Fundamental ATI Exam #8

ego defense mechanisms

Defense mechanisms are psychological strategies that help individuals separate from and put distance between themselves and unpleasant events, feelings, or thoughts. common ego defense mechanisms include denial, rationalization, projection, repression, regression, and compartmentalization.

cranial nerve 8

Vestibulocochlear (hearing and balance)

fight or flight response

When a stressful situation is perceived, signals the amygdala which signals to the hypothalamus to secrete CRF. Once CRF is released it causes the sympathetic nervous system to release hormone epinephrine and norepinephrine.

sleep deprivation

When the body dose not meet its biological sleep requirement, either chronically or acutely. staying awake for 24 hours -sleep deprived or even lessened their sleep hours-partial sleep deprivation

astigmatism

a condition in which the eye does not focus properly because of uneven curvatures of the cornea.

bone oscillator test

a test that determines how effectively vibrations are transmitted through the ossicles. how to diagnosis sensory impairment.

Narcolepsy

chronic sleep condition characterized by sudden sleepiness and sudden periods of sleep.

atelectasis

collapsed lung

repression

concealing unpleasant or painful thoughts, memories, or beliefs in hope of forgetting about them entirely.

apnea

condition in which inspiratory airflow ceases for at least 10 seconds.

Sensory Processing Disorder

difficulty in the way the brain takes in, organizes, and uses sensory information, causing a person to have problems interacting effectively in the everyday environment

Dipoplia

double vision

beta waves

electrical brain waves in the frequency range of 12.0 to 30 hertz

alpha waves

electrical brain waves in the frequency range of 8 to 12 hertz

delta waves

high-amplitude waves seen in deep sleep and when reticular activating system is damped

melatonin

hormone that regulates the sleep-wake cycle

Leptin

hormone that signals the hypothalamus and brain stem to reduce appetite and increase the amount of energy used. The Hunger reducing Hormone

presbyopia

impairment of vision as a result of old age

Wernicke's aphasia

inability to comprehend speech

increased ghrelin levels

increases appetite The hunger hormone.

cataplexy

lack of muscle tone or muscle weakness, and in some cases complete paralysis of the voluntary muscles

Electroencephalography (EEG)

measurement of brain's electrical axctivity

lack of hypocretin

narcolepsy with cataplexy

myopia

nearsightedness

distress

negative or unhealthy stress. causes anxiety, depression.

chronic stress

occurs when stress is heightened, constant, and prolonged. Continuous activation of the nervous system can cause or exacerbate health problems. Manifestations: anxiety, depression, cardiovascular disease, cancer, and suicide.

obstructive sleep apnea

recurrent episodes of upper airway collapse and obstruction while sleeping combined with waking from sleep.

disuse osteoporosis

reductions in skeletal mass routinely accompanying immobility or paralysis. Loss of bone mass due to lack of activity

denial

refusal to acknowledge or accept reality about a situation, despite what might be obvious to others, to avoid the emotional impact.

tactile

relating to the sense of touch

hypopnea

shallow or slow breathing lasting 10 seconds or longer associated with decrease in oxygen saturation.

Acute stress

short term stress- brief trigger of fight or flight. something like vehicle accident, loss of a loved one or victim of a crime. Manifestations: Irritability, chest tightness, headache, gastrointestinal disturbances, sweaty palms, and shortness of breath.

Stage 2 sleep

stage of sleep where the heart rate and body temperature decreases and one becomes more difficult to rouse.

cultural stressors

stress that individuals may experience by living within a society in which they do not culturally fit and/or receiving care that ignores their cultural beliefs

situational stressors

stress that stems from personal, family, or work-related issues.

sleep spindles

sudden bursts of oscillatory brain activity generated in the reticular nucleus of the thalamus that occur during stage 2 of light sleep.

-clone

suffix for nonbenzodiazepines

Rinne and Weber tuning fork tests

tests to assess both function of auditory nerve and ability of ear structures to conduct sound waves to inner ear

sarcopenia

the loss of muscle mass, strength, and function that comes with aging. loss of lean muscle mass

paradoxical effect

the opposite of the intended drug response

resistance stage

the second stage of the general adaption syndrome, the body returns to homeostasis, its normal state.

