best indicator of

nutritional status not only reflecting what the patient has ingested but also what the body has metabolized

different types of data collection

observing interviewing examining

the nurse flushes the injection port with normal saline to prevent

occulsion of the intravenous access divices

pressure injuries can

occur on the sacrum

acromegaly

occurs because of an overproduction of growth hormone in adulthood

hypopituitary dwarfism

occurs from a growth hormone deficiency in childhood

breakthrough pain

occurs in patients who undergo opioid therapy

which action by the nurse indicates a need for correction regarding med adminstration

offering a snack rich in fats after administering acidic meds you want to offer non fat foods because foods rich in fats delay med absorption

which action describes an independent nursing intervention

offering counseling for coping initiating early mobility protocols instructing patients on side effects of meds positioning patients to prevent pressure injry formation

which nontherapeautic communication technique is the nurse using when saying dont worry youll be fine to a patient

offering false reassurance

which nursing intervention is beneficial while administering a bitter med to a child

offering the child a frozen jucie bar

a gauze dressing is

often used for clean stage 2 or 4 pressure injury

which topical med preparation may involve more than 1 med

ointment

which group of patients is most at risk of severe injuries related to falls

older adults

maintenance meds are used

on a daily basis to prevent acute respiratory distress

precipitating factors are the

ones that worsen the primary symptom

a stuporous or semi comatose patient responds

only to pain or persistent vigorous shaking

the nurse intends to use a med that can give immediate relief to a patient which parameter of the drug would the nurse check to determine whether the drug can provide immediate relief to the patient

onset of action

which type of question is used when starting the assessment of a patient

open ended

nurses uses

open ended questions when beginning the assessment of a patient

which class of drugs if administered to the patient with out a prescription is punishable under the controlled substances act

opioid analgesics

opioids activare

opioid receptors in the spinal cord during the transmission phase to block the signal of pain and inhibt the perception of pain

which route of drug administration is appropriate for patient with hemophilia

oral

which route of drug administration is most economical and convenient

oral

which route of med administration is easiest and most desirable

oral

which parameter is the nurse assessing when the patient is asked about the date and time

orientation

the nurse sets the tome for the relationship by adopting a warm empathetic caring manner during the

orientation phase

which diagnosis in the medical record relates to the older patients report of increase hip pain

osteoarthritis

isotonic exercises promote

osteoblastic activity rather than osteoclastic activity

which question would the nurse ask when using the patient health questionnaire 2

over the past 2 weeks have you felt little intreest or pleasure in doing things

hemoglobin levels indicate the

oxygen carrying capacity of the blood

carpal tunnel syndrome results in

pain burning and numbness it occurs because of the atrophy of the median nerve of the wrist and hand

which action would the nurse perform before initially inflating the cuff during a blood pressure assessment

palpate the brachial artery

which supply would the nurse obtain to administer the mini mental state exam

paper pencil

red tender and swollen nail folds along with inflammation along the base of the nail or where it meets the skin on the sides indicates

paronychia

the cerebellum is the

part of the brain that controls and coordinates all voluntary movements particularly highly skilled movements

stage 2 pressure injury

partial thickness loss of dermis shallow open ulcer with a red pink wound bed without sloguh

receptive aphasia (Wernicke's aphasia)

patient can talk but it is difficult understanding language and receiving language

misinterpretation of an actual existing stimulus indicates that the

patient has illusions

intermittent venous access increases

patient mobility safety and comfort

which patient care goal is a ling term goal for a newly diagnosed medically unstable patient with diabetes

patient will achieve glucose control as demonstrated by decrease in hemoglobin a1c level

6 rights of medication administration

patient, time, dose, route, medication, documentation

heat therapy is used for

patients recovering from rectal surgery or experiencing hemorrhoids and vaginal inflammation

which phase of nociceptive pain signifies the conscious awareness of a painful sensation

perception

implementation involved

performing hand hygiene, putting on gloves, explaining the procedures and administering meds

the sender is the

person who encodes and delivers a message

the receiver is the

person who receives and decodes a message

the patient holds the hands back to back while flexing the wrists during the

phalen test this test helps to determine carpal tunnel syndrome

according to the institute for safe medication practices guidelines who is recommended to us a pill splitting device to split tabs in half

pharmacist

the rate and extent of distribution depends on the

physical and chemical properties of the medication and the physiology of the person taking it

central poststroke pain, carpal tunnel, and complex regional pain syndrome are

physiologic disorders assoicated with neuropathic pain

pain is the

physiologic factor that influences a patients activity tolerance

serosanguineous drainage is

pink

how can the nurse administer meds to a patient with unilateral weakness without causing aspiration

place the med in the stronger side of the mouth

plateau concentration

plasma concentration attained and maintained after repeated fixed doses

while caring for a patient who is receiving a jejunal tube feeding the nursing student administers iron through the tube which outcome is expected

poor bioavailability

the parenteral route of administration aids patients who have

poor peripheral perfusion

which action is correct by the nurse when performing a wound irrigation

positioning the patients wound vertical to the collection basin

which med form is commonly prepared for administration by parenteral routes ( meds put into tissue and circulatory system by injection)

powder and solution

a tablet is a

powdered med compressed into a hard disk and is meant to be swallowed whole

which term describes side effect

predictable often unavoidable occur at the usual therapeutic dose

side effect is

predictable and unavoidable adverse effect that is produced at a usual therapeutic dose

only oral syringes should be used when

preparing meds for the enteral route to prevent accidental parenteral administration

STAT

prescription indicated that the med should be administered immediately

which characteristics is associated with c fibers

presences of diffused sensations

the tibiotalar joint is

present in the ankle and feet it permits extension and flexion of the foot in plane

the radiocarpal joint is

present in the wrist it permits flexion and extension of the wrist

folliculitis barbe

presents with multiple pustules and white heads with hair visible at the center of an erythematous base usually on a males face and neck

seborrheic dermatitis

presents with thick yellow to white greasy scales with mild erythema on an infants scalp

the nurse notes a quarter sized area of blancable erythema over the patients sacral area which factor likely caused this finding

pressure

improperly fitted or applied devices and weight of the body on certain bony prominences can cause

pressure on the adjacent skin and underlying tissue result in ulcer and skin breakdown

the nurse is caring for a patient diagnosed with a spinal cord injury at t7 for which area of care would the nurse seek out a physical therapists for assistance

preventing the development of any postural abnormalities assisting the patient in ambulation prescribing exercise to strengthen trunk musculature

the patient is the

primary source of info

which type of assessment is the nurse performing when using a finger to apply light pressure just above the iv site and asking the patient if any tenderness is felt after noting inflammation at the site

problem focused

the effect of exercise on the matabolic system includes and

production of body heat

what is an advantage of summarizing

promotes recall of previous discussions participants focus on key issues useful in the terminal phases of the patient relationship

which anesthetic drug is contraindicated in patients with an allergy to soy producls

propofol

when assessing a patients mobility which info would the nurse document if the patient has difficulty stopping during ambulation

propulsion

which explanation provided the rationale for using a 19 gauge angiocatheter for irrigating a wound with a wide opening

providing ideal pressure for cleanig

a patiwnt with severe muscle cramp tells the nurse the pain is a little better when i massage the muscle or apply a cold pack which criterion of the pqrst method of pain is addressed in the patients statement

provocation/ palliation

which cognitive function would the nurse be assessing when asking the patient to describe childhood teachers and important dates in life such as an anniversary date

