Study For Patho # 2 Several, WTF set
The nurse knows that a client understands the purpose of a sleep diary when the client states:
"I will record the time I go to bed and how long it takes me to fall asleep."
The nurse is assisting an older adult client with dementia in getting dressed after morning care. Which statement would be most beneficial to the client?
"Put your arm in this sleeve."
Self-actualization needs
"What a man can be, he must be."[3]:91 This quotation forms the basis of the perceived need for self-actualization. This level of need refers to what a person's full potential is and the realization of that potential. Maslow describes this level as the desire to accomplish everything that one can, to become the most that one can be.[3]:92 Individuals may perceive or focus on this need very specifically. For example, one individual may have the strong desire to become an ideal parent. In another, the desire may be expressed athletically. For others, it may be expressed in paintings, pictures, or inventions.[3]:93 As previously mentioned, Maslow believed that to understand this level of need, the person must not only achieve the previous needs, but master them.
Pain
"Whatever the experiencing person says it is, existing whenever he says it does"
The 55-year-old client who is newly diagnosed with osteoarthritis of the hips asks the nurse why it hurts when walking. What is the nurse's best response?
"You have lost the padding in your joints and the friction causes pain."
Medical asepsis
"clean technique to prevent cross infection- hand washing, bathing, gowning, gloves, shoe covers, etc." (From Slide) practices designed to reduce the number and transfer of pathogens: synonym for clean technique (from book)
F. Nightengale's theory of Practice
"environmental adaption theory"---Cannons of nursing
Nursing Shortage
# of foreign graduates is small
Steps to certification (3)
(1) Become informed about specific requirements in the chosen specialty. (2) Contact the ANCC or specialty nursing organization offering certification to determine the educational experience & examination requirements. (3) Contact the State board of Nursing for info about legal requirements for practice in a specific specialty area.
Main Purposes of the 1935 Social Security Act
(1) Provide a national old-age insurance system (2) provide federal grants to states for maternal & child welfare services (3) provide vocational rehabilitation services for the handicapped (4) prov. medical care for crippled children & blind ppl (5) proc. a plan to strengthen public health services (6) prov a federal-sate unemployment system
Trends influencing nursing education & practice
(1) rapid knowledge expansion & increasing use of technology (2) practice-bases competency outcomes & ecivence-based contect (3)performance-bases competency learning & objective assessment methods (4) Sociodemographics, cultural diversity, exonomic & political changed, & global issues (5) community-focuses interdisciplinary approaches (6) consumer-orienceted care:engagement, safety & privacy (7) Ethics & bioethical concerns (8) increasing shortage of nurses & faculty (9) disasters,violence, and terrorism (10)increasing professional & personal responsibility
Hildegard Peplau's theory
(1952) --Explored interpersonal relationship of the nurse and the client --Identified the client's feelings as a predictor of positive outcomes related to health and wellness.
Madeline Leininger
(1977) Theory of cultural care diversity & university. Transculural nursing & caring nursin; concepts are aimed toward caring & the compnents of a culture care theory; diversity, iniversality, worldview, and ethnohistory are essntial to the four concepts (care, caring, health, and nursing)
Evidence-based practice
(EBP): nursing care provided that is supported by sound scientific rationale
PIE charting
(P) problem-(I) intervention - (E) evaluation (PIE) :documentation system that does not develop a separate care plan; the care plan is incorporated into the progress notes in which problems are identified by number, worked up using the problem (P)- intervention (I)- evaluation (E) format,and evaluated each shift
Necrosis
(death of tissue)- appears as slough (Sld 18 Ch 31)
diaphoretic
(not from book) adjectiveMEDICINE (chiefly of a drug) inducing perspiration. (of a person) sweating heavily.
periodontitis
(periodontal disease): marked inflammation of the gums that also involves degeneration of the dental periosteum (tissues) and bone.
Orthostatic hypotension
(postural hypotension) - changes in pressure that occurs when moving from lying to sitting to stand position (slide 23 ch 24) temporary fall in blood pressure associated with assuming an upright position; synonym for postural hypotension
subjective data
(symptoms, covert data): information perceived only by the affected person
Clinical manifestations skin hyper pigmentation
***increased ACTH levels activates melanocytes causing skin hyper pigmentation; could be due to other hormones as well
Central or Secondary Hypothyroidism causes
***less common*** -d/t pituitary or hypothalamic failure -TSH, T3, T4 will all be LOW
Clinical manifestations immune suppression
- (body things we can spare our energy)
anuria
- 24 hour urine output is less than 50ml (renal failure or kidney shutdown)
Plasma
- 50% to 55% of the blood volume - Liquid portion that contains organic and inorganic elements
Composition of blood
- 92% water and 8% solutes -6 quarts (5.5 L)
Afebrile
- A person with a NORMAL body temperature - "Without fever"
Febrile
- A person with a fever
Ventricular septal defect (VSD)
- Abnormal communication between the ventricles - Most common type of congenital heart lesion - Two types
Atrial septal defect
- Abnormal opening between the atria; blood flows from left atria to right atria - Ostium primum defect, Ostium secundum defect, Sinus venosus defect
Emphysema
- Abnormal permanent enlargement of the gas-exchange airways accompanied by destruction of alveolar walls without obvious fibrosis - Inherited deficit of α1-antitrypsin - Loss of elastic recoil
Manifestations of Tetralogy of Fallot
- Acute cyanosis at birth or gradual cyanosis - Gradual clubbing, poor growth; Tet spells - If untreated, emboli, stroke, brain abscess, seizures
Obstructive lung diseases
- Airway obstruction that is worse with expiration - Common S/S dyspnea and wheezing
Cheyne-Stokes Respirations
- Alternating periods of deep, rapid breathing followed by periods of apnea; regular. - Associated with: Drug overdose, heart failure, increased intracranial pressure + renal failure
Fever
- An increase ABOVE normal body temperature - Pyrexia - Also called FEBRILE - Most fevers are self limiting + normal temperature will return after the factors causing it are controlled
Hyperventilation
- Any condition causing an INCREASE in CARBON DIOXIDE + a DECREASE in OXYGEN in the blood that INCREASES both the RATE + DEPTH of respirations. - Associated with: Extreme exercise, fear, diabetic ketoacidosis
LONG TERM Regulation of Blood Pressure
- Arterial pressure rises when the body contains TOO MUCH extracellular fluid. In response, increased amounts of sodium + fluid are excreted by the kidneys to return the blood pressure to the person's equilibrium point. - When blood pressure decreases due to decreased extracellular fluid the opposite effect occurs. Extracellular fluid volume regulates blood pressure directly by increasing cardiac output + renal blood flow + indirectly autoregulation of blood flow + indirectly by autoregulation of blood flow, in which autoregulatory mechanisms redirect blood flow to various blood tissues.
Physiology of Blood Pressure
- Arterial walls contain elastic tissue that allows them to stretch + distend (also call compliance) as blood enters with each ventricular contraction. When the heart rests between each beat, the walls of the arteries return ot their original position, although pressure in them does not drop to zero. The arterioles offer RESISTANCE to the PRESSURE of the blood + keep the blood entering the capillaries in a continuous flow rather than in spurts. THEREFORE, THE ELASTICITY OF THE ARTERIAL WALLS, IN ADDITION TO THE RESISTANCE OF THE ARTERIOLES, HELPS TO MAINTAIN NORMAL BLOOD PRESSURE. - With increased age, the walls of arterioles become less elastic, which interferes with their ability to stretch + dilate. This can limit adequate blood flow + contribute to rising pressure within the vascular system. - Blood moves though the circulatory system from areas of HIGHER PRESSURE to areas with LOWER PRESSURE
Common obstructive disorders
- Asthma - COPD - Emphysema - Chronic bronchitis
Manifestations of atrial septal defect
- Asymptomatic at early age - Pulmonary symptoms on exertion at later age
Hypotension
- Below normal blood pressure - A consistently low blood pressure (90-115 mm Hg) is normal in some adults, such as trained athletes - Most cases of hypotension are the result of pathology. - May result from vasodilation of the arterioles, failure of the heart to function, or loss of blood volume (such as with a hemorrhage). - The nurse should immediately report assessments of hypotension, tachycardia, pallor, increased sweating + confusion.
Benefits of Fever
- Benefits only up to 104 F - Destruction of harmful microorganisms - Enhanced response of immune system - Increased performance to anti infective agents
Extramedullary hematopoiesis
- Blood cell production in tissues other than bone marrow i.e. spleen and liver - Usually a sign of disease
Hypertension + Two Classifications
- Blood pressure that is ABOVE normal for a sustained period - One of the most common health problems - Diagnosed when the systolic pressure is 140 mm Hg or higher or the diastolic pressure is 90 mm Hg or higher. - 76.4 million adults in the US have been diagnosed with hypertension. - Often called the "silent killer" as there are few symptoms beyond increased blood pressure - The basis of hypertension is thought to be dysfunction of the neurohormonal system. Overactivation of both ANGIOTENSIN + ALDERSTERONE result in an increase in blood pressure. Over time, this sustained increase results in a permanent remodeling + thickening of the blood vessels. As a result, there is increased peripheral resistance + a back up of pressure to organs is affected by the vascular system, such as the brain, heart + kidneys. - Disorders resulting from hypertension include thickening of the myocardium, enlargement of the ventricles, congestive heart failure, MI, stroke + kidney damage. - Risk factors: race, age, disease, obesity, high cholesterol, sedentary lifestyle high dietary intake of salts/fats/calories, use of oral contraceptives in women, cigarette smoking, regular alcohol consumption + sleep apnea. Two Classifications: 1.) PRIMARY HYPERTENSION: Has NO known cause. Characterized by an increase above normal in both the systolic + diastolic pressures. Also called "essential hypertension". 2.) SECONDARY HYPERTENSION: Less common than primary hypertension. Caused by DISEASE. Common causes are: kidney disease, disorders of the adrenal cortex + disorders of the aorta.
COPD
- Characterized by persistent airflow limitation - Usually progressive - Most common chronic lung disease in world
Asthma
- Chronic inflammatory disorder of the airways - Inflammation results from hyperresponsiveness of the airways - Can lead to obstruction and status asthmaticus - Symptoms include expiratory wheezing, dyspnea, and tachypnea - Peak flow meters, corticosteroids, beta agonists, and anti-inflammatories used to treat
Atelectasis
- Compression atelectasis - Absorption atelectasis - Surfactant impairment - partial or complete collapse of the lung
Assessing a Rectal Temperature
- Considered the most accurate place to take temperature as it records core temperature - Should not be used in newborns, children with diarrhea + patients who have undergone rectal surgery or have a diseases of the rectum - The insertion of the thermometer into the r.e.c.t.u.m can slow the heart rate by stimulating the VAGUS NERVE, assessing a rectal temperature for patients with heart disease or after cardiac surgery may not be allowed in some institutions. - Assessing rectal temp is contraindicated in patients who are neutropenic (have low white blood cell *****) + in patients who have certain neurologic disorders (such as spinal cord injuries) - Do not insert a rectal thermometer into a patient who has a low platelet count. The rectum is very vascular + thermometer could cause rectal bleed - Rectal temperatures are approximately 1 degree HIGHER than oral rectal
S/S of Pulmonary Disease
- Cough - Abnormal sputum - Hemoptysis - Abnormal breathing patterns (Kussmaul and Cheyne-Stokes respirations) - Hypoventilation - Hyperventilation - Cyanosis - Clubbing - Pain
Assessing the Apical-Radial Pulse
- Counting of the pulse at the APEX of the heart + at the radial artery SIMULTANEOUSLY is used to assess the apical-radial pulse rate. - A difference between the apical + radial pulse rates is called the PULSE DEFICIT + indicates that all of the heartbeats are NOT reaching the peripheral arteries or are too weak to be palpated. - TWO nurses are needed: One listens with a stethoscope over the apex of the heart for the heartbeat + the other counts the rate at the radial artery. - The patient's chest wall is exposed so that the stethoscope can be place directly on the skin of the chest wall - one watch with a sweep second hand is placed, so both nurses can read it simultaneously. - The nurses determine where they can best hear + feel the pulse + decide on a time to start counting, such as when the second hand on the watch is at a specified place - Both nurses count for 1 full minute.