Fear and Stress Response

triggers the CNS and Endocrine system resulting in flight or fight response. Amygdala interprets something as dangerous or fearful it will send a response to the hypothalamus. The pituitary gland, the sympathetic nervous system, and adrenal glands all participate in the stress response.

atrophy

(n.) the wasting away of a body organ or tissue; any progressive decline or failure; (v.) to waste away. Smaller and weaker. prolonged misuse of limbs.

The release of epinephrine and norepinephrine cause what?

-Increase in heart rate and blood pressure pumping more blood to the vital organs, brain, large muscles. -The small airways in the lungs dilate and the respiratory rate increases to provide more oxygen to fuel the response. -pupils dilate to increase visual acuity -hearing diminishes to decrease distractions -Mental alertness increases -Muscles become tense -palm and fingers become damp to improve grip -Glucose and fat released from storage to provide the energy needed for the response. -Pain perception is diminished. -Blood clotting factor is enhanced -digestive activity slows -salivation increases. Happens just in seconds of the release.

stage 4 sleep

REM rapid eye movement. the deepest stage of sleep, during which we are least responsive to outside stimulation. Dream stage

what is the order of physiological responses that occur during the three stages of general adaptive syndrome GAS?

1. perceived stressor arouses the central nervous system (CNS) 2. Hormones released from the adrenal cortex create a state of readiness (Fight or flight response) 3. Rising hormone levels result in increased blood pressure and heart rate, blood glucose levels, oxygen intake, pupil dilation, and mental alertness.

Broca aphasia - speech - comprehension - repetition ability - associated features - what is damaged?

1. sparse and nonfluent 2. relatively preserved 3. impaired 4. face and upper limb = right hemiparesis 5. brocas area = broadmann area #44, 45. responsible for making speech (it is infront of motor cortex)

presbycusis

age related hearing loss

A 4-year-old child's parent is employed and works from home. To accomplish their daily work, the parent allows the child to watch television for 6-8 hours per day. Based on this information, what nursing concern is applicable to this family? 1. Lack of diversional activities related to impaired senses. 2. Altered parenting associated with failure to provide stimuli for growth.

2 is correct

A client has newly diagnosed cirrhosis and has pulled his nasogastric tubing for the third time. The client's ammonia levels is above normal. Which nursing concerns is appropriate for this client? 1. Altered thought process. 2. altered rest and comfort 3. unproductive impulse control 4. acute confusion

4. Acute confusion elevated ammonia levels can cause confusion

A nurse is reviewing the concepts of central sleep apnea with colleague. Which of the following statements by the colleague indicates an understanding of central sleep apnea? A. Common causes of central sleep apnea are opioid overdose and congestive heart failure. B. Central sleep apnea is caused by obesity and an inactive tongue. C. central sleep apnea is easily diagnosed using polysomnography. D. Central sleep apnea is related to the recurrent episodes of upper airway collapse and obstructions.

A Correct "Common causes of central sleep apnea are opioid overdose and congestive heart failure." Central sleep apnea (CSA) is the result of reduction of the brain's transmission of signals to the respiratory muscles. This results in the cessation of breathing and is commonly caused by opioid overdose and heart failure. Incorrect "Central sleep apnea is caused by obesity and an inactive tongue. "Obstructive sleep apnea (OSA), not central sleep apnea (CSA), can be caused by obesity, an inactive tongue, and enlarged tonsils. incorrect "Central sleep apnea is easily diagnosed using polysomnography. obstructive sleep apnea (OSA), not central sleep apnea (CSA), is diagnosed using polysomnography. Polysomnography is most often performed in a sleep lab and measures the client's vital signs, oxygen saturation, brain wave patterns, body movements, and snoring patterns. Incorrect "Central sleep apnea is related to the recurrent episodes of upper airway collapse and obstruction." Obstructive sleep apnea (OSA), not central sleep apnea (CSA), is related to the recurrent episodes of upper airway collapse and obstruction.

hypersomnia

A disorder of excessive daytime fatigue without improvement after more sleep.

Melatonin

A hormone manufactured by the pineal gland that produces sleepiness.