remote memory

debridement is the

removal of nonliving tissue and rids the wound of a source of infections, improves visualization of wound and provides a clean base to promote healing

which statment is true regarding an inhaler containing rescue meds

rescue meds provides immediate relief

inhalation meds are often described as

rescue or maintenance meds

inhaled meds are also often described as

rescue or maintenance meds

which findings would the nurse monitor for in a preschooler with autism spectrum disorder who demonstrates strict adherence to routines

resistance to change poor eye contact repetitive speech

which factor would render older women more susceptible to fractures

resorption and osteoporosis

the cerebrum is

responsible for the regulation of voluntary movements and sensory perception

exercise decreases the

resting heart rate and the return to resting state becomes quicker

inflammation of the mucous membrane lining the nose

rhinitis

which finding would lead the nurse to suspect arthritis

rigid spine and neck moving as one unit when the patient turns

there are 3 types of nursing diagnoses

risk problem focused health promotion

dividing balanced activity btwn the arms and legs reduces the

risk of a back injury

a dysphagia screening tool is used to assess the

risk of aspiration

an older adult who was in a car accident and fractured their femur has been immobilized for 5 days which nursing diagnosis is related to patinet safety when the nurse assists this patient out of bed for the first time

risk of inability to tolerate activity

volume controlled infusions reduce the

risks of rapid dose infusion by iv push

factors the influence absorption

route ability of the med to dissolve blood flow to the site body surface area lipid solubility of the med

intermittent venous access

saline lock iv catheter capped off on the end with a small chamber covered by a rubber diaphragm or a specially designed cap

which body fluid places the patient at the lowest risk of skin breakdown

saliva serosanguineous drainage

which location would the nurse assess to confirm jaundice in dark skinned patient

sclera hard/soft palate junction palms

which skin structure would be altered with dryness of the scalp forehead face and chin

sebaceous glands

family and significant others are

secondary sources of info

inappropriate attention span and impulsiveness are

seen in a patient with attention deficit hyperactivity disorder

which level of consciousness is the patient displaying if they are responding only to touch with persistent and vigorous shaking and they withdraw both hands when pressure is applied to the nail beds

semi coma

receiver provides feed back to the

sender

communication channels are means of

sending and receiving messages through visual auditory and tactile senses

hallucinations refer to

sensory perceptions in the absence of an external stimuli

the bones in a synovial joint are

separated from each other and are enclosed in the synovial cavity with synovial fluid inside

which parameter would be measured to determine the protein deficiency in the patient with a wound

serum albumin serum transferrin serum prealbumin

volume control administration

sets are small (150mL) containers that attach just below the primary infusion bag or bottle

the environment is the

setting for sender receiver interaction

which action will the nurse take during bedside hand off at shift change

share info about the patients condition

rescue meds are

short acting and are taken to immediately relieve acute respiratoey distress

rescue meds

short acting and are taken to immediately relieve acute respiratory distress

rescue meds are

short acting provide immediate relief

non time critical meds

should be administered with in 1 hour of the scheduled time

proton pump inhibtors

should be given on an empty stomach you should wait at least 30 minutes before feeding

oral disintegrating meds

should be placed on the patients tongue and should not be chewed

the glenohumeral joint is present in the

shoulder it permits movement of the arm on many axes

a diabetic patient with peripheral neauropathy

shows symptoms of burning pain in the feet bilaterally which worsens during the night

which instruction would the nurse provide the patient to assess the integrity of of the spianl cord

shrug the shoulders

which clinical manifestation would the nurse expect when performing a general survey on a patient diagnosed with marfan syndrome

tall and thin pectus excavatum hyperextensible joints

percussion is

tapping the patients skin with short sharp strokes which produce a palpable vibration and a characteristic sound that depicts the location, size and density of the underlying organ

which activity does the nurse carry out while maintaining a zone of personal distance

teaching or educating a patinet

which intervention perfomed by the nurse is an independent nursing intervention

teaching the patient about deep breathing exercises assistin the patient in taking a bed bath repositioning a patient for relief from pain

bells palsy involves

temporary paralysis of one side of the face

sticking out the lower jaw checks the proper functioning of the

temporomandibular joint

which structure connects muscle to bone

tendon

the nurse is teaching a group of nursing students about tendons which statment about tendons is true

tendons are fibrous bands connecting muscles to bone tendons are strong, flexible and inelastic

lateral violence is a

term to describe workplace bullying such as snide remarks or put downs btwn colleagues

which stage of the interview consists of the nurse saying i have just 2 more questions for you when assessing a patient with complaints of chest pain

terminating the interveiw

which phase of the helpong relationship is represented when the nurse recalls a funny shared experience with a patient shortly before the patient is transferred to another unit

termination

attention span

tested by giving a set of instructions to the patient and observing whether the patient and observing whether the patient follows them properly

intestinal pain and severe stomach cramps indicate

that the patient has visceral pain

lower back pain while standing indicates

that the patient is having incident pain

visceral pain results from

the activation of nociceptors of the visceral organs

negative pressure wound therapy is

the application of subatmospheric pressure to a wount through suction to facilitate healing and collect wound fluid

during modulation phase

the body slowly reduces the pain by stopping the processing of a painful stimulus

proprioception is required by

the body to maintain proper posture

touching the chin toward each shoulder and lifting the chin toward the ceiling tests the function of

the cervical spine

obsession referes to

the constant preoccupation with unwanted or intrusive thoughts

congenital hip dislocation refers to

the displacement of the femoral head out of the acetabulum

the rash of measles first appears behind

the ears then spreads over the face then the neck trunk arms and legs

the pure food and drug acts

the first american law to regulate meds

dependent nursing interventions require

the health care providers prescriptions to treat a medical diagnosis

polycythemia is

the increased red blood cell count that results in ruddy blue colored skin

while using a breath actuated inhaler

the inhaler should not be shaken

Scoliosis

the lateral s or c shaped spinal column with vertebral rotation

during perception

the limbic system interprets the noxious stimuli and elicits emotional responses to pain in the patient

a fractured clavicle can occur during birth and may result in

the loss of moro reflex in the affected side and limited arm range of motion and a lump in the clavicle region

trough is

the minimum blood serum concetration of a med reacched just before the next scheduled dose

initial pain assessment

the nurse askes the questions concerning location, intensity and duration pain

mcgill questionnaire

the nurse asks the patient to rank a list of descriptors in terms of their intensity and to give an overall intensity rating of pain

which message does the nurse convey to a patient when sitting at an angle facing the patient

the nurse is interested in what the patient is saying

according to hippa

the nurse should maintain confidentiality about the health info of the patient

in the beginning of an interview or while setting the stage

the nurse uses introductory questions and statements

self confidence is important because

the nurse who conveys confidence and comfort while communicating can more readily establish an interpersonal caring relationship

to assess the correct body position of the patient

the nurse will ask the person to sit comfortably with the arms relaxed at the sides and the head turned toward the nurse

when using the numeric rating scale

the nurse would ask the patient to chose a number to rate the pains intensity

palpation applies

the nurses sense of touch to assess factors such as swelling, vibration or pulsation, rigidity or spasticity, crepitation, the presence of lumps or masses and the presence of thenderness or pain

which statement describes the advantage of administering meds by the oral route

the oral route is easy to adminster the oral route rarely causes anxiety the oral route is convenient and comfortable