Bradypnea
- DECREASE in respiration - LESS THAN 10 breaths / min + shallow - Occurs in some pathologic conditions -An increase in intracranial pressure depresses the respiratory center, resulting in irregular or shallow breathing, slow breathing or both. - Certain drugs, such as opioids (ex. morphine, hydromorphone) can DEPRESS the respiratory rate. - Associated with: Depression of the respiratory center by medications, brain damage
Hypoventilation
- Decreased rate + depth; irregular - Associated with: overdose of narcotics or anesthetics
Chief functions of the hematologic system
- Delivery of substances needed for cellular metabolism - Removal of wastes - Defense against microorganisms and injury - Maintenance of acid-base balance
Hematopoietic stem cells (HSCs)
- Develop into blood cells - Colony-stimulating factors (CSFs)
Dyspenea
- Difficult or labored breathing. - Placing the patient in an upright position can help the breath easier, a condition known as ORTHOPENEA. While sitting or standing, gravity LOWERS organs in the abdominal cavity AWAY from the diaphragm. This gives the lungs more room for expansion within the chest, allowing the intake of more air with each breath.
Platelets
- Disk-shaped cytoplasmic fragments - Essential for blood coagulation and control of bleeding
Lymph nodes
- Facilitate maturation of lymphocytes - Transport lymphatic fluid back to the circulation - Cleanse the lymphatic fluid of microorganisms and foreign particles
Hyperprexia
- Fever greater than 106 F - A medical emergency - Body must be cooled rapidly to prevent brain damage
Kussmaul respirations
- Hyperpnea - Deep and labored breathing
Chronic bronchitis
- Hypersecretion of mucus and chronic productive cough that lasts for at least 3 months of the year and for at least 2 consecutive years - Inspired irritants increase mucus production and the size and number of mucous glands - The mucus is thicker than normal - Bronchodilators, expectorants, and chest physical therapy used to treat
Tachypena
- INCREASED respiration - May occur in response to an increased metabolic rate, such as when a person has a fever. CELLS REQUIRE MORE OXYGEN at this time + produce more carbon dioxide that must be removed. The rate increases as much as 4 breaths/min with every 1 F that the temperature rises above normal. - Associated with: Fear, anxiety, exercise, respiratory disorders
Pulmonary fibrosis
- Idiopathic - A respiratory disease in which scars are formed in the lung tissues, leading to serious breathing problems
Manifestations of coarctation of the aorta
- If severe decreased CO, acidosis, hypotension at birth - If undiagnosed, no manifestations until find hypertension in upper extremities at older age
Pulse Deficit
- Indicates that all of the heartbeats are NOT reaching the peripheral arteries or are too weak to be palpated. - Read by assessing the apical-radial pulse.
Manifestations of aortic stenosis
- Infant: if significant faint pulses, hypotension, tachycardia, and poor feeding - Older children: may have complaints of exercise intolerance - Risk for bacterial endocarditis
Bronchiolitis
- Inflammatory obstruction of the small airways - Most common in children - Occurs in adults with chronic bronchitis, in association with a viral infection, or with inhalation of toxic gases
Eosinophils
- Ingest antigen-antibody complexes - Induced by IgE hypersensitivity - Increase in parasitic infections
Orthostatic Hypotension
- Is a DECREASE in SYSTOLIC blood pressure of 20 mm Hg or a DECREASE in DIASTOLIC blood pressure from the sitting or supine position. - Results from an inadequate physiologic response to postural (positional) changes in blood pressure - May be acute or chornic as well as sympotomatic or asymptomatic - Associated with dizziness, lightheadedness, blurred vision, weakness, fatigue, nausea, palpaitations + headache. - Older adults may experience ortostatic hypotension without symptoms + may lead to falls. - Occurs when one rises to an erect position, either supine to sitting, supine to standing or sitting to standing - Caused by DEHYDRATION, BLOOD LOSS, problems of the NEUROLOGIC, CARDIOVASCULAR or ENDOCRINE SYSTEMS and /or use of certain classes of medication
Neurogenic Fever
- Is the result of damage to the hypothalamus from pathologies such as intracranial trauma, intracranial bleeding or increased intracranial pressure - Does NOT respond to antipyretic medications
Bradycardia
- Low pulse rate - Below 60 beats/min in an adult - SINUS BRADYCARDIA results when the SA node generates a slower than normal impulse rate. Occurs at times when metabolic needs are decreased, form certain medications, vagal nerve stimulation, during suctioning of respiratory secretions, severe pain + increased intracranial pressure + MI. - Emergyency treatment consists of administering atropine intravenously to BLOCK vagal stimulation + to restore normal heart rate.
Pneumonia
- Lower respiratory tract infection - Caused by bacteria, viruses, fungi, protozoa, or parasites - Healthcare acquired (HCAP) or community acquired (CAP)
Manifestations of VSD
- May be asymptomatic - If severe: increased pulmonary blood flow from left-to-right shunt; pulmonary hypertension (Eisenmenger syndrome)
Granulocytes
- Membrane-bound granules in their cytoplasm - The granules contain enzymes capable of destroying microorganisms - Inflammatory and immune functions - Capable of ameboid movement (diapedesis)
Agranulocytes
- Monocytes and macrophages make up the mononuclear phagocyte system (MPS) - Monocytes: immature macrophages - Macrophages: in tissues - Lymphocytes: mature to T cells, B cells, plasma cells - Natural killer (NK) cells
Erythrocytes
- Most abundant cell in the body - Responsible for tissue oxygenation - Biconcavity and reversible deformity - 120-day life cycle
Pneumococcal
- Most common and lethal form of pneumonia
Tuberculosis
- Mycobacterium tuberculosis - Acid-fast bacillus - Airborne transmission - Tubercle formation - Caseous necrosis - Positive tuberculin skin test (PPD)
Aortic stenosis
- Narrowing of the left ventricular outlet - Causes increased workload on left ventricle and left ventricular hypertrophy - Various types
Pulmonic stenosis
- Narrowing of the pulmonary valve causing resistance to flow from right ventricle to pulmonary artery - Right ventricular hypertrophy - Pulmonary atresia
Treatment of Fever
- Nursing care related to fever focuses on increasing patient comfort + preventing complications BACTERIAL + MICROBE ORIGIN: Appropriate antibiotic or anti-infective. Antipyretic (fever reducing) drugs such as aspirin, ibuprofen or acetaminophen may be administered in certain circumstances. These drugs reset the elevated set point regulated by the hypothalamus - Aspirin should NOT be taken by anyone younger than 19 years old during fever causing or flue like illnesses - Cool sponge baths, cool packs + hypothermia (cooling) blankets may be used - Oral fluids are increased to maintain cellular + intravascular status + to prevent dehydration - Simple carbohydrates are included in the diet to prevent tissue breakdown
Pulmonary embolus
- Occlusion of a portion of the pulmonary vascular bed by a thrombus, embolus, tissue fragment, lipids, or an air bubble - Pulmonary emboli commonly arise from the deep veins in the lower leg - Virchow triad (Venous stasis, hyper-coagulability, and injuries to the endothelial cells that line the vessels)
Physical Effects of Fever
- Patients with fever may experience: loss of appetite, headache, hot + dry skin, flushed face, thirst, muscle aches + fatigue - Respirations + pulse rate increase - Young children may experience seizures - Older adults may have periods of confusion + delirum - Fever blisters may develop in some people as the fever activates the type I herpes simplex virus. - Fluid, electrolyte + acid-base imbalances are potentially dangerous complications of fever.
Apnea
- Periods during which there is NO breathing - If apnea lasts longer than 4 to 6 minutes, brain damage + death may occur
Venous sinuses
- Phagocytosis of old, damaged, and dead blood cells - Blood storage: 300ml
Neutrophils
- Polymorphonuclear neutrophil (PMN) - Phagocytes in early inflammation
SHORT TERM Regulation of Blood Pressure
- Primarily NEURAL (nerve) + HUMORAL (body fluids). - These mechanisms correct TEMPORARY changes in pressure that occur during activities such as changing position or exercising + are also responsible for maintaining blood pressure during life-threatening situations. - The neural centers for blood pressure regulation are located in the cardiovascular center. The cardiovascular center transmits PARASYMOATHETIC impulses to the heart via the VAGUS nerve + SYMPATHETIC impulses to the heart + blood vessels via the SPINAL CORD + PERIPHERIAL SYMPATHETIC NERVES - Vagus Nerve STIMULATION = SLOWER heart rate - BARORECEPTORS located in the heart + the walls of arteries are stimulated by changes in stretch + sent impulses to the cardiovascular center - May different humoral mechanisms, along with hormones help regulate blood pressure - EPINEPHRINE (a sympathetic neurotransmitter) is released by the adrenal gland to increase heart rate + contractility, thereby increasing cardiac output. - The RENIN-ANGIOTENSIN-ALDERSTERONE system causes VASOCONSTRICTION in the arterioles. This leads to increased peripheral vascular resistance as a short-term mechanism + also increases sodium + water retention by the kidneys to increase circulatory fluid volume, thus increasing blood pressure as a long-term mechanism. - VASOPRESSIN (antidiuretic hormone [ADH]) is released from teh posterior pituitary when stimulated by decreased blood volume + blood pressure or by an increased osmolarity of body fluids. It has a direct vasoconstricting effect on blood vessels, increasing peripheral resistance.
Cor pulmonale
- Pulmonary heart disease - Right ventricular enlargement - Secondary to pulmonary hypertension - Pulmonary hypertension creates chronic pressure overload in the right ventricle
Tachycardia
- Rapid heart rate - Decreases cardiac filling time, which, in turn, DECREASES STROKE VOLUME + CARDIAC OUTPUT - An adult has tachycardia when the pulse rate is 100 to 180 beats/min
Mutual Recognition Model
- Resolution adopted in 1997 by the delegate assemby of the NCSBN. - Provides for individual state boards to adopt an interstate compact, allowing nurses licenses in one state to practice in all other states and territories.
Treatment of Hypothermia
- Rewarming the patient by covering with additional clothing + blankets, the use of a heating blankets + pads + radiant warmers - Warm fluids are administered either orally or through the intravenous route
Assessing the Apical Pulse
- Should be assessed using a stethoscope - Assessed when giving medications that alter heart rate + rhythm - The preferred method of pulse assessment for infants + children less than 2 years old - The contraction of the heart can be heard in the space BETWEEN the 5yh + 6yth ribs, about 3 inches to the LEFT of the medial line + slightly below the nipple - The apical rate of an infant can also be easily palpated with the fingertips as well as being auscultated.
Types of non-small cell lung cancer
- Squamous cell carcinoma - Adenocarcinoma - Large cell carcinoma
Normal Blood Pressure
- Studies of healthy people indicate that blood pressure can be within a wide range + still be normal. - A rise or fall of 20 to 30 mm Hg in a person's blood pressure is SIGNIFICANT, even if it is within the generally accepted normal range. - Although blood pressure varies constantly, sustained long-term changes are NOT considered normal. - The American Heart Association reccommends that blood pressure readings be measured on TWO or MORE subsequent occasions before determining if the blood pressure is outside acceptable parameters. - Measurements should be taken after the patient rests for at least 5 minutes + has NOT consumed caffeine or smoked for 30 minutes before the measurement.
Dyspnea
- Subjective sensation of uncomfortable breathing
Systolic Pressure
- The HIGHEST pressure - Created during ventricular CONTRACTION
Diastolic Pressure
- The LOWEST pressure - Created during ventricular RELAXATION
Heat Loss
- The SKIN is the primary site of heat loss - The circulating blood brings ehat to the skin's surface, where small connections between the arterioles + the venules lie directly below the skin surface. These connections, called arteriovenous shunts, may remain open to allow heat to dissipate or remain closed + retain heat in body. The SYMPATHETIC nervous sytem controls the shunts.
Temperature
- The difference between the amount of heat produced by the body + the amount of heat lost ot hte environment measured in degrees - Core body temperature (intracranial, intrathoracic + intra-abdominal) is HIGHER than surface body temperature - Normal body temperature ranges from 96.7 to 100.5 F - Temperatures vary by time of day, with temperatures being lowest in early morning + highest in late afternoon
Blood Pressure
- The force of the moving blood AGAINST arterial walls. - Measured in millimeters of mercury (mm Hg) + is recorded as a fraction: numerator = systolic pressure _______________________________________________ denominator = diastolic pressure For example: If the blood pressure is 120/80 nnGg, 120 is the systolic pressure + 80 is the diastolic pressure.