Amygdala

A limbic system structure involved in memory and emotion, particularly fear and aggression. Senses fear/stress sends message to the Hypothalamus.

Hypocretin

A neurotransmitter that regulates arousal, wakefulness, and appetite Decreased levels: Found in clients who have narcolepsy.

eustress

A positive stress that energizes a person and helps a person reach a goal

posttraumatic stress disorder (PTSD)

A prolonged and heightened stress reaction to a traumatic even that last more a month. Manifestations: Flashbacks, nightmares, sweating, increased heart rate, and an exaggerated startle response to certain noises or experiences that might remind them of the trauma.

A nurse is caring for a client who has a migraine headache and reports that they are getting worse. Which of the following questions should the nurse ask the client to determine if the headaches are a stress-related disorder? A. What is the intensity of your migraine headaches? B. How often do the migraine headaches occur? C. Are you eligible for workers' compensation? D. What type of support is available to you when you have migraine headaches? E. What coping strategies do you use when you experience a migraine headache?

A,B,D,E What is the intensity of your migraine headaches is correct. How an individual appraises a stressor determines how they will respond to the stressor. The onset and severity of stress-related disorders is affected by the type, frequency, and intensity of the stressor, perception of the stressor, access to support systems, and the individual's ability to effectively cope with the stressor. How often do the migraine headaches occur is correct. How an individual appraises a stressor determines how they will respond to the stressor. The onset and severity of stress-related disorders is affected by the type, frequency, and intensity of the stressor, perception of the stressor, access to support systems, and the individual's ability to effectively cope with the stressor. Are you eligible for workers' compensation due to the migraine headaches is incorrect. Eligibility of workers' compensation is not a factor when appraising a stress-related disorder. What type of support is available to you when you have a migraine headache is correct. How an individual appraises a stressor determines how they will respond to the stressor. The onset and severity of stress-related disorders is affected by the type, frequency, and intensity of the stressor, perception of the stressor, access to support systems, and the individual's ability to effectively cope with the stressor. What coping strategies do you use when you experience a migraine headache is correct. How an individual appraises a stressor determines how they will respond to the stressor. The onset and severity of stress-related disorders is affected by the type, frequency, and intensity of the stressor, perception of the stressor, access to support systems, and the individual's ability to effectively cope with the stressor.

hypothalmus function

ACTIVATES the Stress response. -In fear responses releases corticotropin-releasing-factor (CRF) -regulates stress, part of your reptilian brain. -Any form of stress is understood through the hypothalamus, and tells your adrenal gland to release stress hormones → homeostasis regulation, anything that throws homeostasis off balance will trigger a response

Parasomnias

Abnormal behaviors such as nightmares or sleepwalking that occur during sleep.

projection

Attributing one's own thoughts, feelings, or motives to another.

A nurse manager is conducting an in-service about the physiological functions of sleep for a group of staff nurses. Which of the following statements by one of the nurses indicates an understanding of the teaching? A. Sleep is a process that decreases the development of new neural pathways that assist with retention of knowledge and memorization. B. The brain and neurons continue to communicate with each other during sleep to remove the toxins that built up in the brain while awake. C. The circadian rhythm is an external process that controls the sleep-wake cycle. D. Clients experience the highest quality of sleep when they complete three out of the four stages of sleep.

B Incorrect "Sleep is a process that decreases the development of new neural pathways that assist with retention of knowledge and memorization." Sleep increases, rather than decreases, the development of new neural pathways that assist with retention of knowledge and memorization. Correct "The brain and neurons continue to communicate with each other during sleep to remove toxins that built up in the brain while awake. During sleep, the brain and neurons continue to work together to assist with the removal of toxins that build up in the brain while awake. Incorrect "The circadian rhythm is an external process that controls the sleep-wake cycle." The circadian rhythm is an internal process that controls the sleep-wake cycle and occurs every 24 hr. Incorrect "Clients experience the highest quality sleep when they complete three out of the four stages of sleep." Clients experience the highest quality sleep when they complete all four stages of sleep.