during the transduction phase

the pain signals are transmitted from the site of injury to the spinal cord

during the transmission phase

the pain signals move from the spinal cord to the brain

the presence of depressed skin at the site of the surgery indicates

the patient has an atrophic scar caused by the loss of tissue

the presences of tightly packed papules at the site of the surgery indicates

the patient has linchenificaation caused by prolonged or intense scratching

in the perception phase

the patient shoes an emotional response to the pain stimulus

open ended questions encourage

the patient to talk more

for the most accurate bp reading

the patients feet mmust be flat on the floor

arthritis and mechanical back pain are

the physiological disorders associated with nociceptive pain

the melanocytes intercalated along the basal cell layer produce

the pigment melanin which gives brown tones to skin

a positive tinel sign refers to

the presence of tingling or buring in reaction to percussion over the median nerve at the wrist which indicates carpal tunnel syndrome

in the modulation phase

the release of a third set or neurotransmitters from the brain will show analgesic effect

in the transduction phase

the release of neurotransmitters from the injury site to the spinal cord takes place

the skin is

the sentry that guards the body from environmental stresses such as trauma, pathogens and dirt and adapts it to other environment influences

during an assessment the questions focus on

the signs and symptoms of the patient

circumlocution

thought process abnormality in which the patient substitutes a word or phrase such as thing to denote an object

an adequate balance in the body is maintained by the nervous system specifically

through the cerebellum and inner ear

the preinteraction phases involves the

time before the nurses inital interaction with the patient

duration is

time during which med is present in consentration great enoguh to produce a respnse

onset

time it takes after a med is administered for it to produce a response

which safety measures would the nurse implement to prevent aspiration when administering oral meds

time the meds with meals choose a different route if the risk of aspiration increases recommend self administration if possible

which microorganism would cause athletes foot

tinea pedis

if an older adult patient reports pain and swelling at the base of the thumb which test would the nurse perform to further assess for carpal tunnel

tinel

mottling or pallor may occure because of

tissue hypoxia that alters circulation

primary intention healing

tissue surfaces closed minimal or no tissue loss formulation of minimal granulation and scarring

once a med enters the blood stream its carried throughout the

tissues and organs

the cries scales is used

to assess the pain intensity in postoperative or preterm infants

which statment explains the nurses action of flushing the intravenous lock with normal saline by pushing slowly on the l=plunger

to clear the intravenous lock of blood

while teaching a patient about metered dose inhalers the nurse discusses the 3 point position which statement describes the rational for this nursing intervention

to help the patient activate the canister

the finger tips are best

to palpate skin texture, fluid accumulation and presence of abnormal body mass because of the concentration of the sensory nerve endings

membrane permeability refers to the ability of a med

to pass through tissues and membranes to enter the target cells

the nurse instructs a patient to rinse his or her mouth with water after using a corticosteroid inhaler which statment describes the rationale for this instruction

to prevent a fungal infection

whihc reason would the nurse have for cleaning a wound with normal salin using an irrigating syringe

to remove wound debris

the mini cog test is used

to screen whether the patient has cognitive impairment

for which patient would the nurse straighten the ear canal by pulling the auricle down and back when administering eardrops

toddler

inappropriate removal of tape can cause the

top layer of skin to be pulled and the separation of epidermis from dermis this can cause blisters

which condition would involve the accumulation of sodium urate crystals int eh joint space

tophi with chronic gout

which abnormal hair condition would motivate the nurse to ask about cancer and chemo treatments

toxic alopecia

the older client is at risk for which effect of meds

toxic effect

which topical medication may lead to respiratory depression in the case of an overdose

transdermal patch

which phase of nociceptive pain response involves the release of bradykinin and prostaglandins

transduction

cutis marmorata

transient mottling in the trunk and extremities is caused by low environmental temp

cutis marmorata is

transient mottling, reticulated red or blue patter in the trunk and extremities in response to cooler room temps.

in which phase of nociception do opioids block the signal of pain

transmission

histamine, bradykinin, prostaglandins

transmit a pain message or action potential along the sensory afferent nerve fibers to the spinal cord

which type of dressing is used for stage 1 pressure ulcer

transparent film dressing

the patient with beau lines has a

transverse depression across the nail extending to the nail bed because of acute illness or trauma

pronation occurs in the

transverse plane

which type of syringe is used to administer a small and precise amount of meds subcutaneously in infants and newborns

tuberculin syringe

which of the following nursing interventions are crucial in preventing negative effects of immobility

turning the client every 2 hours assisting with coughing and deep breathing exercises performing rom exercisses

pronation

turning the palm downward

repetitive speech is

typical in a child who has autism spectrum disorder

after a med is absorbed it is distributed within the body to tissues and organs and

ultimately to its specific site of action

the patient with late clubbing may have elevation of inner edge of nails because of an

underlying condition such as hear tor lung disease

the bones in nonsynovial joints are

united by fibrous tissue or cartilage

c fibers are

unmyelinated sensory fibers that cause pain signals to be more diffuse

allergic reaction

unpredictable response of meds that occurs with repeated administration

a pressure injury covered in eschar is an

unstageable pressure injury

jaundice that occurs immediately

upon birth or within the first 24 hours of like is pathologic jaundice and may indicate hemolytic disease

raised, irregularly shaped skin eruption with a reddened margin and pale center is

urticaria

maintenance meds are

used on a daily schedule to prevent acute respiratory distress

the gnasc tool is

used to asses stage 1 pressure injuries in patients with dark skin

palpation is

used to assess texture, temp and swelling

Nursing Diagnosis

used to evaluate the response of the whole person to actual or potential health problems

an electronic thermometer with a red tipped probe is

used to measure rectal temp

the generalized anxiety disorder scale

used to screen for anxiety and anxiety disorders

which statement accurately describes the unit dose system

uses carts for distribution has labeled drawers

the nurse can use 2 approaches for comprehensive assessment this include

using a structured database format and a problem oriented approach

which action by the nursing student indicates a need for correction regarding administration of a liquid form med through small bore feeding tubes

using an intravenous syringe to prepare the med

the brief pain inventory scale the patient can rate the pain

using these graduations based on the effect of pain on mood, walking =, functional ability and sleep in the past 24 hours

immobility can cause which of the following urinary problems

uti

which health pattern describes the patients spiritual attitude according to gordons model

value belief pattern

how fast a med reached a site depends on the

vascularity of the carious tissues and organs

the sender also seeks both

verbal and nonverbal feedback

which parameter is assessed when using the glasgow coma scale

verbal response motor response eye opening response

flat percussion note

very soft high a dead stop of sound, absolute dullness very short

ligaments are

white shiny flexible bands of fibrous tissue that bind joints and connect bones with cartilage

albinism would cause a

whitish pink color in a light skinned patient

the braden scale is a

widely used tool for risk assessment of pressure injury development and is composed of six subscales

fibromyalgia syndrome manifests as

widespread pain in the muscles

the patient who falls under the category class 3 obesity

will have a bmi of more than 39.9

a patient with normal gait

will have a smooth and even walk cylce

a patient who has delirium

will have incoherent convos

1st exposure to an allergen

will sensitize the immune system

the nurse checks for the trendelenburg sign in a patient

with congenital hip disorders

which though process abnormality is the patient exhibiting if during a convo the nurse finds that a patient has jumbled language is illogical and uses words that have no real meaning

word salad

consider using silicone dressings as a

wound contact layer to promote atraumatic dressing change

calcium alginate dressings are used for

wounds with excessive drainage, the dressing forms a gel when it comes in contact with the wound fluid

which skin color would the nurse observe in a child being fed vitamin A supplements regularly

yellowish orange

closed end questions usually have a

yes or no response and dont allow the patient to explain his condition freely

a patient prescription calls for 30 mL of a med to be taken which info would the nurse provide regarding the administration of the med according to a household measurement

you should take 2 tbsp of the med

a patient says to the nurse i have been drinking 4 glasses of whiskey daily for the past 2o yrs and i never had any problems i dont know why my health care provider has asked me to stop drinking how would the nurse paraphrase this statement

your not convinced that you need to stop drinking

which intervention would the nurse perform before obtaining the weight of a 6 month old infant on a platform scale

zero out the scale

Nursing Implementation

Formally begins after a plan of care is developed. The nurse initiates interventions that are designed to achieve the goals and expected outcomes needed to support or improve the patient's health status.