Pulse Rate
- The number of pulsations felt over a peripheral artery or heard over the apex of the heart in 1 minute - Normally corresponds to the same rate at which the heart is beating
Heat Production
- The primary source of heat production in the body is METABOLISM - When additional heat is required to maintain homeostatic balence, EPINEPHRINE + NOREPINEPHRINE (SYMPATHETIC neurotransmitters) are released to rapidly alter metabolism so that energy production decreases + heat production increases - THYROID hormone also INCREASES metabolism + heat production but over a much longer time period. - Shivering is initiated by the hypothalamus + produces heat through muscle tremors - Contraction of pilomotor muscles of the skin causes heat production
Physiology of the Pulse
- The pulse is regulated by the AUTONOMIC nervous system though the sinoatrial (SA) node (the pacemaker) - PARASYMPATHETIC stimulation of the SA node via the vagus nerve DECREASES the heart rate - SYMPATHETIC stimulation of the SA node INCREASES the heard rate + force of contraction
Physiology of Respirations
- The rate + depth of breathing can change in response to tissue demands. - These changes are brought about by the inhibition or stimulation of the respiratory muscles by the respiratory centers in the brain - Activation of the respiratory centers occurs via impulses form chemoreceptors located in the aortic arch + carotid arteries via stretch + irritant receptors in the lungs + via receptors in muscles + joints - An increase in carbon dioxide is the most powerful respiratory stimulant, causing an increase in respiratory depth + rate - The cerebral cortex of the brain allows voluntary control of breathing, such as when singing or playing a musical instrument - The rate + depth of inhalation + exhalation are normally smooth, effortless + without conscious effort - Factors such as environmental changes + pathophysiologic alterations in various body systems may result in increases or decreases in respiratory rate + depth.
Risk factors for COPD
- Tobacco smoke - Occupational dusts and chemicals - Air pollution - Any factor affecting lung growth during gestation and childhood
Inhalation disorders
- Toxic gases - Pneumoconiosis - Silica - Asbestos - Coal
Mixing Defects
- Transposition of the great arteries - Aorta arises from the right ventricle and the pulmonary artery arises from the left ventricle - Results in two separate, parallel circuits
Pleural Abnormalities
- Transudative effusion - Exudative effusion - Empyema - Chrlothorax
Biot's Respirations
- Varing depth + rate of breathing, followed by periods of apnea; irregular. - Associated with: Meningitis + severe brain damage.
F. Nightengale's theory of Practice
- Ventilation and warming - Variety - Chattering hopes and advice - Cleanliness - Noise - Diet - Light
transient incontinence
- appears suddenly and lasts for 6 months or less - usually caused by treatable factors (medical treatment, infection, IV fluid, etc)
nocturia
- awakening at night to urinate
hematuria
- blood in the urine
nephrotoxic
- capable of causing kidney damage
overflow incontinence
- chronic retention of urine - involuntary loss of urine associated with over distention and overflow of the bladder
UTI
- cloudy pee as soon as you pee
Bedside commodes (BSC)
- commodes with chairs - straight back chairs or wheelchairs with open seats with a shelf or a holder underneath that holds a bedpan or bucket
total incontinence
- continuous and unpredictable loss of urine, resulting from surgery, trauma, or physical malformation
reflex incontinence
- emptying of the bladder without the sensation of the need to void - result of spinal cord injuries
polyuria
- excessive output of urine (diuresis)
turbidity of urine
- fresh urine should be clear or translucent - as urine stands and cools, it becomes cloudy - cloudiness in freshly voided urine is abnormal and could be due to RBC`s, WBC`s, vaginal discharge, sperm, or prostatic fluid
color of urine
- freshly voided is pale yellow, straw-colored, or amber - some meds or foods can alter this
urinary diversion
- involves the surgical creation of an alt. route for exertion of urine
pH of urine
- normal pH is about 6.0, with range of 4.6-8 - urine becomes alkaline on standing when CO2 diffuses into the air - high protein diet causes urine to become excessively acidic
odor of urine
- normal urine smell is aromatic - as it stands, it develops an ammonia odor bc of bacterial action - foods can change odor - urine high in glucose content has a sweet odor - urine that is heavily infected has a fetid odor
incontinent
- not able to control voiding; involuntary control - one of the most common chronic health problems
Assessing urine
- note color, odor, clarity, & presence of any sediment
dysuria
- painful or difficult urination
glycosuria
- presence of sugar in the urine (sweet odor)
proteinuria
- protein in the urine - indication of kidney damage
pyuria
- pus in the urine - urine would be cloudy
2 types of bedpans
- regular: - fracture pan: use when client has had fracture of femur or lower spine, can't raise themselves easily, very thin, or elderly
oliguria
- scanty or greatly diminished amount of urine voided in a given time - 24 hour urine output is less than 400 ml
continent
- self control over voiding
urgency
- strong desire to void
functional incontinence
- urine loss caused by the inability to reach the toilet because of environmental barriers, physical limitations, loss of memory, or disorientation
mixed incontinence
- urine loss with features of 2+ types of incontinence
procedure for using a urinal
- usually a client can use a urinal independently but there are some cases in which may have to assist - placed at the bedside with a lid for the client to use at any time - male and female versions - female urinals may be used when a male can not use a regular urinal (obsess, small penis, etc) females rarely use urinals - provide privacy - provide the client access to the call bell - when removing the urinal: wear gloves, measure the amount if the client is on I&O, empty into the toilet, clean the urinal, rinse the water, return the urinal to the client`s bedside, don't put on bedside table)
elimination
- when confined to bed or limited activity - males: use urinals for voiding, bedpans for bowel movements - females: use bedpans for both voiding and bowel movements
urinary retention
- when urine is produced normally but is not exerted completely from the bladder - due to meds, enlarged prostate, or vaginal prolapse
Clinical manifestations protein wasting
- which means they'll have skinny limbs
Clinical Manifestations cortisol-induced insulin resistance
-(receptors on target cell affected), therefore, there is an increase in gluconeogenesis and usage of glycogen storage
Orem's Self Care Deficit Theory
-- Facilitates client self-care by measuring the client's deficit relative to self-care needs -- Nurse implements appropriate measures to assist the client in meeting needs by matching with an appropriate supportive intervention.
Middle range theory parts
-- Physiologic factors (age, mode of delivery) -- Psychologic factors (anxiety, depression) -- Situational factors (social support) -- Symptom (fatigue)
With SIADH, the patient will have low serum osmolarity, which means
-<225 -low amount of electrolytes in comparison to water -HYPONATREMIA (<135)**
Patients with SIADH have abnormally high
-ADH/vasopressin secretion -leading to an increased number of aquaporin channels in the renal collecting ducts, retaining water
Hypoplastic left heart syndrome
-Abnormal development of the left-sided cardiac structures (Obstruction to blood flow from the left ventricular outflow tract) -Underdevelopment of the left ventricle, aorta and aortic arch; mitral atresia or stenosis; coarctation of the aorta -Manifestations occur early in newborn (cyanosis, tachypnea, decreased CO) -Fatal in early life if untreated
Stages of the Kawasaki Disease
-Acute: capillaries, venules, arterioles, and the heart become inflamed -Subacute: inflammation of larger vessels; coronary aneurysms appear -Convalescent: medium-sized arteries begin granulation process; small vessel inflammation decreases -Post-convalescent: scarring of vessels, thickening of tunica intima, calcification, coronary artery stenosis
Anterior Pituitary secretes
-Adrenocorticotropic hormone (ACTH) releases cortisol -Melanocyte-stimulating hormone (MSH) promotes pituotary secretion of melatin -Somatotropic hormones Growth hormone: Prolactin(breast milk) -Glycoprotein hormones:egg/sperm Follicle-stimulating hormone Luteinizing hormone: female and male, progesterone and testosterone -Thyroid-stimulating hormone -Luteinizing hormone-reproduction process -Follicle-stimulating hormone -Beta-lipotropin -Beta-endorphins: help rel
Huntington's
-Also known as chorea -Autosomal dominant hereditary degenerative disorder -Severe degeneration of the basal ganglia (caudate nucleus) and cerebral cortex >>depletion of gamma-aminobutyric acid (GABA)
Secreted by the posterior pituitary
-Antidiuretic hormone (ADH): diuretics release fluid so antidiuretic retain fluid and increase plasma --Controls plasma osmolality -Oxytocin Uterine contractions and milk ejection in lactating women
Brain death
-Can no longer maintain internal homeostasis -Completion of all appropriate diagnostic and therapeutic procedures -Unresponsive coma -No spontaneous respirations (apnea) -Pupils dilated, fixed, no reflexes -Flat EEG (isoelectric)
Adrenal Cortex disorders: Primary Hyperaldosteronism
-Conn's Syndrome; too much salt -abnormality of the adrenal cortex
Hypokinesia
-Decreased mvmt -Akinesia -Bradykinesia -Loss of associated mvmt
Who is at risk for developing hypoparathyroidism?
-DiGeorge syndrome -family history of parathyroid disorder -autoimmune endocrine diseases, e.g., Addison's disease (attacking parathyroidism) -r/t alcoholism, malnutrition, malabsorption, TPN, chemo, ATB therapy
The Endocrine System Functions:
-Differentiation of reproductive system and CNS in fetus -Stimulation of growth and development -Coordination of the male and female reproductive systems -Maintenance of internal environment:homeostasis -Adaptation to emergency demands of body
Pathophys of Awareness disorders
-Direct destruction caused by ischemia -Indirect destruction caused by compression -Effects of toxins, chemicals, or metabolic disorders
Dystonia
-Dystonic posture and mvmt -Decorticate posture -Decerebrate posture -Basal ganglian posture -Senile posture
Mechanism of Hormone Action: Lipid-soluble hormones
-Easily diffuse across the plasma membrane and bind to cytosolic or nuclear receptors -Steroid hormones
Dementia
-Failure of many cerebral functions including intellectual processes -Orientation, memory, language, judgment, decision making Mechanisms -Neuron degeneration -Brain tissue compression -Atherosclerosis -Brain trauma Can be genetically predisposed
Patent ductus arteriosus
-Failure of the ductus arteriosus to close -allows blood to shunt from the aorta to pulmonary artery causing left-to-right shunt
Lower motor neuron syndromes
-Flaccid paresis or flaccid paralysis -Hyporeflexia or areflexia -Fibrillation Diseases: -Paralytic poliomyelitis -Guillain barre syndrome -Progressive spinal muscular atrophy -Progressive bulbar palsy -Bulbar palsy
Primary hyperthyroid conditions include
-Graves disease (autoimmune) -toxic multi-nodular goiters -thyroid cancer -thyrotoxic crisis or thyroid storm
Heart Failure
-Heart is not able to maintain cardiac output at level that meets demands of body -Result from poor ventricular function -Complication of many congenital heart defects
Upper motor neuron syndromes
-Hemiparesis or hemiplegia -Diplegia -Paraparesis or paraplegia -Quadriparesis or quadriplegia -Pyramidal motor syndromes -Spinal shock
Mechanism of Hormone Action: Water-soluble hormones
-High molecular weight -Cannot diffuse across the plasma membrane -First messenger:(insulin, binds to plasma membrane) Hormone Signal transduction -Second-messenger molecules: Calcium Cyclic adenosine monophosphate (cAMP) Cyclic guanosine monophosphate (cGMP) Tyrosine kinase system Inositol triphosphate (IP3)
Grave's disease is a Type...