A nurse is teaching a newly licensed nurse about the development of dreams. The nurse should include that which of the following areas of the brain transmits the sensory data that is used to develop dreams? A. Hypothalamus B. Thalamus C. Cerebral Cortex D. Pineal gland

B Incorrect Hypothalamus The hypothalamus contributes to the regulation of a variety of bodily functions, including sleep. However, the hypothalamus does not transmit the sensory data that is used to develop dreams. CORRECT Thalamus The nurse should include that the thalamus transmits images, sounds, and sensations to the cerebral cortex, which are used to develop dreams during rapid eye movement (REM) sleep. Incorrect Cerebral cortex The cerebral cortex controls the perception of sensory information. The cerebral cortex receives, rather than transmits, the sensory information that is used to develop dreams. Pineal glandThe pineal gland produces melatonin, which regulates the sleep-wake cycle. The pineal gland does not transmit the sensory data that is used to develop dreams. Incorrect Pineal gland The pineal gland produces melatonin, which regulates the sleep-wake cycle. The pineal gland does not transmit the sensory data that is used to develop dreams.

A nurse is reviewing the plan of care for a client who was admitted with insomnia and recent weight gain. Which of the following is a benefit of increased sleep that could prevent further weight gain for the client? A. Increased ghrelin production B. Increased leptin production C. Decreased hypocretin levels D. Decreased Melatonin levels

B Increased ghrelin production Sleep helps to prevent weight gain by decreasing, not increasing, the production of ghrelin, the hunger hormone. Increased leptin Sleep helps to prevent weight gain by increasing the production of leptin, the hunger-reducing hormone. Decreased hypocretin levels Hypocretin levels do not impact weight gain or loss. Decreased hypocretin levels are found in clients who have narcolepsy (NT1). Decreased melatonin levels Melatonin levels are not impacted by sleep. Melatonin is a hormone present in the body that helps to regulate the sleep-wake cycle.

A nurse is caring for a client who has a history of migraines. The client tells the nurse, "I have not been sleeping well. My migraine headaches have returned after not having one for over a year." The nurse should identify that which of the following are potential contributing factors to the client's migraine? (Select all that apply) A. Sleep-wake homeostasis B. Sensory Overload C. Sleep Deprivation D. Increased melatonin E. Decreased hypocretin levels.

B, C Sleep-wake homeostasis is incorrect. Sleep-wake homeostasis is the second biological mechanism that assists the body to remember to sleep after a given time. It is not a likely contributing factor to the client's new onset of migraine headaches. Sensory overload is correct. Sensory overload can lead to sleep deprivation and is a possible contributing factor to the client's new onset of migraine headaches. Sleep deprivation is correct. Sleep deprivation has been known to trigger migraines. Therefore, the nurse should identify that sleep deprivation is a potential contributing factor to the client's new onset of migraine headaches. Increased melatonin is incorrect. Melatonin can assist with sleep and relaxation. It is not a likely contributing factor to the client's new onset of migraine headaches. Decreased hypocretin levels is incorrect. Hypocretin is a hormone responsible for maintaining alertness that is produced in the hypothalamus. It is not a likely contributing factor to the client's new onset of migraine headaches.

exhaustation stage

Body can no longer defend itself. prolonged exposure to stress may result in illness or disease. The exposure to elevated or fluctuating endocrine or neural responses causes excessive wear and tear on the body organs, resulting in allostatic load. long term can cause physiological problems like chronic hypertension, depression, and autoimmune disorders.

A nurse is caring for a client who needs to be awakened for the administration of an oral medication. which of the following findings should indicate to the nurse that the client was in stage 3 of the sleep cycle when awakened? A. The client was easily awakened. B. The client states that they were having a pleasant dream. C. The client experiences mental cloudiness for 30-60min D. Prior to being awakened the client's breathing was irregular and their heart rate was elevated.