Expressive aphasia (Broca's)

The inability to produce language ( despite being able to understand language)

a spacer is

a 10 to 20 cm long tube that attaches to the pressurized metered dose inhaler and allows the med particles to slow down and separate into smaller pieces

osteoporosis is

a bone disorder characterized by a decrease in bone mass and density which increases the risk of fractures

a large or oval patch of light brown pigmentation present at birth is know as

a cafe au lait spot

which statment is accurate regarding orally administered meds

a capsule is a med encased in a gelatin shell acidic meds pass through the gastric mucosa more rapidly oral meds have a more prolonged effect than parenteral meds the oral route is the most commonly used route of med administration

which statement is accurate regarding orally administered medixation

a capsule is a medication encased in a gelatin shell acidic meds pass through the gastric muscosa more rapidly oral meds haave a prolonged effect than parenteral meds the oral route is the most commonly used route of med administration

the unit does system uses

a cart with a 24 hr supply of meds for each patient

which prescription might the nurse anticipate for a patient with new onset bowel incontinence that is causing compromised skin integrity

a change in dietary prescription

erythema toxicum is

a common skin rash associated with red macules on the cheeks and trunk ( flea bite rash) appears in the first 3 to 4 days of like

maintenance meds are used on

a daily schedule to prevent acute respiratory distress

hallux valgus is

a deformity in which the great tow deviates away from the medial prominence of the head of the first metatarsal

a troche is

a flat tab that should be dissolved in the mouth for med release

the simple descriptor scale consists of

a list of words such as no pain mild pain moderate pain severe pain

developing initiative is

a major task for a preschooler

thigh pressure is preferably measured in

a prone position it can also be measured in supine

standing orders allow

a quick response to a rapidly changing clinical situation

small, raised and reddened vesicles are

a rash

Verbal Descriptor Scale

a rating scale on which people are asked to describe their pain by choosing the phrase that most closely resembles the pain that they are experiencing

ointment

a semisolid preparation, usually oily, for external application to the skin or mucous membranes and usually containing a medicinal substance

a papule is

a solid elevated circumscribed primary lesion less than 1 cm in diameter appears because of superficial thickening of the epidermal layer of the skin

Mini-Mental State Examination (MMSE)

a test of the cognitive functions of the mental status examination (memory, orientation to time and place, naming, reading, copying or visuospatial orientation, writing, and the ability to follow a three-stage command

blocking is

a thought process disorder in which a patient suddenly becomes silent or abruptly stops speaking in the middle of a convo

a beau line is

a transverse furrow or groove across the nail and extends down to the nail bed

gyrate indicates

a twisted coiled sprial or snakelike configuration

nonpersonal is not

a type of communication

a bulla is

a type of primary lesion that appears superficially in the epidermal layer of the skin

the lateral meniscus is

a wedge shaped cartilage that cushions the tibia and femur and protects them from external pressure

which angular motion would involve moving the arm away from the midline of the body

abduction

facing the direction of movement prevents

abnormal twisting of the spine

respiratory airways and mucous membranes have many bvs so meds are

absorbed most quickly after administration

a child who is

abused in the home may lack parental bonding and therefore may show no sepaaration anxiety if the parents are out during the assessment

which type of pain is the patient experiencing when after an appendectomy the nurse notes that the patient has pain, hypertension, tach, stoic face and breathing difficulty

acute

for which condition would the nurse first assess a patient curling over in the fetal position while sitting on the exam chair

acute abdominal pain

when meds should be given as desired

ad lib

effervescent meds arE

added to a glass of h2o and immediately given before dissolving

the nurse is providing care to a patient with a pressure injury that is covered in eschar which dressing prescription will the nurse use for this patient

adherent film

chemotherapeutic agents, insulin and antibiotics are

administered through the intraperitoneal route

chemotheraputic agents are

administered through the intrapleural route

which nursing interventions avoids aspiration in childrent

administering medications in liquid form

the prescription order for a patient contains morphine sulfate, 2mg IV q2h prn, for incisional pain which intervention by the nurse would be appropriate for this patient

administering the med only when the patient requires it

the aspects of a patient behavior that would be assessed during a general survey include

affect speech pattern facial expressions personal hygiene

which factor would directly affect bp

age race sex stress level

when administering enoxaparin

air within the syringe shouldnt be expelled because doing so can effect the dosing

which condition would cause the skin tone of a light skinned patient to be whitish pink in color

albinism

the nurse compares leg lengths of the patient while performing the

allis test to assess for hip dislocation

a patient develops buccal irritation after the administration of a buccal med for 3 days which nursing instruction would have prevented this irritation

alternating the cheeks with each dose

duration

amount of time for which the drug produces its effect and doesnt provide info regarding onset of action

the fourth korotkoff sound is

an abrupt muffling sound that occurs when the artery no longer closes in any part of the cardiac cycle

when patient is exposed to the same allergen for the 2nd time

an anaphylactic reaction may occur

Dysarthria

an articulation disorder in which the patients speech sounds are distorted and unintelligible

toxic effect

an effect that occurs after prolonged intake of meds

a cyst is

an encapsulated fluid filled cavity in the dermis or subcutaneous layer

pain felt by the patient while changing position is

an indicator of incident pain

itermittent venous access also called saline lock is

an intravenous cathered capped off on the end with a small chamber covered by a rubber diaphragm

chloasma is

an irregular brown patch of hyperpigmentation on the face that occurs with pregnancy or in women taking oral contraceptive pills

which method of iv med administration involves introducing a concentrated dose of a med directly into the systemic circulation

an iv bolus

Nursing Planning

an organized nursing care plan based on the nursing Dx, goals and interventions are set by both patient and nurse

a patient develops sudden onset of bronchiolar constriction, edema of the pharynx and larynx and sob after administration of a med which type of reaction is this

anaphylactic reaction

perception is the third phase of nociception

and is associated with conscious awareness of a painful sensation

vancomycin is an

anitbiotic

deliberate fasting and self induced vomiting can occur in

anorexia nervousa bulimia

closed ended questions are

answered only with a yes or no response

which behavior fosters the development of trust

answering the nurse call system promptly answering the questions honestly demonstrating competence when implementing treatment

cruciate ligaments provide

anterior and psoterior stability and help control rotation of the knee

vitamin c acts as an

antioxidant

administration of meds through a parenteral route often causes

anxiety

lorazepam is an

anxiety drug

which instruction given by the nurse would be appropriate if a pressurized metered dose inhaler was prescribed to the patient

apply approximately 5 to 10 lbs of pressure to the top of the canister to administer the med

which responsibility can be delegated to an assistive personnel during wound care

applying an elastic bandage reporting any movement restrictions of the patient

which task can be delegated to. assistive personnel in caring for a patient who has pressure ulcers

applying an. elastic bandage

hydrogel covered with foam is

appropriate for a pressure injury that requires protection and absorption of moisture

adherent film dressings are

appropriate for unstagebale pressure injuries

patients taking meds through the sublingual route

are instructed not to swallow or drink water until the tab dissolves

transdermal disks

are meds that are absorbed through the skin slowly over a long period

Phase IV Korotkoff sounds

are muffled softer sounds and indicates diastole

intravenous injections

are primarily used for fluid replacement in patients who are unable ti take oral fluids

diarrhea, tachy and restlessness

are signs and symptoms of generalized anxiety disorder

cherry angioma

are small smooth slightly raised bright red dots that commonly appear on the trunk of all adults older than 30 years of age