-II hypersensitivity/autoimmune disorder
Coarctation of the aorta manifestations
-If severe decreased CO, acidosis, hypotension at birth -If mild, no manifestations until find hypertension in upper extremities at older age
Hormones are released:
-In response to an alteration in the cellular environment -To maintain a regulated level of certain substances or other hormones-homestasis
Inappropriate amounts of hormone deleviered to targer cell
-Inadequate hormone synthesis -Failure of feedback systems -inactive hormones -dysfunctional delivery. system
Adrenal medulla
-Innervated by the sympathetic nervous systems; epinephrine is majority thats released; stimulate fight or flight -Chromaffin cells (pheochromocytes) --Chromaffin cells secrete the catecholamines epinephrine (majority) and norepinephrine -Release of catecholamines has been characterized as a fight or flight response -Catecholamines promote hyperglycemia bc need to increase blood sugar levels
Cerebral death
-Irreversible coma, death of hemispheres exclusive of the brain stem and cerebellum -No behavioral or environmental responses -Brain can continue to maintain internal homeostasis Survivors -remain in coma -emerge into vegetative state -Progress into minimally conscious state (MCS) -Locked in syndrome
Adrenal Glands
-Located close to upper pole of each kidney -adrenal cortex -adrenal medulla
Seizures
-Manifestation of disease -Sudden, transient alteration of brain function caused by abnormal excessive discharges of cortical neurons -Epilepsy -Convulsion
Seizures and etiologic factors
-Metabolic disorders -Congenital malformations -Genetic predisposition -Prenatal injury, postnatal trauma -Myoclonic syndromes -Infection -Brain tumor -Vascular disease -Substance abuse
Amytrophic lateral sclerosis
-Neurodegenerative disorder involving upper and lower motor neurons -Causes progressive muscle weakness -Unknown etiology -Starts w muscle weakness and progresses to muscle atrophy, spasticity, and loss of manual dexterity and gait
Alzheimer disease
-Neurofibrillary tangles -Senile plaques -Forgetfulness, emotional upset, disorientation, confusion, lack of concentration, decline in abstraction, problem solving, and judgment -Diagnoses made by ruling out other causes of dementia
Hypertension in children differs from adults because:
-Often has an underlying disease -Renal disease or coarctation of aorta -A cause of the hypertension in children is almost always found
Aging and the Endocrine System
-Organ atrophy and weight loss with vascular changes -Decreased secretion and clearance of hormones -Variable change in receptor binding and intracellular responses: they may not be able to uptake hormones as well bc may not be able to bind them old people go to bed early bc melatonin builds in body earlier glucose intolerance bc not eating as much decreased sexual activity decreased calcitonin so decreased bone density and increased risk of fractures
Intracellular disorders have acquired defects in
-POST-receptor signaling cascades -INSIDE the target cell
Amylin
-Peptide hormone co-secreted with insulin -Delays nutrient uptake: delaying gastric emptying after meals -Suppresses glucagon secretion
Cerebrovascular Disease
-Perinatal stroke -Childhood stroke --Ischemic - sickle cell, cerebral arteropathies, cardiac anomalies --Hemorrhagic - congenital AV malformations
Pancreatic somatostatin
-Possible involvement in regulating alpha- and beta-cell secretions: inhibit secretion of insulin polypeptides Gastrin,ghrelin,andpancreaticpolypeptidesstimulate appetite
Lipid-soluble hormones are primarily circulating bound to a carrier
-Rapid and long-lasting response -Diffuse freely across the plasma and nuclear membranes and bind with cytosolic or nuclear receptors -have to be attached to something to move through the plasma -estrogen , progestrogen -rapid with long lasting effects last from hours to days
Frontotemporal dementia
-Rare, severe, degenerative -Death of frontal lobe tissue and dementia -Familial association -Most cases involve gene mutation
melatonin regulates
-Regulates circadian rhythms and reproductive systems: more melatonin, more sleepy, bring down resp. rate; as it wears off we start to wake up during the day -Role in onset of puberty: assists in release of gonadotropin
Secondary Hyperparathyroidism
-SOMEWHERE ELSE AFFECTING THE THYROID -compensatory response of parathyroid glands to chronic hypocalcemia -associated with DECREASED renal activation of vitamin D (renal failure) or malabsorption within the gut; both organs are causing low Ca+
Glucagon
-Secretion is promoted by decreased blood glucose levels -Stimulates glycogenolysis:breakdown of glycogen, gluconeogenesis, and lipolysis
islets of Langerhans
-Secretion of glucagon and insulin Cells: Alpha—glucagon-stimulate breakdown of glycogen Beta—insulin-opposite effect of glucagon and amylin Delta—somatostatin and gastrin- F cells—pancreatic polypeptide:digestive enzymes
Water-soluble hormones circulate in free, unbound forms
-Short-acting response -Bind to surface receptors -lasting seconds to minutes
Parathyroid glands
-Small glands located behind the upper and lower poles of the thyroid gland -Produce parathyroid hormone (PTH) --Increases serum calcium and decreases serum phosphate --Antagonist of calcitonin (thus increases bone resorption and serum calcium) --Vitamin D (cofactor-needed so path can properly work) needed for PTH function
Hormones General characteristics:
-Specific rates and rhythms of secretion: maintaining homeostasis --Diurnal, pulsatile, and cyclic and patterns that depend on circulating substances -Operate within feedback systems (positive and negative) -Affect only target cells with appropriate receptors(key looking for lock on target cells) -Are excreted by kidneys or deactivated by liver or cellular mechanisms
Neural Tube Defects
-Spina bifida occulta -Vertebral defect that is not visible -No neurologic dysfunction -Spinal cord and spinal nerves normal
Arousal
-State of awakeness -Structural (supertentorial, infratorial, metabolic) -Psychogenic
Insulin
-Synthesized from proinsulin -Secretion is promoted by increased blood levels of glucose, amino acids, GI hormones (regulated by serum blood glucose, so when blood levels rise, it is going to be secreted) -Facilitates the rate of glucose uptake into the cells of the body -Anabolic hormone --Synthesis of proteins, lipids, and nucleic acids
Posterior Pituitary Hormones
-Synthesized with their binding proteins in the supraoptic and paraventricular nuclei of the hypothalamus -can be effected by alcohol and different drugs and stuff like that
Endocrine Pancreas
-The pancreas is both an endocrine and an exocrine gland: produces hormones and also produces digestive enzymes -islets of langerhans: glucagon, insulin -Gastrin, ghrelin, and pancreatic polypeptides -Pancreatic somatostatin -Glucagon -Insulin -Amylin
Thyroid gland
-Two lobes lie on either side of the trachea -Isthmus: separate lobes -Follicles (follicle cells surrounding colloid) -Parafollicular cells (C cells) -Secrete calcitonin which treats any bone disorders -Regulation of thyroid hormone secretion -Thyrotropin-releasing hormone and thyroid-stimulating hormone control rate of metabolism in body follicles are cavities ike behave and les tsp be absopred in there an released into body
Mechanism of Hormone Action
-Water-soluble hormones circulate in free, unbound forms (short-acting response ex. insulin) -Lipid-soluble hormones are primarily circulating bound to a carrier
Myxedema and Hypothyroidism
-a complex of connective tissue fibers separated by large amounts of protein and mucopolysaccaride binds water, resulting in a meshwork of fluid and fibers...more substantive, therefore, will not pit -results in non-pitting, body edema in the eyes, hands and feet
Pathophysiology of hypocortisolism
-a decrease in cortisol leads to -a decrease in aldosterone which leads to -a decrease in androgens which leads to -an increase in ACTH (loss of negative feedback loop, always on causing a darkness in skin tone)
Who is usually affected by acromegaly?
-adults -40 to 50 year olds **yet is usually a slow progression, so s/sx may not truly appear until that age
Panhypopituitarism
-all pituitary hormones are ABSENT -Cortisol -Thyroid -GH (significant in children) -gonadal failure; loss of secondary sex characteristics -no prolactin (no lactating in women postpartum; the pituitary gland is the problem, not the hypothalamus)
What is the most common cause of HYPERpituitarism?
-benign adenoma -a slow growing tumor that presses on the cells or the anterior pituitary **70-90% of the anterior pituitary gland needs to be damaged BEFORE clinical symptoms will appear
Clinical manifestations of BOTH primary and secondary hyperparathyroidism
-bone resorption which will lead to pathological fractures, kyphosis of dorsal spine and vertebral compression (getting shorter, hunchbacked) -PRIMARY ONLY: hypercalciuria (excess amount of Ca+ spilling over into the urine, ALKALINE URINE, hyperphosphaturia just due to the natural role of PTH -these components lead to kidney stones which may lead to kidney infection -muscular, nervous, and GI systems affected: fatigue, HA, depression, anorexia, N/V (VAGUE) **S/SX depend if Ca+ is low (secondary) or high (primary)
What can cause SIADH?
-brain injury (closed head injury) or infection (can be anything from a trauma to a stroke to meningitis) -ectopically produced ADH associated with a cancer
Small cell lung CA
-cancer cells can perform unlike they should -these cells can secrete high amounts of ADH
Inappropriate response by target cell
-cell surface receptor-associated disorders -intracellular disorders
With diabetes insipidus, patients are not able to
-concentrate urine -may be partial or total
Primary hypothyroidism is due to
-congenital defects -autoimmune thyroiditis (Hashimoto disease) -latrogenic loss of thyroid tissue after treatment of hyperthyroidism
Adrenal Cortex Disorders: hypercortisolism
-cushing disease -excessive anterior pituitary secretion of ACTH (secondary disease); not in the adrenal cortex -more common in adults and in women
When there is a loss of thyroid tissue, there is
-decreased production of T3 and T4 which INCREASES the production of TSH, which causes hyperplasia of the thyroid (GOITER); constant stimulation of receptors keeps the thyroid large
Again, since the urine is quickly exiting the renal system, the urine specific gravity is
-decreased, below 1.002 -very dilute urine **polydipsia d/t thirst mechanism; need COMPENSATION
Clinical Manifestations glucose intolerance
-development of DM
Origin of the name Diabetes Insipidus
-diabetic patients tended to urinate a lot -nothing to do with sugar though
Extension to hypothalamus leads to
-disturbances of wakefulness, thirst, appetite and temperature **extension means the tumor is now pressing on the hypothalamus
Clinical manifestations "thin skin"
-due to loss of collagen -purple striae due to loss of collagen (capillaries visible) -skin stretches over adipose tissue **white striae are d/t rapid weight loss and gain
How is someone diagnosed with hyperthyroidism?
-elevated thyroid hormone levels -T3 and T4
Awareness
-encompasses all cognitive functions
Appearance of patient with Acromegaly
-enlarged extremities, like forehead and tongue -maxilla lengthens and the mandible protrudes -the voice deepens -if it is before the growth plate closes, giantism can occur
What may be a casual factor of thyroid carcinoma?
-exposure to ionizing radiation during childhood -e.g. Hodgkin reaction
Adrenal Cortex disorders: Secondary Hyperaldosteronism
-extra adrenal stimulus -like angiotensin in the RAA system
Two types of failure when it comes to hormonal disorders...
-feedback mechanisms fail to function -dysfunction of an endocrine gland d/t cancer, an autoimmune disease, etc
Signs and symptoms of Graves disease: ophthalmopathy
-functional abnormalities: gaze lag; eyelids are slow too -infiltrative changes like fatty buildups under the eyes and inflammation/edema -GLOBE PROTRUSION -bulging eyes=exophthalmos
Since the urine is constantly exiting the body, the blood serum osmolarity is
-high -above 295 -hypernatremia
The hormonal disorders will either be described as
-hypo -hyper
Patients with hypoparathyroidism will be
-hypocalcemic -hyperphosphatemic
Clinical manifestations virilization
-in females; means "like a man" -e.g. facial hair, acne, oligomenorrhea **change made by a hormone other than cortisol
With SIADH, there is water intoxication
-in the blood -d/t enhanced renal water retention
Intracellular disorders: example of inadequate synthesis of a second messenger
-inadequate synthesis of the second messenger cAMP so that the target cell fails to express the usual hormonal effect
Adrenal Cortex Disorders: cushing syndrome
-increased cortisol regardless of etiology -s/sx refers to the manifestations -2nd kinds, 3rd is d/t drugs
Most of the s/sx of hypoparathyroidism deals with hypocalcemia
-increased nerve and muscle excitation -tetany...check with the 2 tests -seizures, laryngeal spasms (think of the location of the organ), loss of body/scalp hair, bone deformities
Pathophysiology of hyperaldosteronism
-increased sodium reabsorption leads to an increase in extracellular volume and hypokalemia
With SIADH, there is concentrated urine
-increased specific gravity, above 1.030 -urine will be very dark, not a lot (oliguria)
HypOparathyroidism is commonly caused by
-injury during head and neck surgery (injury to the glands) **all people would experience low Ca+ and high PO4- in this scenario
Hypothyroidism has an
-insidious onset, hard to see coming
HypOpituitarism
-involves the organ itself, so its a primary disorder **most common is Sheehan syndrome
Clinical manifestations altered mental status
-irritability and depression (psychotic episodes)...think roid rage
S/sx of hypothyroidism
-low BMR, therefore, cold intolerance, lethargic **complete opposite of Grave's disease -myxedema is characteristic sign of SEVERE/long-standing disease....alters composition of dermis and other tissues
With low levels of PTH, there is
-low serum calcium and high serum phosphate
Cushing-like syndrome
-may develop in relation to EXOGENOUS administration of glucocorticoids -high dose of steroids
Clinical manifestations hypertension
-minteralcorticoids promote increase in Na+ and a decrease in K+ -aldosterone; therefore, a change made by a hormone other than cortisol
Hypothyroidism is the
-most common thyroid disorder -again, most common in women
Clinical manifestations catabolic effects:
-muscle weakness, osteoporosis/pathological fractures
Thyroid hormone
-must have iodine in the body for the thyroid gland to work -Secreted in response to TSH -90% T4(iodine ions)-tetraiodinan ions and 10% T3 --Most T4 then converted to T3 -Bound to thyroxine-binding globulin, thyroxine-binding prealbumin, albumin, or lipoproteins(how it travels throughout the body) -Affects growth and maturation of tissues, cell metabolism, heat production, and oxygen consumption-has the impact on your metabolism
Central type of Diabetes Insipidus is called and involves
-neurogenic -caused by an absence of ADH -d/t a lesion of the hypothalamus, pituitary stalk, posterior pituitary **more specifically a stroke and/or ischemia could have been the cause
With SIADH, hyponatremia can lead to severe consequences like
-neurological damage -swollen brain cells
Pathophysiology behind hypercortisolism
-no diurnal/circadian secretion patterns of ACTH and cortisol and -no increase in ACTH and cortisol secretion in response to a stressor -there is no reserve for fight or flight without a rhythm
What is characteristic of secondary hyperthyroidism?