C Incorrect The client was easily awakened. The nurse should identify that a client who was easily awakened was most likely in stage 1 of the sleep cycle, rather than stage 3. During stage 1 of the sleep cycle, the client begins to relax and body and eye movements begin to decrease. If left uninterrupted, the client will progress quickly to stage 2 of sleep, where awakening becomes more difficult. Incorrect The client states that they were having a pleasant dream. Stage 4 of the sleep cycle, also known as rapid eye movement (REM) sleep, is the dreaming stage of sleep. If a client is awakened during this stage, their dreams will be interrupted. CORRECT The client experiences mental cloudiness for 30 to 60 min. Stage 3 of the sleep cycle is the deepest stage of sleep in which muscle, tissue, and bones regenerate and the immune system strengthens. If a client is awakened during stage 3 of the sleep cycle, the nurse should expect the client to experience mental cloudiness for 30 to 60 min. Incorrect Prior to being awakened, the client's breathing was irregular and their heart rate was elevated. Irregular breathing and increased heart rate are an indication that the client is in stage 4 of the sleep cycle, also known as rapid eye movement (REM) sleep.

Crises

Crisis is a threatening situation triggered by a precipitating even whereby an individual experiences a strong behavioral, emotional, or psychiatric response. unanticipated even with insufficient time to prepare or respond.

A nurse is assessing a client who reports difficulty staying awake during the day and experiencing involuntary episodes of lost muscle tone. The nurse should identify that these are manifestations of which of the following conditions? A. Hypersomnia B. Narcolepsy (NT2) C. Narcolepsy (NT1) D. Insomnia

C Incorrect Hypersomnia Hypersomnia is excessive daytime fatigue that does not improve after receiving additional sleep. Hypersomnia is not accompanied by involuntary episodes of lost muscle tone. Incorrect Narcolepsy (NT2) Narcolepsy is a chronic sleep condition that is characterized by sudden sleepiness and sudden periods of sleep. Clients who have narcolepsy (NT2) have difficulty staying awake. However, these clients do not experience involuntary episodes of lost muscle tone. Correct Narcolepsy (NT1) The nurse should identify that the client is exhibiting manifestations of narcolepsy (NT1). Narcolepsy (NT1) is a chronic sleep condition that is characterized by sudden sleepiness and sudden periods of sleep accompanied by cataplexy, or episodes of involuntary loss of muscle tone brought on by strong emotions, such as laughter. Clients who have narcolepsy (NT1) with cataplexy lack hypocretin in their central nervous system. Clients who have both NT1 and NT2 narcolepsy might experience nocturnal hallucinations, paralysis while asleep, and vivid dreams. Incorrect Insomnia Insomnia is the inability to obtain adequate sleep despite having adequate opportunity to sleep. Clients who have insomnia might experience daytime fatigue and loss of energy, but they do not have trouble staying awake or experience involuntary loss of muscle tone.

A nurse is discussing the stages of sleep cycle with a client. The nurse should include that the immune system is strengthened, and tissues and bones are repaired during which of the following stages of sleep cycle? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4

C Stage 1 Stage 1 of the sleep cycle is the lightest stage of sleep. In this stage, breathing remains at a regular rate and muscle tone is present in the skeletal muscle. This stage of sleep is not associated with healing. Stage 2 Stage 2 of the sleep cycle is the stage of sleep where the heart rate and body temperature decrease and one becomes more difficult to rouse. This stage of sleep is not associated with healing. Stage 3 The nurse should include that the immune system is strengthened and tissues and bones are repaired during stage 3 of the sleep cycle. Stage 4 Stage 4 of the sleep cycle, also known as rapid eye movement (REM) sleep, is the stage of sleep where dreaming occurs. This stage of sleep is not associated with healing.

A nurse is providing care to a client who has undergone skin grafting to her face due to a burn injury, The client states, "I know it could have been worse, but my face will never be the same as it was. I haven't been able to look at myself in the mirror because of what I might see. "The nurse interprets this statement as most likely reflecting which pattern? A. Role performance B personal identity C. Body image D. Self-esteem

C. Body image

Compartmentalization

Categorize life experiences into segments to avoid facing the anxieties while in that mindset.

episodic acute stress

Characterized by frequent bouts of acute stress, usually associated with taking on too much responsibility. Short tempered, irritable, and anxious. manifestations: tension headaches, hypertension, and migraines.

allostatic load

Chronic exposure to elevated or fluctuating endocrine or neural responses causes excessive wear and tear on the body organs, resulting in allostatic load. The nurse should identify that the client's constant stress may be manifesting itself in physical ailments such as periodic asthma attacks.

transactional theory of stress and coping (TTSC)

Describes stress as a dynamic process and a transaction between a person and their environment. How an individual appraises (assess/evaluates) a stressor determines how they will respond to the stressor.

rapid eye movement (REM) sleep

Dream Stage stage of sleep in which the eyes move rapidly under the eyelids accompanied by low muscle tone and the person is typically experiencing a dream.

comfort

Easement from the pain of suffering from negativity, emotional, and physical distress. being comforted has one feel accepted, safe, stronger, and valued.