5 mL and 3 mL syringes

are used ofr large volumes of parenteral meds administration

subcutaneous inections

arent to be given over bony prominences because it can cause injury

when would the nurse begin to assess a newborn for physiologic jaundice

around the 4th day of life

the knee joint is an

articulation of three bones femur tibia patella

recent memory can be tested by

asking a question the nurse can corroborate such as asking the patient what he or she had for breeakfast

which patient condition may be caused by poor precationary measures taken by the nursing student while adminstering medication through the oral route

aspiration

the nurse accidently gives a patient a med at the wrong time which action would the nurse take first

assess the patient for adverse effects

the bwat is used to

assess the wound status

different types of problem solving in nursing

assessment diagnosis planning implementation evaluation

acrocyanosis is

associated with bluish discoloration of the skin on mainly hands and feet and is caused by hypothermia

puncture wounds are

associated with the risk of internal bleeding and infection

the tympanic membrane helps in

auditory function

toddler displays explorative behavior and desires to be independent thus developing

autonomy is a major task for a toddler

the health care provider instructs the nurse to administer a booster dose of tetanus toxoid to a 7 yr old patient which nursing action is appropriate

avoiding injections when the patient is asleep having the parent hold the child in a position of confort

which phrase best explains the term propriception

awareness of the position of the body and its parts

skin tags or acrochordons frequently occur on the

axilla

neutrophils ingest

bacteria and small debris

paronychia is caused either by

bacterial or fungal infection

factors of communication that influence the nature of the relationship among participants include the

balance of power and control and a shared history of the participants

syringe pump

battered operated and contains a very small amount of fluid

subcutaneous injections shouldnt

be given over large underlying muscles because the medicine can be accidently injected into muscles

insulin should never

be mixed with aany other meds because it can hamper the effectiveness of the insulin

talipes equinovarus or club foot occurs

because of genetic or environmental factors

spina bifida occurs

because of incomplete closure of the posterior vertebrae

decreased estrogen levels and increased resorption also causes bones to

become porous

which term is used to describe deteriorated skin condition related to prolonged unrelieved pressure on a body part

bed sore pressure sore pressure ulcer decubitus ulcer

oral disintegrating tabs

begin to dissolve immediately therefore they shouldnt be pushed through th e foil

cutaneous pain

begins in the skin surface and subcutaneous tissues

flexion involves

bending a limb at a joint

the iv route is the

best route for establishing constant therapeutic blood levels

serum alumin is a

biochemical indicator of protein deficiency and malnutrition

rapid mood swings indicate

bipolar disorder

laceration wounds tend to

bleed profusely depending on the depth of the wound

hypoventilation may occur because of atelectasis resulting from

blockage of bronchioles by secretions and the collapse of distal lung tissue

which thought process abnormality would the nurse report on a patient with schizophrenia who starts to communicate then abruptly stops speaking in the middle of a convo

blocking

plateau is

blood serum concentration of med reached and maintained after repeated fixed doses

koplik spots are

bluish white red based elevations of 1 to 3 millimeters located in the mouth

which term is used to explain the relationnship of one body part to another along a horizontal or vertical line

body alignment

weight bearing and other exercises help slow

bone loss

which site would the nurse use to administer a med through the intraosseous route

bone marrow

a joint is the connection btwn

bones

a ltcf encourages nurses to assess patients at risk of developing pressure injuries based on 6 subscales: moisture sensory perception activity mobility nutrition and friction or shear force which tool is the ltcf using for risk assessment of pressure injury development

braden scale

during the transduction phase

bradykinin and prostaglandins are released from injured tissues these chemicals transmit pain signals from the injury site to the spinal cord

which statement is accurate regarding the steps involved administering meds by inhilation

breath actuated metered dose inhalers dont use a spacer

while using the painad assessment tool the nurse would monitor 5 parameters

breathing vocalization consolability facial expression body language

which color would be sanguienous drainage on a patients dressing

bright red

the patient with reflective sympathetic dystrophy has

brittle nails and the skin appears pale, dry and shiny

the prepatellar bursa lies

btwn the patella and the skin prevents friction and thus helps the muscles and tendons glide smoothly over the bone

which test would the nurse be performing when firmly stroking the medial aspect of the knee 3 times and then taping lateral aspect of the knee

bulge sign

which type of primary lesion would be superficial in the epidermis more than 1 cm in diameter and rupture easily

bulla

straightening the ear canal

by pulling the auricle upward and outward is performed in children 3 yrs of age and older

which dressing would the nurse use for a patient with a clean stage 3 pressure injury

calcium alginate

mixing insulin detemir with any other insulin

can make it ineffective

medication encapsulated in a gelatin to be swallowed is a

capsule

glutamate

carries the pain impulse across the synaptic cleft to the dorsal horn neurons

ligaments connect bones to

cartilage

delayed administration of time critical meds

cause harm or subtherapeutic responses

erbs palsy is

caused by a briachial plexus injury

which clinical manisfestation would the nurse anticipate in a patient with a history of cushing syndrome

centripetal obesity

which statement by the parent would indicate effective learning about preventing diaper rash

change my babys diaper frequently

addisons disease is

characterized by cortisol deficiency which stimulates the production of melanin and results in bronzed or tanned skin

osteoarthritis is

characterized by hard nontender heberden and bouchard nodules

scoliosis is

characterized by lateral curvature of the thoracic and lumbar segments of the spine

chickenpox is

characterized by the presence of small tight vesicles that first appear on the trunk and then spread to the face arms and legs

assessment involves

checking the accuracy and completeness of each med administration record with the health care providers med prescription

compulsion

checks and rechecks things repeatedly even though its not necessary

which finding would when assessing a the nurse expect when assessing a dark skinned patient diagnosed with carbon monoxide poisioning

cherry red nail beds with carbon monoxide poisioning

which condition would the nurse anticipate after observing a patient leaning forward and bracing themselves on the arms of the chair

chronic obstructive pulmonary disease

which condition would be suspected in a patient with swan neck deformity and ulnar deviation of the fingers

chronic rheumatoid arthritis

rapid infusion of the iv fluid may cause

circulatory overload in patients on tv therapy

when an individual is unable to think of an objects name and substitutes it with a phrase to describe that object is referred to as

circumlocution

which thought process abnormality is the patient exhibiting if when the nurse asks when a fall occured the patient responds with a discussion about how much it snowed last night, where the patient went and what the patient was wearing

circumstantiality

which thought process abnormality would the patients speech indicate if the patient tells the nurse id like to go to my room, broom, tomb, loom, doom. id like to have dinner now, cow, how, wow

clanging

the nurse asks a patient when you tell me that youre having a hard time living up to expectation are you talking about your family expectations which therapeutic communication technique does this illustrate

clarifying

a bmi of 30 to 24.9 indicates

class 1 obesity

hydrocolloid dressings for

clean category stage 2 pressure injuries in body areas where they will not roll or melt