-normal to increased TSH levels -d/t TSH secreting pituitary tumors
Primary Hyperparathyroidism
-occurs more in older adults -grow and secrete, grow and secrete, grow and secrete -most (80%) results from chief cell adenoma= increased secretion of PTH -PTH is not responding to usual feedback control of hypocalcemia; secreting PTH despite NOT having LOW levels of Ca+ -patient is now HYPERCALCEMIC; no negative feedback loop
Without PTH, resorption
-of calcium from bone is impaired; therefore, there is no s/sx in the bone
Why do patients with acromegaly have a decreased life expectancy?
-only if their condition is left untreated -acromegaly leads to HTN and DM (Higher blood glucose levels may result from excessive growth hormone production) -eventually the HTN will lead to an after load problem, causing LVH and HF -The incidence of heart disease is increased, likely due to enlargement of the heart muscle, which impairs its functioning (called cardiomyopathy). High blood pressure is more common in acromegaly. Some people have problems with their heart valves. Heart failure may occur if acromegaly is uncontrolled.
Myxedema Coma
-opposite of thyroid storm, yet still a medical emergency -diminished LOC -everything shuts down...hypothermia, hypoventilation, hypotension, hypoglycemia, lactic acidosis
Endocrine System organs
-pineal gland pituitary gland thyroid gland parathyroid gland thymus pancreas adrenal gland testis ovary
Central/secondary hyperthyroid includes
-pituitary adenoma *back in the brain, outside the thyroid)
Latrogenic
-post surgical
Sheehan syndrome
-postpartum pituitary infarction d/t hemorrhage -the pituitary gland is extremely VASCULAR, therefore, is vulnerable to infarct -the pituitary gland DOUBLES IN WEIGHT during pregnancy -PAN PITUITARY
Signs and symptoms of Graves disease: dermopathy
-pretibial myxedema -subcutaneous swelling on anterior portion of LEs -maybe some induration and erythema (hardness and redness)
ACTH independent cushing syndrome
-primary -usually d/t adrenal tumors in the gland -does NOT matter what is up with ACTH
Adrenal Cortex disorders: hypocortisolism (other corticosteroids may be low too)
-primary=addison's disease -most often caused by autoimmune reaction/disease that destroys cortical cells
Clinical manifestations
-progressive weakness throughout day, especially with stress (decrease in fluid) -GI disturbances (anorexia, N/V, diarrhea) -hypoglycemia w/ mental confusion r/t an absence of cortisol (decrease in gluconeogenesis and usage of glycogen storage by liver) -hyperpigmentation r/t increased secretion of ACTH -vitiligo (white patchy areas of depigmentations d/t destruction of melanocytes) -hypotension (there is a decrease in blood volume since there is a renal loss of Na+) -addisonian crisis
Thyrotoxic storm
-rare but very serious -metabolic processes are too revved up...fatal
Regulation of calcium reabsorption from
-renal tubules is impaired YET -phosphate reabsorption by renal tubules increases
Intracellular disorders: the cell can also (and thirdly),
-respond abnormally to the second messenger
Adrenergic effects
-rev up -increased heart rate -palpitations -nervousness -HTN -increased cardiac contractility -heat intolerance, skin hot and moist
Intracellular disorders: inadequate synthesis of a second messenger
-second messengers are needed to transduce the hormonal signal into an intracellular event
ACTH dependent cushing syndrome
-secondary -may occur at any age, but mainly 30-50 -most common complication of cushing disease
Addisonian Crisis
-severe hypotension and vascular collapse
Other reasons for pituitary infarction?
-shock -sickle cell disease -head trauma -meningitis -vascular malformations -surgical ablation
The mucous membranes in the larynx and pharynx thicken causing
-slurred speech and hoarseness -thickness causing this
Ectotopically means
-somewhere else in the body
What is diagnostic for primary hyperthyroidism?
-suppressed serum TSH -depressed negative feedback control, turn off stimulating hormone, do not need it
SIADH stands for
-syndrome of inappropriate antidiuretic hormone **affects posterior pituitary gland
With Nephrogenic Diabetes Insipidus,
-target organ response; intracellular disorder -caused by faulty response of renal cells to ADH -r/t diseases and drugs like anesthetics -can be acquired (like statement above) or genetic **there is an inhibition of generation of cAMP in the renal cells (decrease in formation of aquaporin channels)
Parathyroid hormone regulates
-the amount of Ca2+ and PO4- in the blood and in the bone -Causes efflux of Ca+ from the bone to the blood (resorption); PO4- at times, too -also leads to Ca+ reabsorption within the kidney; the kidney releases Vitamin D allowing enhanced absorption of Ca+ in the gut; PO4- is always excreted
Adenomatous tissue secretes
-the hormone of the cell type from which it arose; can just happen with one cell type like only GH -may hyper secrete GH, TSH, FSH, LH
The clinical manifestations of hypopituitarism are variable d/t
-the hormones affected
With the anterior pituitary gland, neurosecretory cells from
-the hypothalamus secrete RELEASING (tropic) and INHIBITING hormones into the pituitary portal system -the anterior pituitary secretes its hormones in response
Cell surface receptor associated disorders lead to a DECREASE in
-the number of receptors -therefore there is defective hormone-receptor binding
In the posterior pituitary, neuro-secretory cells in
-the thalamus produce oxytocin and ADH -the axon endings secrete or transmit the hormones into the bloodstream
Cell surface receptor associated disorders, instead of a problem with the number of receptors,
-there can be impaired receptor function -receptors become "insensitive" to the hormone even though the hormone can physically be at the receptor **think of insulin resistant diabetes
In order for a patient to be diagnosed with SIADH,
-there has to be the absence of conditions that alter volume status -there cannot be CHF or renal disease -in order to make a nursing diagnosis, there needs to be a matching clinical story
Cell surface receptor associated disorders can deal with ANTIBODIES
-these antibodies either block receptors completely or mimic the action of the needed hormone **autoimmune -can be a positive or negative effect (neither are good)
Adrenal Medulla disorder: Pheochromcytoma
-these tumors secrete catecholamines continuously **very rare, few are malignant -causes HTN, tachycardia, palpitations -headache -weight loss -diaphoresis **s/sx related to SNS
Signs and symptoms of Graves disease: goiter
-thyroid enlargement (goiter) -caused by stimulation of TSH receptors by the IgG autoantibodies -these antibodies not only cause the release of T3/T4 but cause growth
Findings of thyroid carcinoma
-thyroid nodules -mets to the lungs, brain and bone **not smooth with palpation -changes in voice, swallowing -most are euthyroid (normal T3, T4): normal size, normal hormone -most tumors are well differentiated **more likely to look like thyroid cells more than they don't
Grave's disease is the result of
-thyroid stimulation with auto-antibodies against the TSH receptor, which stimulates the production of T3 and T4 **will not see increased TSH
Hyperthyroidism can also be called
-thyrotoxicosis
Why does dermopathical changes occur?
-thyrotropin receptor antigens on fibroblasts and recruited T lymphocytes; reacting to the T lymphocytes since this is an autoimmune disease
Thyroid Carcinoma
-treatable one; most do not succumb -most common endocrine malignancy, but still relatively rare -occurs more in women
Clinical manifestations weight gain:
-truncal obesity, moon face and buffalo hump r/t accumulation of adipose tissue in trunk, facial, and cervical areas -there is also Na+ and H2O retention
Patients with DI can urinate
-up to 12 liters per day **polyuria**
Acromegaly (from a pituitary tumor, hyperpituitarism)
-usually a GH secreting adenoma
Hypothyroidism affects
-virtually all body systems
A pituitary adenoma can also lead to
-visual disturbances -r/t pressure on optic chiasm and other cranial nerves (oculomotor, trigeminal)
Cell surface receptor associated disorders occur mainly with
-water soluble hormones like INSULIN because there has to be a connection with a receptor and fat-soluble hormones can be diffused through the membrane
Intracellular disorders: may be faulty response to hormone-receptor binding
-water-soluble hormones -there is no generation of a second messenger period **this can deal with the receptors that are present within the cell, even within the nucleus**
A nurse is teaching a client about the respiratory system. Which area (see diagram) should the nurse use to identify a structure that is a part of the upper airway? 3681172309 1 Area 1 2 Area 2 3 Area 3 4 Area 4
1 Area 1
How is the majority of oxygen transported to a client's cells and tissues? 1 Bound to hemoglobin 2 Dissolved in the plasma 3 Bound to white blood cells 4 Dissolved in the pulmonary capillary
1 Bound to hemoglobin
A nurse is talking about the structure of the pulmonary system that provides a defense mechanism by moving entrapped particles toward the oropharynx to be swallowed or expectorated. Which structure is the nurse describing? 1 Cilia 2 Nostrils 3 Turbinates 4 Macrophages
1 Cilia
What type of specialized respiratory epithelial cells line a client's conducting airways? 1 Ciliated epithelial cells 2 Keratinized epithelial cells 3 Squamous epithelial cells for gas diffusion 4 Cells that secrete enzymes to digest foreign particulates
1 Ciliated epithelial cells
Which piece of equipment should the nurse obtain to monitor a client's oxygen saturation level? 1 Oximeter 2 Stethoscope 3 Nasal cannula 4 Arterial blood gas kit
1 Oximeter
A nurse is teaching about the circulation that feeds the lung tissues and participates in gas exchange. Which term should the nurse use to describe this type of circulation? 1 Pulmonary circulation 2 Bronchial circulation 3 Coronary circulation 4 Systemic circulation
1 Pulmonary circulation
10 Factors Contributing to Blood Pressure Variations in Healthy People
1.) AGE: Older adults have decreased elasticity of the arteries, which INCREASES peripheral resistance + therefore INCREASES blood pressure 2.) CIRCADIAN RHYTHM: Normal fluctuations occur during the day. BP is LOWEST in morning. BP can rise as much as 5 to 10 mm Hg by late afternoon + generally falls during sleep. 3.) GENDER: Women usually have lower BP than men of the same age until menopause. 4.) FOOD INTAKE: BP increases after eating. 5.) EXERCISE: Systolic BP rises during periods of exercise 6.) WEIGHT: BP is usually higher in the obese 7.) EMOTIONAL STATE: Anger, fear, excitement + pain generally cause the BP to rise 8.) BODY POSITION: BP tends to be lower in a prone or supine position than when sitting or standing 9.) RACE: There is generally an increased BP in African Americans 10.) MEDICATIONS: Varies
10 Factors Affecting Respiratory RATE, DEPTH + MOVEMENTS
1.) AGE: Respiratory rate DECREASES with age 2.) EXERCISE: Exercise INCREASES respiratory rate + depth 3.) ACID-BASE BALANCE: Alteration sin acid-base balance (especially ACIDOSIS) commonly result in INCREASED rate + DEPTH of respirations (hyperventilation) 4.) BRAIN LESIONS: Lesions of the brain (such as hemorrhage or tumors) or brainstem can cause a change in BOTH the depth + rate of resirations, most commonly manifested as Cheyne-Stokes respirations. 5.) INCREASED ALTITUDE: INCREASE respiratory rate + depth prior to adaptation by INCREASING hemoglobin levels. 6.) RESPIRATORY DISEASES: Varies 7.) ANEMIA: May result in INCREASED rate of respirations as anemia decreases in oxygen-carrying hemoglobin 8.) ANXIETY: May cause signing type respirations (increase DEPTH) + increased RATE 9.) MEDICATIONS: Varies 10.) ACUTE PAIN: INCREASES respiratory RATE but may DECREASE respiratory DEPTH
Blood Pressure Errors: 9 Reasons for FALSELY LOW ASSESSMENTS
1.) Hearing deficit 2.) Noise in environment 3.) Viewing the meniscus from above eye level 4.) Applying TOO WIDE of a cuff (cuff should be at least 40% of arm circumference, with a length to width radio of 2:1) 5.) Inserting earpieces of stethoscope incorrectly 6.) Using cracked or kinked tubing 7.) Releasing the valve rapidly 8.) Misplacing the bell beyond the direct area of the artery 9.) Failing to pump the cuff 20-30 mm Hg above the disappearance of the pulse
4 Methods of Assessing Respirations
1.) Inspection (observing + listening) 2.) Listening with stethocope 3.) Monitoring arterial blood gas results 4.) Using a PULSE OXIMETER to determine oxygenation of blood
4 Mechanisms of Heat Loss
1.) Radiation - diffusion of heat. Ex. not wearing a coat in winter. 2.) Convection - Dissemination of heat by motion between areas of unequal density. Ex. A fan or breeze. 3.) Evaporation - Conversion of a liquid to vapor. Ex. Sweating. 4.) Conduction - Transfer of heat to another object via direct contact. Ex. Wearing an ice pack, causing the ice to melt.