K-complex

Electrical waveform on an electroencephalogram seen mainly during stage 2 sleep cycle.

Nonbenzodiazepines (Used for sleep)

Eszopiclone (Lunesta, Valnoc) pagoclone pazinaclone suproclone suriclone zopiclone (imovane, zimovane, somnol)

irritable bowel syndrome (IBS)

Gastrointestinal condition characterized by abdominal pain and changes to bowel elimination patterns that can include diarrhea and or constipation.

a nurse is preparing to administrate medication to a client. which of the following medication should the nurse identify as an ototoxicity?

Loop Diuretics NSAIDS Aminoglycoside antimalaria medications Chemo therapeutic drugs

regression

Moving back to a previous developmental stage to feel safe or have needs met.

circadian rhythm

Natural internal process that regulates the sleep-wake cycle within a 24-hour period.

Corticotropin-releasing hormone (CRH)

Not only releases epinephrine and norepinephrine but also -ACTH -adrenalin corticotropin hormone from the pituitary gland. Hormone travels through the blood to stimulate the adrenal glands on top the kidneys. If the stress continues the release is sustained by cortisol and epinephrine and adrenal from the adrenal cortex.

perasympathetic nervous system

Once the stress and threat is over it Returns the body to a relaxed state of energy conservation.

Insomonia

Ongoing inability to sleep despite having the opportunity to sleep.

OAE

Otoacoustic emission test Otoacoustics are sounds emitted by hair cells Measures function of inner ear If infant fails OAE administer ABR

difference between pain and comfort

Pain can be caused by the client's emotional state or actual or potential damage to tissues, whereas comfort is defined as obtaining relief from pain, negativity, and emotional and physical distress. encouragement to stay positive.

developmental stressors

Stress that occurs as an individual moves through the stages of life. such as physical appearance, friends, school, marriage, beginning a career, beginning a family, and leaving family home.

adventitious stressors

Stress that results from events of disaster; they are generally rare, unexpected, and can result from natural disasters.

polysomnography

Test to diagnose OSA Test that documents heart rate, blood pressure, breathing, oxyhemoglobins, saturation, brain wave patterns, body movements, and snoring patterns.

Stage 3 of Sleep cycle

The Immune system is strengthened, and tissues and bones are repaired during stage 3 of the sleep cycle. deep sleep begins, brain begins to generate slow delta waves.

General Adaptation Syndrome (GAS)

The body's attempt to maintain equilibrium and homeostasis. -three-stage physiological response that appears regardless of the stressor that is encountered.

alarm stage

The first stage of the general adaption syndrome, includes the fight or flight response.

Stress

The mental, emotional, or physical response and adaptation to real or perceived changes and challenges. Stress response: initiated by the nervous and endocrine systems when a stressor is perceived as serious threat. Can cause health issues.

temporary dysphagia

The patient has difficulty swallowing when oral feeding begins. Due to conditions that affect the CNS such as stroke, MS, head injury, and dementia

central sleep apnea

The reduction of the brain's transmission to the reparatory muscles resulting in the cessation (stops) of breathing. common causes is overdose and heart failure.

Stage 1 sleep

The state of transition between wakefulness and sleep, characterized by relatively rapid, low-amplitude brain waves. lighted sleep-breathing remains regular and muscle tone is present in the skeletal muscle.

anosmia

absence of the sense of smell

Elevated ammonia levels

ammonia builds up in the blood and travels to the brain and can cause confusion, disorientation, and coma. causes damage to the liver and brain.

sleep-wake homeostasis

assists the body to remember to sleep after a given time