After the nurse dresses a patient's wound, which nursing intervention would help prevent the contamination of that previously cleaned wound?

cleaning the wound from the center to the surrounding skin

serous drainage is

clear

elixr is

clear fluid containing water and or alcohol that is given orally

inspection involves

close careful scrutiny first of the patient as a whole and then of each body system

the medication in dry powder inhalers may

clump in humid climates

which structure would connect the knee joint at both sides and prevent its dislocation

collateral ligaments

planning involves

collecting the medication administration record as well as taking steps to avoid interruptions

tophi are

collections of sodium urate crystals that appear in and around the joint

isotonic contraction is

combination of concentric and eccentric muscle actions for active movement

the mongolian spot is

common variation of hyperpigmentation in african american, asian, american indian and latino newborns

intraosseous route

commonly used for infants and toddlers who have poor intravascular access (bone marrow)

communicating and verifying meds changes with the patient occurs during the

communication phase

nonverbal communication describes

communication without verbal messages

which assessment includes a thorough interview health history review of systems and extensive head to toe

comprehensive assessment

extract

concentrated form of meds that is made by removing the active part of a med from its other components and is given orally

dysphonia

condition in which the patient has difficulty talking because of voice impairment and has an abnormal pitch or volume of speect

falsification of events to fill in memory gaps indicates

confabulation

talipes equinovarus refers to

congenital and fixed malposition of the foot

the nurse checks for the ortolani sign in a patient with

congential hip disorders

while taking an interview open ended questions generally strengthen the

connection btwn the nurse and patient which encourages listening on the nurses part

which intervention performed by the nurse is an interdependent intervention

consulting with a physiotherapist for postoperative exercises collabing with the home health department to ensure the patient will have home health visits conferring with the unit discharge coordinator to help the patient return home

a canister is a

container that consists of the drug and propellant

the message is the

content of the communication

oral medication administration is

contraindicated when a patient is unconscious, has gastric suction or is awaiting surgery

the nurse in the palliative care unit is administering a higher than prescribed dose of opioid analgesic to a patient with terminal stage cancer to relieve pain which act or law does this nurses action violate

controlled substance act

if a patients heart rhythm is regular

counting the pulse for 30 seconds and multiplying by 2

the dermis or inner supportive layer consists mostly of

ct or collagen

which critical thinking attitude motivates the nurse to communicate and know more about the patient

curiosity

when gathering history the nurse should focus on the

current complaints and the body system currently involved

us food and drug administration is the

current monitoring body for maintaining the standards of meds

povidone iodionine, hydrogen peroxide and sodium hypochlorite are

cytotoxic fluids that are used to clean highly colonized wounds

which statment is true regarding dry inhalers

dpis can be activated by a patients breath dpis clump if the patient is in a humid climate dpis created an aerosol when a patient inhales

foam dressings are preferred around

drainage tubes to absorb the drainage

which patient behavior would be assessed when administering the mini cog. screening exam

drawing a clock face

elastic net should be used for

dressing extremities

which option describes a hydrocolloid dressing

dressing that forms a gel that interacts with the wound surface

a lethargic or somnolent patient will

drift off to sleep when not stimulated

which finding would the nirse observe in a patient who is lethargic

drifts off to sleep when not stimulated

which type of inhaler requires less manual dexterity

dry powder inhaler

if the patient with impaired hand function has chronic hyperplasia of the palmar fascia which diagnosis would the nurse anticipate

dupuytren contracture

pressure reduction reduces the

duration and magnitude of pressure over vulnerable areas of the body and contributes to comfort hygiene dignity and functional ability

gathering info from patient about all current prescriptions, otc meds and homeopathic products occurs

during the obtain, verify document phase

which sign or symptom would be observed in a patient experiencing a panic attack

dyspnea sweating increased heart rate

which speech abnormality would the nurse monitor for in patient with brocas aphasia who understands what is being said but has difficulty using the language appropriately

dysrthria

repetition of words said by others in a mumbling and mocking tone is

echolalia

right sided heart failure causes

edema and jugular vein distension

while transferring and handling a patient the height of the be should be at

elbow level

which thermometer would measure the oral temp of a child within 25 seconds

electronic thermometer with blue tipped probe

crossed legs artifically

elevate the bp

which function would pressure dressings perform when applied with an elastic bandage

eliminates the dead space in underlying tissues to allow healing

the pituitary is an

endocrine gland that is located at the bottom of the hypothalamus

during the transmission phase

endogenous opioids are released which activate opioid receptors and block the transmission of pain impulses

an accurate nursing diagnosis helps

ensure effective and efficient nursing interventions

the centers for medicare and medicaid services program doesnt

ensure testing of drugs

which statement is true regarding enteral syringes

enteral syringes are a different color than parenteral syringes

coated tablets that dissolve in the intestine are

enteric coated tabs

which route is used for the administration of regional analgesia for surgical prcedures

epidural

vitamin a promotes

epithelialization wound closure inflammatory response angiogenesis collagen formation

clustering, collecting and interpreting data are common sources of

errors in the nursing diagnostic process

the rn determines if the patients goals are met examines effectiveness of interventions in which step

evaluating

grade 0 muscle strength is used to

document no muscle contraction

which total score using the generalized anxiety disorder 7 scale indicates the patient has moderate levels of anxiety

10

which score on the 4 unrelated words test would alert the nurse to the possibility of a diagnosis of alzheimer dementia

0 to 1

prescription of 240 mL indicates

1 cup

prescription of 960 mL indicates

1 quart

prescription of 5 mL indicates

1 tsp

which age would the nurse test an infants language development and ability ti use one word sentence

1 yr

how far beyond the wound edges would the nurse extend the transparent film when framing the periwound area of a patient for negative pressure therapy

2.5 to 5 cm which is 1 to 2 inches

at which age would the nurse begin routine monitoring of bp in children at low risk of hypertension

3 yrs

how would the nurse document pedal pulses of a patient which are determined to be full and bounding

3+

what would the mx score that can be given to a patient when using the mini mental stat exam

30

enteral tubes whould be flushed with at least

30 mL of water before and after giving meds

the needle is inserted at an angle of

30 to 45 degrees into the vein when the intravenous route is used

the nurse administers an analgesic medication to a patient with a stage 4 pressure ulcer who needs to have a dressing change in relation to administering the analgesic

30 to 60 minutes after administration

perception is the

3rd phase of nociceptive pain and it signifies conscious awareness of painful sensation in the patient

Nursing-sensitive patient outcome

A measurable patient, family, or community state, behavior, or perception largely influenced by and sensitive to nursing interventions

while assessing the muscles around the wrist joint of a patient the nurse finds full range of motion against gravity and some resistance which grade would the nurse document in the patients medical record

4

the nurse would count the pulse of a patient with an irregular heart rate for how many seconds