The 4 Vital Signs
1.) Temperature (T) 2.) Pulse (P) 3.) Respiration (R) 4.) Blood Pressure (BP) - Pain is often considered the 5th vital sign - pulse oximetry (the noninvasive measurement of arterial oxyhemoglobin saturation) is also often included in vital signs in hospitalized patients - The health status of a person is reflected in these vital signs. - A change in vital signs might indicate a change in health.
Blood Pressure Errors: 6 Reasons for FALSELY HIGH ASSESSMENTS
1.) Using a manometer not calibrated at the zero makr 2.) Assessing the blood pressure immediately after exercise 3.) Viewing the meniscus from below eye level 4.) Applying a cuff that is too narrow 5.) Releasing the valve too slowly 6.) Reinflating the bladder during ausculation
3 Parts of Respirations
1.) VENTILATION: Breathing, also called respirations. It is the movement of gasses in + out of the lungs. Inspiration is the act of breathing in + expiration is the act of breathing out. Controlled by BOTH the AUTONOMIC + VOLUNTARY nervous system. THE COMPONENT THAT IS ASSESSED BY NURSES AS A VITAL SIGN. 2.) DIFFUSION: Is the EXCHANGE of oxygen + carbon dioxide between the alveoli IN THE LUNGS + the circulating blood. 3.) PERFUSION: The EXCHANGE of of oxygen + carbon dioxide between the circulating blood + tissue CELLS.
Normal Respiratory Rate: Adult
12 - 20 breaths a minute
Normal Respiratory Rate: Teen
12 - 22 breaths a minute
How many pairs of cranial nerves?
12 pairs
Normal Blood Pressure Reading
120 / 80
Prehypertension Reading
120-139 / 80-89
High Blood Pressure Reading: Stage 1
140-159 / 90-99
Normal Respiratory Rate: Aged Adult
16 - 24 breaths a minute
High Blood Pressure Reading: Stage 2
160+ / 100+
Normal Respiratory Rate: Preteen
18 - 26 breaths a minute
Lillian Wald
1911 chaired a commitee formed by member of the Associated Alumnae of aTraining Schools for Nurses, and later became the ANA (American Nurses Association) & NLN (National League for Nursing)
Social Security Act
1935...set the precedent for the passage of the Medicare and medicaid Acts that followed in 1965
Spirt of Nursing Statue
1938, places in Arlington National Cemetery to honor military nurses. (of Florence Nightingale)
Clara Mass
1976 stamp, Clara Maas, She Gave Her Life, commemorated the 100th birthday of Maas.
A nurse is teaching a client about the process of gas transport. Which steps should the nurse include in the teaching session? 1 Sighing, diffusion, reserve 2 Diffusion, perfusion, ventilation 3 Perfusion, rebreathing, sighing 4 Ventilation, reserve, rebreathing
2 Diffusion, perfusion, ventilation
A nurse is asked where gas exchange occurs in the respiratory system. How should the nurse respond? 1 In the cilia 2 In the alveoli 3 In the bronchi 4 In the trachea
2 In the alveoli
A nurse is teaching about the type of lung receptor that is activated when a client inhales dust and starts to cough. Which term should the nurse use to describe this type of lung receptor? 1 J receptors 2 Irritant receptors 3 Chemoreceptors 4 Stretch receptors
2 Irritant receptors
A client asks the nurse what causes "sneezing attacks." The nurse should answer this question based upon the knowledge that which structure triggers the sneeze reflex? 1 Nasal hairs and turbinates 2 Irritant receptors in the nares 3 Upper respiratory tract mucosa 4 Irritant receptors in the trachea and large airways
2 Irritant receptors in the nares
Which information indicates the nurse has a correct understanding of the location of a client's respiratory center? 1 It is located in the alveoli. 2 It is located in the brain stem. 3 It is contained in the cerebral cortex. 4 It is contained in one major type of neuron.
2 It is located in the brain stem.
Which term should the nurse use to describe the serous membrane covering the client's lungs? 1 Parietal pleura 2 Visceral pleura 3 Parietal peritoneum 4 Visceral peritoneum
2 Visceral pleura
Most authorities agree that an individual's sleep-wake cycle is fully developed by what age?
2 to 3 years
Normal Respiratory Rate: Child
20 - 25 breaths a minute
Normal Respiratory Rate: Toddler
20 - 30 breaths a minute
Normal Respiratory Rate: Infants
20 - 40 breaths a minute
C
26. A nurse recalls posthemorrhagic anemia can result in death when a patient's blood loss is in excess of: a. 20% to 29% b. 30% to 39% c. 40% to 49% d. 50% to 59% REF: p. 506
Which term should the nurse use to describe receptors that monitor the pH and arterial pressure of carbon dioxide (Paco2) of arterial blood? 1 J receptors 2 Irritant receptors 3 Chemoreceptors 4 Stretch receptors
3 Chemoreceptors
A nurse is teaching a client about the type of cell lining the bronchi. Which information from the client indicates teaching was successful? 1 Hila cells line the bronchi. 2 Carina cells line the bronchi. 3 Ciliated cells line the bronchi. 4 U-shaped cartilage cells line the bronchi.
3 Ciliated cells line the bronchi.
A nurse is teaching a client about the major muscles of inspiration. Which information should the nurse include as an example of a major muscle of inspiration? 1 Scalene 2 Trapezius 3 Diaphragm 4 Sternocleidomastoid
3 Diaphragm
A client is a mouth breather. Which processes are not as efficient as those in a nose breather? 1 Diffusing and perfusing 2 Coughing and exhaling 3 Filtering and humidifying 4 Ventilating and vocalizing
3 Filtering and humidifying
An infant has a condition that causes a deficiency of surfactant. When the parents ask the nurse where surfactant is made, how should the nurse respond? 1 In the trachea 2 In the large airways 3 In the air sacs of the lungs 4 In the tiny, small respiratory tubes
3 In the air sacs of the lungs
A nurse is asked what the most important cause of pulmonary artery constriction is. What is the nurse's best reply? 1 It is hematocrit. 2 It is carbonic acid. 3 It is low alveolar Po2. 4 It is plasma proteins.
3 It is low alveolar Po2.
Which is the most important cause of pulmonary artery constriction in a client? 1 Acidemia 2 Alkalosis 3 Low alveolar Po2 4 High alveolar Po2
3 Low alveolar Po2
Which term should the nurse use to describe the region between the lungs that contains the client's heart, great vessels, and esophagus? 1 Hilum 2 Alveolus 3 Mediastinum 4 Pleural cavity
3 Mediastinum
What type of pressure is located in the client's pleural space? 1 Partial 2 Positive 3 Negative 4 Complete
3 Negative
n which zone of a client's lung are the arterial and venous pressures greater than alveolar pressure? 1 Zone I 2 Zone II 3 Zone III 4 Zone IV
3 Zone III
Love and Belonging needs
3. Love and belongingness needs - friendship, intimacy, trust and acceptance, receiving and giving affection and love. Affiliating, being part of a group (family, friends, work). The original hierarchy of needs five-stage model includes: 1. Biological and Physiological needs - air, food, drink, shelter, warmth, sex, sleep. 2. Safety needs - protection from elements, security, order, law, stability, freedom from fear. 3. Love and belongingness needs - friendship, intimacy, trust and acceptance, receiving and giving affection and love. Affiliating, being part of a group (family, friends, work). 4. Esteem needs - achievement, mastery, independence, status, dominance, prestige, self-respect, respect from others. 5. Self-Actualization needs - realizing personal potential, self-fulfillment, seeking personal growth and peak experiences.
Normal Respiratory Rate: Newborn
30 - 55 breaths a minute
How many pairs of spinal nerves?
31 pairs
How many vertebrae are there?
33 total 7 Cervical 12 Thoracic 5 Lumbar 5 Fused Sacral 4 Fused Coccygeal
A nurse is teaching the staff about the acinus. Which information should the nurse include about a structure of the acinus? 1 Nares 2 Larynx 3 Trachea 4 Alveolar ducts
4 Alveolar ducts
The nurse plans to teach a client about oxygen and carbon dioxide. Which information would be appropriate for the nurse to include in the teaching plan? 1 Carbon dioxide is less soluble than oxygen. 2 Oxygen diffuses more quickly than carbon dioxide. 3 The capillary beds do not allow for the exchange of carbon dioxide. 4 Carbon dioxide is eliminated to maintain normal acid-base balance.
4 Carbon dioxide is eliminated to maintain normal acid-base balance.
A nurse assesses an adult client as part of an annual health examination. Which assessment finding does the nurse recognize as abnormal while the client is at rest? 1 Respirations: even and regular 2 Occasional bowel sounds in all quadrants 3 Diameter of chest increases during inspiration 4 Sternocleidomastoids contract during inspiration
4 Sternocleidomastoids contract during inspiration
Which information from the client indicates teaching by the nurse was successful about upper airway structures? 1 The carina is in the upper airway. 2 The trachea is in the upper airway. 3 The bronchi are in the upper airway. 4 The oropharynx is in the upper airway.
4 The oropharynx is in the upper airway.
Normal Pulse Rate: Aged Adult
40 - 100 beats / min
Nursing Process
5 step systematic method for giving patient care; involves- Assessing, Diagnosing, Planning, Implementing, and Evaluating
Normal Pulse Rate: Teen
55 - 105 beats / min
Normal Pulse Rate: Adult
60 - 100 beats / min
Normal Pulse Rate: Preteen
65 - 110 beats / min
Normal Pulse Rate: Child
70 - 115 beats / min
Normal Pulse Rate: Toddler
70 - 120 beats / min
Normal Pulse Rate: Newborn
70 - 190 beats / min
How many bones in the cranium?
8 bones
Normal Pulse Rate: Infants
80 - 150 beats / min
Adrenal cortex
80% of an adrenal gland's total weight Zona glomerulosa: aldosterone secreted, targets kidneys, increases their absorption of sodium, water; accelerates loss of potassium Zona fasciculata: middle layer, secretes glucocorticoids so cortisol, targets liver, accelerates rate of glucose synthesis and glycogen formation Zona reticularis: most inner layer of cortex, has androgens (aldosterone, estrogen), more effect on women and children, promotes bone and muscle and blood formation -Stimulated by adrenocorticotropic hormone (ACTH): regulate release of cortisol, stress can increase this secretion -Glucocorticoid hormones --Direct effects on carbohydrate metabolism --Anti-inflammatory and growth-suppressing effects --Most potent naturally occurring glucocorticoid is cortisol; more stress more cortisol secretion Mineralocorticoid hormones --Affect ion transport by epithelial cells ---Increase the activity of the sodium pump of the epithelial cells: increase absorption of sodium and water ---Cause sodium retention and potassium and hydrogen loss Most potent naturally occurring mineralocorticoid is aldosterone ---Regulated by the renin-angiotensin system Adrenal estrogens and androgens --Estrogen secretion by the adrenal cortex is minimal --The adrenal cortex secretes weak androgens ---Androgens are converted by peripheral tissues to stronger androgens such as testosterone
Bradycardia
= less than 60 beats/min (Slide 11 chap24)
Dysrhythmia/ arrhythmia
?? an abnormal cardiac rhythm
Physiologic needs
??Physiological needs are the physical requirements for human survival. If these requirements are not met, the human body cannot function properly and will ultimately fail. Physiological needs are thought to be the most important; they should be met first. Air, water, and food are metabolic requirements for survival in all animals, including humans. Clothing and shelter provide necessary protection from the elements. While maintaining an adequate birth rate shapes the intensity of the human sexual instinct, sexual competition may also shape said instinct.[2]
A immunoglobin produced by the body in response to a specific antigen is called: A) Antibody B) Antigen C) Disinfection D) Antimicrobial
A
Interval between entrance of organisms in the body and the appearance of the first symptoms: A) Incubation stage B) Prodromal stage C) Full Illness stage D) Convalescent Stage
A
Microorganism that uses the respiratory tract as a portal of exit. A) TB and Flu B) Neisseria Gonorrhea C) Tetanus D) Staph aureus
A
The absence of disease-producing microorganisms; using methods to prevent infection is called: A) Asepsis B) Antigen C) Disinfection D) Antimicrobial
A
The normal white blood cell count ranges from 5,000 - 10,000/mm. What change indicates an acute infection? A) Increase in WBC count. B) Decrease in WBC count.
A
The nurse sets up a nonbarrier sterile field on the patient's over-bed table. In which of the following instances is the field contaminated? A) Sterile saline soluition is spilled on the field. B) The nurse, who has a cold, wears a double mask. C) Sterile objects are kept within 1-inch border of the field. D) The nurse keeps the top of the table above his or her waist.
A
The severity of a patient's illness depends on all of the following except: A) Incubation period B) Extent of infection C) Susceptility of the host D) Pathogenicity of the microorganism.
A
What are symptoms such as pain, tenderness & redness at the wound site called? A) Localized B) Manageable C) Systemic D) Virulence
A
What can you expect not to change during infections? A) Basophils B) Monocytes C) Lymphocytes D) Eosinophils
A
What change is found in sterile culture of urine or blood when there is a presence of infection found? A) Microorganism growth B) Clear in color C) Odorless D) Thicker than normal
A
What is a age related decline in immune system function? A) Immune senescence B) Immune senility C) Immune depression D) Immune Serinity
A
What is a pathogen? A) Infectious agent B) An instrument used to clear a patient's airway C) Cancerous cell
A
What is an infection in which the causative organism is acquired from outside the host called? A) Exogenous B) Endemic C) Antigen D) Endogenous
A
What is bacteria that thrives with liggle or no free oxygen called? A) Anaerobic B) Carriers C Reservoirs D) Aerobic
A
What is colonization? A) Organism that multiplies within a host but does not cause an infection. B) Mass spreading of a contagious disease. C) A area where a group of people all live within close range of one another.
A
What is the ideal temperature for human microbes to flurish? A) 20-43 degrees C or 68-104 degrees F B) 24-41 degrees C or 75-106 degrees F C) 22-33 degrees C or 72-91 degrees F D) 37-43 degrees C or 98.6-109 degrees F
A
What isolation precaution level should be used for airborne and droplets? A) 2nd Tier, contact & protective equipment. B) 1st Tier, just gloves C) 3rd Tier, Full package with positive pressure room D) 4th Tier, Full package with negative pressure room
A
When a patient on respiratory isolation must be transported to another part of the hospital, the nurse: A) Places a mask on the patient before leaving the room. B) Obtains a health care provider's order to prohibit the patient from being transported. C) Instructs the patient to cover his or her mouth and nose with a tissue when coughing or sneezing. D) Advises other health team members to wear masks and gowns when coming in contact with the patient.
A
Which is not a Portal of exit? A) Ears B) Skin C) Mucous membranes D) Resiratory tract E) Urinary tract F) GI tract
A
Which is the most common mode of direct transimmion? A) Person to Person B) Inanimate objects C) Body fluids that travel D) Droplets or particles in the air E) Contaminated items F) Internal & External transmission.
A
Which of the following is the most effective way to break the chain of infection? A) Hand hygiene B) Wearing gloves C) Placing patients in isolation D) Providing private rooms for patients
A
Who is most at risk for infections due to Stress? A) A person under emotional or physical overload. B) Nursing Student C) Soldier D) Politician
A
Your ungloved hands come in contact with the drainage from your patient's wound. What is the correct method to clean your hands? A) Wash them with soap and water. B) Use an alcohol-based hand cleaner. C) Rinse them and use the aolcohol-based hand cleaner. D) Wipe them with a paper towel.
A
A
A 10-year-old male is diagnosed with leukemia. The nurse assesses for which other condition that could be associated with his disease? a. Down syndrome b. Hemophilia c. Hyperthyroidism d. Pheochromocytoma REF: p. 513
D
A 10-year-old male presents with abdominal swelling, night sweats, fever, and weight loss. He is diagnosed with Burkitt lymphoma. Upon obtaining the history, which of the following is the most likely cause? a. Cytomegalovirus (CMV) b. Adenovirus c. Human papillomavirus (HPV) d. Epstein-Barr virus (EBV) REF: p. 519
C
A 15-year-old female presents with splenomegaly, hepatomegaly, and lymph node enlargement. She is diagnosed with infectious mononucleosis. What should the nurse tell the patient about the recovery time? a. 72 hours b. 3 to 5 days c. A few weeks d. Six months REF: p. 511
B
A 15-year-old male is diagnosed with infectious mononucleosis. When the patient asks how he got this disease, how should the nurse respond? The most likely cause is: a. Adenovirus b. Epstein-Barr virus (EBV) c. Cytomegalovirus (CMV) d. Toxoplasma gondii REF: p. 511
B
A 15-year-old male with infectious mononucleosis is being given instructions on how to prevent the spread of this infection to others. Which statement represents a correct instruction? a. Wear a surgical mask when others are in the room. b. Do not share drinking glasses or eating utensils. c. Avoid all contact with other people. d. No precautions are necessary. REF: p. 511
A
A 2-year-old malnourished child has vitamin B12 and folate deficiencies. A blood smear suggests the deficiency is macrocytic and normochromic. The nurse would expect the hemoglobin to be: a. Normal b. Sporadic c. Low d. High REF: p. 501
A
A 20-year-old female has an increase in eosinophils. When the patient wants to know the most likely cause of the eosinophilia. What is the nurse's best response? a. Parasitic invasion and allergic reactions b. Viral and bacterial infections c. Stress and anxiety reactions d. Fungal infections and delayed hypersensitivity REF: p. 509
D
A 20-year-old female undergoes lab testing for anemia. Results show high iron, bilirubin, and transferrin and low hemoglobin and hematocrit. Which of the following is the most likely diagnosis to be documented on the chart? a. Pernicious anemia b. Folate deficiency anemia c. Iron deficiency anemia d. Sideroblastic anemia REF: p. 505
B
A 21-year-old female was recently diagnosed with iron deficiency anemia. In addition to fatigue and weakness, which of the following clinical signs and symptoms would she most likely exhibit? a. Hyperactivity b. Spoon-shaped nails c. Gait problems d. Petechiae REF: p. 504
A
A 21-year-old woman was recently diagnosed with iron deficiency anemia. Her hematocrit is 32%. Which of the following treatments would the nurse expect to be prescribed for her? a. Iron replacement b. Splenectomy c. A bone marrow transplant d. No treatment is necessary REF: p. 504
C
A 22-year-old female just delivered a healthy baby girl. She suffered from eclampsia during her pregnancy, and on the second postpartum day she complained of bleeding gums and bruising on her arms and legs. Hematology lab tests indicate that she had disseminated intravascular coagulation (DIC). Further review of lab tests by the nurse revealed an increase in: a. Platelets b. Hematocrit c. Fibrin degradation products (FDPs) d. Protein C REF: p. 528
D
A 25-year-old female has a heavy menses during which she loses a profuse amount of blood. Which of the following adaptations should the nurse expect? a. Movement of fluid into the cell b. Decreased cardiac output c. Decreased oxygen release from hemoglobin d. Peripheral vasoconstriction REF: p. 501
C
A 30-year-old female presents with hematuria, menorrhagia, and bleeding gums. She is diagnosed with immune thrombocytic purpura (ITP). A nurse realizes the most likely cause is: a. Allergy-induced platelet lysis b. An immune response to hypersplenism c. Antibody destruction of platelets d. T cell injury to megakaryocytes REF: p. 524
D
A 34-year-old male presents in the emergency room with extreme fatigue and shortness of breath. His skin and sclera appear to have a yellowish discoloration. These assessment findings are consistent with which type of anemia? a. Posthemorrhagic anemia b. Iron deficiency anemia c. Aplastic anemia d. Hemolytic anemia REF: p. 501
D
A 35-year-old female is diagnosed with lymphadenopathy. Which assessment finding will help confirm this diagnosis? a. Small, hard lymph nodes b. Disordered lymph nodes c. Nonpalpable, nontender lymph nodes d. Enlarged lymph nodes REF: p. 515
C
A 35-year-old female is diagnosed with vitamin B12 deficiency anemia (pernicious anemia). How should the nurse respond when the patient asks what causes pernicious anemia? A decrease in ______ is the most likely cause. a. Ferritin b. Gastric enzymes c. Intrinsic factor d. Erythropoietin REF: p. 501
C
A 35-year-old male has enlarged lymph nodes in the neck and a mediastinal mass. He was diagnosed with Hodgkin lymphoma. Which of the following abnormal cells would the nurse expect to find with this disease? a. Merkel cell b. Schwann cell c. Reed-Sternberg cell d. Kupffer cell REF: p. 516
B
A 35-year-old male with hyperthyroidism begins treatment to decrease thyroid activity. A nurse monitors for which of the following conditions that could result secondary to the treatment? a. Eosinophilia b. Basophilia c. Monocytosis d. Lymphocytosis REF: p. 509
C
A 40-year-old female develops disseminated intravascular coagulation (DIC). Upon obtaining the history, which finding is the most likely cause of this condition? a. Snake bite b. Blood transfusion c. Sepsis d. Immune thrombocytopenic purpura (ITP) REF: p. 527
B
A 40-year-old male vegetarian is diagnosed with folate deficiency anemia. He reports that he is an alcoholic. Which of the following factors put him at greatest risk for developing his disease? a. Being vegetarian b. Being alcoholic c. Age d. Gender REF: p. 503
A
A 45-year-old male is diagnosed with macrocytic, normochromic anemia. The nurse suspects the most likely cause of this condition is: a. Defective DNA synthesis b. Abnormal synthesis of hemoglobin c. Defective use of vitamin C d. Blocked protein synthesis REF: p. 501
A
A 45-year-old male is diagnosed with sideroblastic anemia. When he asks what the most likely cause of this disease is, what is the nurse's best response? a. Ineffective iron uptake and abnormal hemoglobin production b. Misshapen erythrocytes with low hemoglobin c. Decreased levels of tissue iron with megaloblastic erythrocytes d. Premature erythrocyte destruction and erythropoietin deficiency REF: p. 505
C
A 5-year-old female is diagnosed with acute leukemia. The nurse will most likely treat this patient with: a. Bone marrow transplant b. Immunotherapy c. Chemotherapy d. Localized radiation therapy REF: p. 513
B
A 5-year-old male was diagnosed with normocytic-normochromic anemia. Which of the following anemias does the nurse suspect the patient has? a. Sideroblastic anemia b. Hemolytic anemia c. Pernicious anemia d. Iron deficiency anemia REF: p. 501
D
A 50-year-old female is diagnosed with primary thrombocythemia. A nurse would expect the blood smear to reveal _____ platelets. a. Defective b. Fragmented c. Consumed d. Overproduced REF: p. 525
A
A 50-year-old female was diagnosed with sideroblastic anemia. Which of the following assessment findings would most likely occur? a. Bronze colored skin b. Decreased iron c. Normochromic erythrocytes d. Aplastic bone marrow REF: p. 505
A
A 52-year-old male IV drug user was diagnosed with hepatitis C 5 years ago. He is now experiencing impaired blood clotting. The nurse suspects a decrease in which of the following vitamins? a. K b. D c. E d. B12 REF: p. 526
A
A 57-year-old male presents to his primary care provider for red face, hands, feet, ears, and headache and drowsiness. A blood smear reveals an increased number of erythrocytes, indicating: a. Polycythemia vera (PV) b. Leukemia c. Sideroblastic anemia d. Hemosiderosis REF: p. 506
B
A 58-year-old female presents in the clinic presenting with fatigue, weight loss, and tingling in her fingers. Laboratory findings show low hemoglobin and hematocrit, a high mean corpuscular volume, and normal plasma iron. These assessment findings are consistent with which type of anemia? a. Hemolytic anemia b. Pernicious anemia c. Iron deficiency anemia d. Aplastic anemia REF: p. 501
B
A 60-year-old female emphysema patient experiences a rapid and pounding heart, dizziness, and fatigue with exertion. Which of the following respiratory assessment findings indicate the respiratory system is compensating for the increased oxygen demand? a. Bronchoconstriction b. Increased rate and depth of breathing c. Dyspnea d. Activation of the renin-angiotensin response REF: p. 501
B
A 62-year-old female tells her health care provider she has been experiencing regular night sweats that cause her to wake up drenched. She also remarks that she has been unintentionally losing weight. Physical exam reveals enlarged lymph nodes on her neck that do not appear to be painful. She should be screened for which of the following cancers? a. Epstein-Barr virus b. Hodgkin lymphoma c. Acute leukemia d. Burkitt lymphoma REF: p. 517
C
A 65-year-old male experienced loss of appetite, weight loss, lemon-yellow skin, liver enlargement, and a beefy red tongue shortly before his death. Autopsy suggested pernicious anemia, and the cause of death would most likely reveal: a. Brain hypoxia b. Liver hypoxia c. Heart failure d. Kidney failure REF: p. 503
B
A 65-year-old male is diagnosed with multiple myeloma. He reports severe pain. This pain can be attributed to: a. Neuropathic infiltrations b. Destruction of bone tissue c. Tissue hypoxia d. Accumulation of toxic proteins REF: p. 520
B
A 67-year-old female has chronic gastrointestinal bleeding. A nurse recalls the primary cause of her anemia is: a. Vitamin B12 deficiency b. Iron deficiency c. Folate deficiency d. Bone marrow failure REF: p. 504
A
A 67-year-old female is admitted to the emergency department with a diagnosis of polycythemia vera (PV). Which treatment should the nurse discuss with the patient? a. Therapeutic phlebotomy b. Restoration of blood volume by plasma expanders c. Administration of packed red blood cells d. Iron replacement therapy REF: p. 507
C
A 67-year-old female is admitted to the emergency department with a diagnosis of polycythemia vera. Upon taking the history, the patient will most likely report: a. Hyperactivity b. Decreased blood pressure c. Chest pain d. A pale skin color REF: p. 507
D
A 67-year-old male was diagnosed with polycythemia vera (PV) but refused treatment. His condition is at risk for converting to: a. Chronic lymphocytic leukemia b. Burkitt lymphoma c. Multiple myeloma d. Acute myeloid leukemia REF: p. 508
C
A 68-year-old female is admitted to the emergency department with a diagnosis of polycythemia vera (PV). A nurse realizes the patient's symptoms are mainly the result of: a. A decreased erythrocyte count b. Rapid blood flow to the major organs c. Increased blood viscosity d. Vessel injury REF: p. 507
B
A 70-year-old male is brought to the emergency department, where he dies shortly thereafter. Autopsy reveals polycythemia vera (PV). His death was most likely the result of: a. Acute renal failure b. Cerebral thrombosis c. Sepsis d. Acute leukemia REF: p. 508
What is the appropriate term for the thick filaments of myosin that constitute a central dark band?