60

which size tape would the nurse use to stabilize a large dressing

7.5 cm which is 3 inches

which pressure injury is expected to heal through granulation and reepithelialization

stage 4

risk nursing diagnosis

Describes human responses to health conditions/life processes that may develop

which test would help assess a flexion deformity of the patients hip

thomas test

Gorden's 11 Functional Health Patterns

Health Perception Health Management Pattern Nutritional Metabolic Pattern Elimination Pattern Activity Exercise Pattern Sleep Rest Pattern Cognitive-Perceptual Pattern Self-Perception-Self-Concept Pattern Role-Relationship Pattern Sexuality-Reproductive Coping-Stress Tolerance Pattern Value-Belief Pattern

Nursing Evaluation

Involves measuring if goals in planning step were met: progress is evaluated; changes in nursing diagnoses, goals & care plan may result; NA has keep role as NA's observations are used for this step

which instruction regarding sublingual nitroglycerin would the nurse provide to the patient

dont swallow the med place the med under the tongue

supination is

Palm up

components of a med prescription

dose frequency of the med route generic name

which role does vitamin a play in wound healing

Promotes wound closure

no dressing is appropriate for an intact

stage 1 pressure injury

flacc is a

different nonverbal pain assessment tool that helps evaluate pain intensity of pain in younger child

pain that is felt at a

different site than the site of orgin is referred pain

a composite file dressing can be used for a clean

stage 2 pressure injury

while administering a med if a patient has

difficulty swallowing a med the nurse should notify the health care provider

lotion

Semiliquid suspension that usually protects, cools, or cleanses skin

when using the verbal descriptor scale

THE NURSE WOULD ASK PATIENTS TO describe their feelings and the intensity of the pain that they are experiencing

which condition warrants the use of cold therapy

direct trauma

which technique would the nurse use to address lateral violence

directly ask for the abuse to stop

which term would the nurse document to describe individual lesions that remain separate from each other

discrete

a calcium alginate dressing is appropriate for a clean

stage 3 or 4 pressure injury

what regulatory agency is responsible for rigorous testing of medications before making them available to the public

US FDA

organic mental health disorders

disorders of decreased mental function resulting from a medical or physical disease

herpes zoster, trigeminal neuralgia and distal polyneuropathy are

disorders that cause neuropathic pain because they cause a primary lesion called a neuroma and damage the nervous system

discrete describes

distinct individual lesions that remain separate from each other

nonblanchable erythema indicates

damage to bvs and tissue

seborrheic keratosis looks

dark greasy and stuck on

which assessment finding would likely be the cause of a pulse oximeter not providing a reading when the nurse attempts to determine the patients o2 saturation

dark nail polish

the removal of devitalized tissue from a wound describes which process

debridement

dose and frequency of a med

decided based on the patients weight and amount of med required to obtain the therapeutic effect

spontaneous movements are

decreased in a patient who is lethargic

which statement describes the role of state nurse practice acts in nursing

defining the scope of nurses professional functions

the first sound heard as the blood pressure cuff begins to

deflate is the first korotkoff sound which indicates systolic bp

which action by the nurse during a blood pressure assessment would lead to a falsely high diastolic reading

deflating blood pressure cuff to slowly

the nurse askes the patient with lower back pain how does the pain limit your daily activities to determine which aspect of the patients pain experience

degree of impairment

agression is a characteristic of

delirium

which mental health disorder is classified as an organic disorder

delirium alcohol intoxication dementia

which mental health disorder is associated with agnosia

dementia

lack of exercise causes

demineralization of bones leading to osteoporosis

route of a med

depends on the types of med and condition of patient

intradermal injections

deposit meds into the dermis

subcutaneous injections

deposit the meds just below the dermis of the skin

irritability, apathy and extreme sadness are emotional states common in

depression

the nurse would use the patient health questionnaire 9 to screen a patient for which condition

depression

which mental health disorder is observed in children

depression autism adhd

a problem focused diagnosis

describes a clinical judgment concerning an undesirable human response to a health condition/life process that exists in an individual, family, or community.

neologism

describes the use of words that are invented by the patient and that hold no actual meaning except to the patient

Denver II screening test

detects devolpmental delays in infants and preschoolers

while administering an oral med to a patient with dysphagia which health care professional should the nirse collaborate with to determine the best techniques for med administration

dietitian speech therapist occupational therapist

conditions that limit blood flow or blood perfusion inhibt the

distribution of a med

anxiety and schizophrenia are classified as

psychiatric mental health disorders

Hypochondriasis

psychological condition in which the patient excessively worries about his or her own health

growth and development status is related to

psychophysiological context

adults, adolescents and preschoolers require

pulling the auricle upwards and outwards

if the nurse finds the nail base of a patient to be soft spongy and at an angle of 180 degrees for which additional condition would the nurse monitor

pulmonary disease

a patients wound drainage appears thick and yellow whic type of drainage is this considered

purulent

which action would the nurse take while removing a dressing on an older adult patient

push the skin away from the adhesive

which joint would facilitate pronation and supination movements of the hand and the forearm

radioulnar

keratoses are

raised thickened areas of pigmentation that look crusted scaly and warty

inhalational routes provide

rapid relief for local respiratory problems

which speech disorder causes a patient to have difficulty understanding language

receptive aphasia

which route of the administration is suitable for administering a suppository

rectal

where would the nurse place a rectal suppository in an adult

rectal wall 10 cm into the rectum

erythrocytes are

red nlood cells

actinic keratoses are

red tan scaly plaques that increase over the years to become raised and roughened

a splinter hemorrhage is associated with the presence of

reddish brown linear steaks on the fingers and toenails

which assessment finding would related to erythema in a dark skinned patient diagnosed with polycthemia

reddish lips

which physiologic change affecting the metabolism of meds would the nurse be aware of in geriatric patients

reduced liver function reduced absorptive capacity

Phase 1 of Korotkoff sounds

refer to the systolic pressure there are soft and clear tapping sounds with increasing intensity

achilles tenosynovitis

refers to the inflammation of the tendon sheath near the ankle

agnosia

refers to the loss of the ability to recognize objects, persons, sounds or smells

peak concentration

refers to the time taken to attain the highest effective concentration and doesnt provide info related to the onset of action

which condition would a nurse suspect in a patient with a broken leg who reports swelling, stiffness and burning pain in the leg who has noticeably brittle nails and pale dry shiny skin

reflexive sympathetic dystrophy

functions of the skin include

regulates boy temp prevents invasion of microorganisms assists in the prodcution of vitamin d

which cognitive function is the nurse assessing during a mental status assessment when the nurse asks about the patients first job

remote memory

which sense would the nurse use during a routine physical exam

sight smell touch hearing

pharyngeal edema (constriction of bronchiolar muscles) and severe wheezing are

signs of an anaphylactic reaction and is life threatening

which dressing would be inappropriate for a patient with a clean stage 2 pressure injry

silver

sanitization is

simply cleaning the wound

while interviewing the patinet the nurse should not

sit straight in the chair because it affects awareness attention and immediacy

grade 1 muscle strength indicates

slight contraction

which characteristic would be present in stage 3 pressure injury

slough may be present but doesnt obscure the depth of tissue loss

onychomycosis is a

slow persistent fungal infection that causes changes in color

volume controlled infusions administer meds in

small amounts such as 100ml

tuberculin syringe

small diameter syringe that is useful for preparing small precise doses of meds for subcutaneous injection in infants and newborns

senile lentigines, liver spots are

small flat brown macules that appear on the foremarm and dorsa of the hands as seen on older adults

which term describes the type of communication involved when the nurse teaches individuals about healthy meal planning

small group

herpes zoster causes

small grouped vesicles that emerge along the route of cutaneous sensory nerve pathways then form pustules then crusts and are unilateral

which patient assessment would the nurse report as a normal skin finding

smooth firm skin

customs and expectations are

sociocultural elements that affect and interaction

dull percussion note

soft high muffled thud short

a caplet is a

solid dosage form of med whic is available in coated form and meant to be swallowed whole

which info will the nurse elicit to help arrive at the probable cause when a patient is reporting severe abdominal pain in the right iliac region

some questions about the digestive system

moisture or fricition injury to superficial layers causes

soreness upon touch

Phase III and II Korotkoff sounds

sounds are knocking and swooshing sounds and also indicate diastolic pressure

which part of a pressurized metered dose inhaler or device is used to improve drug absorption in a patients airway

spacer

when developing client goals it is important to use the smart acronym which stands for

specific measurable attainable realistic times

clanging

speech disorder in which the patient chooses words that sound similar but dint carry a logical connection and that usually rhymes or puns

breakthrough pain

spikes btwn long acting pain meds

to assess posture the nurse should ask the patient to

stand still and observe the normal plumb line through the anterior ear, shoulder, hip and patella and ankle

us pharmacopeia and the national formulary sets

standards for medication strength, quality, purity , packaging, safety and dose form

which type of prescription order would the nurse carry out until the health care provider cancels the order

standing order

which criterion would the nurse observe while performing a body structure assessment of a patient

stature symmetry contour

which action would the nurse take if infiltration is noted at the iv site of a patient receiving iv therapy

stopping the iv infusion

which guideline would the nurse follow for the safe use of narcotices

store narcotics in locked containers frequently count narcotics especially during shift change document and record patient details

the process of extension involves

straightening a limb at a joint

a topper dressing helps prevent

strike through of the wound drainage

phobia

string irrational fear of an object or situation

one should maintian a 45 or 90 degree angle to administer meds through the

subcuatenous route

for low molecular weight heparin

subcutaneous injection is preferred

quality refers to the

subjective difference caused by the distinctive overtones of a sound

film dressings are used for

superficial ulcers

an abrasion is a

superficial wound with less bleeding it is considered a partial thickness wound because it doesnt involve deep layers of the dermis

which position would the nurse instruct a frail older adult patient to assume for the exam process

supine

which position would the nurse instruct the patient with overwhelming fatigue to assume during the assessment

supine

Which adjuvant treatment is only considered for patients diagnosed with an unstageable pressure injury?

surgical consultation for debrdiement

which communication technique is nontherapeutic

sympathizing

needles of the enteral syringes do not attach to the

syringes and cant be inserted into any type of intravenous line

the working phase involves

taking actions to meet the goals set for the patient

fMRI determines

the structural and neurochemical changes caused in the brain by nociception

peak is

the time it takes for a med to reach its hightst effective concetration

the question are you ever awakened by pain indicates

the timing criterion because the nurse is assessing the time of pain

which statement is true regarding irrigation equipment used for cleaning wounds

the volume of the irrigant should be higher than the volume of the wound

precut gauze is used when

the wound drains

the nurse assesses a patients abdominal wound and finds that the wound is in the proliferative phase of healing which change in the wound might have led the nurse to this conculsion

the wound is filled with granulation tissue the wound contracts to reduce the area that requires healing there is reepithelialization of the wound surface

if a patient experiences lower back pain for more than 6 months

then it indicates chronic pain

summarizing is a

therapeutic communication technique that involves a concise review of key aspects of an infection

focusing is a

therapeutic communication technique that involves centering a convo on key elements or concepts of a message

clarifying is a

therapeutic communication technique to check whether one understands a message accurately by restating an unclear or ambiguous message to clarify the senders meaning

focusing, clarifying and summarizing are

therapeutic techniques

the human body maintains

thermostatic equilibrium by a feedback mechanism regulated in the hypothalamus of the brain

which info would the nurse include in patient teaching regarding the lesions of seborrheic keratosis

they dont become cancerous

which statment is true regarding hydrogel dressings

they enhance autolytic debridement

creativity and perseverance are attitudes conducive to communication because

they motivate the nurse to identify innovative sloutions

purulent drainage is

thick and yellow

crusts are the

thick dried exudates left after the bursting of vesicles or pustules

when a child diagnosed with impetigo presents with vesicles having an erythematous base for which additional assessment finding would the nurse monitor

thick honey colored crusts

on the palm and soles skin is

thicker because of work and weight bearing

the epidermis is

thin but tough and ts cells are bound tightly together into sheets that formed a rugged protective barrier

subjective data

things a person tells you about that you cannot observe through your senses; symptoms

which factor increases the risk of injury when applying heat therapy to a wound for a pediatric patient

thinner layers of skin

while caring for a patient who orally takes herbal and nutritional supplements a rn teaches a nursing student about the interactions of a newly prescribed oral med with the nutritional and herbal supplements the patient is already administering how does this knowledge help the nursing student provide effective care for this patient

this knowledge helps determine the best time for the med administration

which factor would the nurse consider when using the method of confrontation as a therapeutic means of communication with the patient

this should be done gently and after establishing trust this method improves patient self awareness in a therapeutic way using this technique helps the patient become aware of inconsistent feelings

which term would be used to describe the pain for a patient with a gastric ulcer who reports dull, deep , squeezing pain in the stomach

visceral

pain associated with appendicitis and cholecystitis is

visceral pain

which pain assessment tool is being used when the nurse askes the patient to make a mark along a 10 cm horizontal line from no pain to worst pain imaginable

visual analogue scale

when a patient is devoid of melanin pigment in patchy areas of the skin on the face, neck, feet and body folds which condition would the nurse document

vitiligo

medwatch is

voluntary program that enables health care personnel to report any adverse effects of meds

which appearance would be typical of a patient with organic brain syndrome

wears a raincoat on a hot sunny day with out a cloud in the sky

because of damage to capillaries plasma may leak giving the wound a

weepy appearance

Pharmacokinetics

what the body does to the drug

the nurse would ask a patient which question to test for recent memory

what time did you get up today

a patient experiencing a cardiopulmonary event may present with

wheezing diaphoresis sob

transpersonal communication is

when a patient is communicating through prayer meditation or other means witha higher power or deceased loved one

observation occurs

when the nurse is in contact with the client or support person

calcium alginate dressings are used

when the pressure injury is producing significant exudate

when would the nurse administer a medication scheduled on call for surgery

when the surgical staff is coming to get the patient

grade 4 muscle strength is

when there is full range of motion against gravity and some resistance

which question would the nurse ask to determine possible anorexia nervosa in a femal adolescent patient who presents with marked weight loss and reports exercising 2 hours every day

when was your last menstrual period

The nurse asks another nurse how to collect a laboratory specimen and is told, "Why don't you figure it out?" Which would be the best response?

when you brush me off like that it takes me even longer to do my job

the nurse has to inquire about the pain that the patient is experiencing asking

where exactly the pain is gives the location of pain if the patient has turned or moved helps the nurse to establish mobility status as well as severity of pain rate the pain on a scale of 0-10 helps asses the severity of the pain

tendons are

white glistening fibrous bands of tissue that connect muscles to bones

which assessment finding would the nurse expect in an infant diagnosed with milia

white papules on the cheeks forehead nose and chin