A band
A client's heart valve that is located between the right atrium and right ventricle is stenosed. The nurse will be caring for which client?
A client with a stenosed tricuspid valve The tricuspid valve is located between the right atrium and right ventricle, and it prevents blood in the right ventricle from returning to the right atrium during systole. The mitral valve, also known as the bicuspid valve, is not located between the right atrium and right ventricle but rather between the left atrium and left ventricle. The semilunar valves are the pulmonary and aortic valves, so they are not located between the right atrium and right ventricle.
A nurse hears in report that the team will be caring for a client with a low ejection fraction. The nurse will be caring for which client?
A client with ventricular failure A decrease in ejection fraction is a hallmark of ventricular failure. Deep vein thrombosis does not affect ejection fraction; it is a venous problem. A client with increased heart contractility and a client with an overactive sympathetic nervous system will tend to have increased, not decreased, ejection fraction.
Self-efficacy
A concept included in social learning theory, refers to a person's perceived ability to successfully complete a tasks.
Clubbing
A condition affecting the fingers and toes in which proliferation of distal soft tissues, especially the nail beds, results in thickening and widening of the extremities of the digits; the nails are abnormally curved, the nail beds excessively compressible, and skin over them red and shiny
Afebrile
A condition in which the body temperature is not evelvated
Doppler Ultrasound
A device used to assess pulses that are difficult to palpate or auscultate.
Fever of Unknown Orgin (FUO)
A fever of 101 F or higher that lasts for 3 weeks or longer without an identified cause
B
A newborn is diagnosed with congenital intrinsic factor deficiency. Which of the following types of anemia will the nurse see documented on the chart? a. Iron deficiency anemia b. Pernicious anemia c. Sideroblastic anemia d. Hemolytic anemia REF: p. 502
Participating
A nurse and patient set objectives and become involved in the learning process together.
B
A nurse checks individuals with liver disease for clotting problems because: a. The liver is often the site of platelet pooling. b. Clotting factors are produced in the liver. c. High levels of bilirubin interfere with the clotting system. d. Treatment medications for liver failure cause fibrinolysis. REF: p. 526
D
A nurse is preparing to teach the staff about aplastic anemia. Which information should the nurse include? Aplastic anemia is caused by: a. Iron deficiency b. Excess levels of erythropoietin c. Hemolysis d. Stem cell deficiency REF: p. 506
C
A nurse is teaching the staff about disseminated intravascular coagulation (DIC). Which information should the nurse include? The sequence of events in DIC is initiated by the release of: a. Histamine b. Fibrin c. Tissue factor d. Plasmin REF: p. 527
Acute Epiglottitis
A patient presents with a high fever, irritability, sore throat, inspiratory stridor, muffled voice and severe respiratory distress what would the nurse suspect
Croup
A patient presents with a seal-like barking cough, they recently had an episode of rhinorrhea, sore throat, low-grade fever, inspiratory stridor and a hoarse voice, what would the nurse suspect
Which patient would the nurse place in a protective prone position?
A patient prone to hyperextension of the spine
The nurse uses gait belts when assisting patients to ambulate. Which patient would be a likely candidate for this assistive device?
A patient who has leg strength and can cooperate with the movement
C
A patient's anemia is described as having erythrocytes that demonstrate anisocytosis. The nurse would recognize the erythrocytes would be: a. Pale in color b. Present in various sizes c. Able to assume various shapes d. Live only a few days REF: p. 501
Elective surgery
A procedure that is performed to improve the patient's quality of life, both physically and psychologically. The surgery is scheduled in advance and at the patient's direction. The date is convenient to both the surgeon and the patient. Other factors are considered before hand: time for preparation, planning, and evaluation of patient. This is NOT an urgent procedure. EX: hysterectomy for uterine fibroids and cholecystectomy for chronic gallbladder disease
Emergency surgery
A procedure that is unanticipated and is performed immediately to preserve the life of the patient, a body part, or a body function. Delaying this surgery will have a detrimental effect on the patient. On the other hand, morbidity and mortality rates increase due to risks associated with underlying causes, surgical procedures, and medications administered during and after surgery. EX: perforated appendix and gunshot wound
Hyperpituitarism
A release of too much anterior pituitary hormones and is commonly caused by a benign, slow-growing pituitary adenoma
B
A staff member asks what leukocytosis means. How should the nurse respond? Leukocytosis can be defined as: a. A normal leukocyte count b. A high leukocyte count c. A low leukocyte count d. Another term for leukopenia REF: p. 508
Urgent surgery
A surgery that is performed when a patient's health condition is not immediately life threatening, but has potential risks for complications if not performed. The surgery is performed within 24 hours of diagnosis to prevent complications. During this 24 hours, the patient is continued to be evaluated. EX: pin for hip fracture or bowl resection to remedy a bowl obstruction
Pulse
A throbbing sensation that can be palpated over a peripheral artery, such as the radial artery or the carotid artery - plpable when blood is EJECTED as the left ventricle contracts + pumps blood into the vascular system - As the heart contracts to eject blood into an already full aorta, smooth muscle in the arteries expands to compensate for the increase in pressure of the blood. This rhythmic distention of the arterial walls is the result of surges of blood as the heart beats. The distention of the arteries moves along the arterial system until it reaches the capillaries, where vessel walls lack elasticity + peripheral resistance to blood flow. The peripheral pulses may be felt wherever artery passes over a solid structure, such as bone or cartillage - Pulse is an indicator of the effectiveness of the heart as a pup + the adequacy of peripheral blood flow - Heart sounds are produced bye the CLOSURE of the valves of the heart - The apical pulse is the result of the CLOSURE of the MITRAL + TRICUSPID valves ("lub") +the aortic + pulmonic valves ("dub"). The combination of the two valves is counted as ONE beat
Traumatic brain injury
A traumatic insult to the brain possibly producing physical, intellectual, emotional, social, and vocational changes
Kinesthetic
A type of learner who learns best with a hands-on approach.
The normal range for lymphocytes is 20 - 40%. Select possible findings below. (Select all that apply) A) Decreased levels indicate sepsis B) Increased levels are found with chronic bacterial & viral infections. C) No change means the patient is dehydrated. D) Findings will vary depending on patients medications
A, B
Which are examples of infectious diseases? (Select all that apply) A) Viral Meningitis B) Pneumonia C) Appendicitis D) Flu
A, B, D
Which of the following require airborne precautions of negative air flow, small droplet (HEPA filter)? (Select all that apply) A) Measles B) Chicken Pox C) Pneumonia D) Varicella Zoster E) TB
A, B, D, E
What is the proper order for removing Personal Protective Equipment (PPE)? A) Gloves B) Hand hygiene 1 C) Mask D) Hand hygiene 2 E) Eye wear F) Hand hygiene 3 G) Gown
A, B, E, G, D, C, F
Which is not a part of the sterilization process? (Select all that apply) A) Hand Hygiene B) Process by which all microorganisms, including spores, are destroyed. C) Use of PPE
A, C
What does inflammatory Exudate consist of? (Select all that apply) A) Accumulated fluid B) Colligen C) Dead tissue D White Blood Cells E) Adepose Tissue
A, C, D
Which is not a sign or symptom of localized infection? (Select all that apply) A) Increased appetite B) Fever (is the only systemic symptom that can be caused by a local infection). C) Dizziness D) Foul odar/ discharge for affected area E) Heat at affected site. F) Pain G) Pus H) Redness & Swelling at affected site
A, D
Which of the following does not qualify for droplet precautions that require 3-6 ft. infectious zone around patient? (Select all that apply) A) Cardio Myopathy B) Large droplet (influenza) C) Diphtheria D) Cancer E) Rubella F) Strep pharyngitis G) Diabetes H) Pneumonia I) Scarlet fever J) Pertussis K) Mumps
A, D, G
Which of the following is not a sterile item that requires the use of sterile conditions be followed? A) Oral care sponges B) Urinary catheters C) Cardiac and intravascular catheters D) Surgical instruments E) Stethoscope F) Implants
A, E
Factors Affecting Pulse
AGE + GENDER: Women have a slightly higher pulse rates than men. Pulse rate decreases as a person ages due to decreased metabolic rate. PHYSICAL ACTIVITY: The pulse rate increases with exercise. Well conditioned athletes have a significantly DECREASED pulse rate due to the greater efficiency + strength of the heart muscle. FEVER + STRESS: Fever causes increased pulse rate due to increased metabolic demands + compensatory mechanisms to increase heat loss. Increased levels of stress cause an increased pulse rate. MEDICATIONS: Change can be an intended effect or an unintended adverse effect. DISEASE: Many acute + chronic health conditions affect a patient's pulse rate.
Adventitious breath sounds
Abnormal breath sounds heard over the lungs.
Ventricular septal defect
Abnormal communication between the ventricles Most common type of congenital heart lesion Two types
Atrial septal defect
Abnormal opening between the atria; blood flows from left atria to right atria
Cheyne-Stokes respirations
Abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop in breathing called an apnea
Hypoparathyroidism
Abnormally low levels of PTH commonly due to damage of the parathyroid during thyroid surgery
Asepsis
Abscence of disease-producing microorganisms; using methods to prevent infection
Diabetic ketoacidosis (DKA)
Accumulation of ketone bodies cause a drop in pH resulting in metabolic acidosis. Switch to lipid metabolism. Type 1
What is Guillan-Barre syndrome?
Acquired inflammatory disease causing demyelination of the peripheral nerves with relative sparing of axons Acute onset, ascending motor paralysis Humoral and cellular immunologic reaction
ADL's
Activities of Daily Living: self-care activities such as eating, bathing, dressing, and toileting (book)
The nursing student learns in Fundamentals that the primary purpose for using proper body mechanics is for which of the following reasons?
Acts to prevent injury to the client and/or nurse
Manifestations of Tetralogy of Fallot
Acute cyanosis at birth or gradual cyanosis Gradual clubbing, poor growth; Tet spells If untreated, emboli, stroke, brain abscess, seizures
What is Encephalitis?
Acute febrile illness, usually of viral origin with nervous system involvement Most common forms of encephalitis are caused by arthropod-borne viruses and herpes simplex virus
aerobic
Aerobic: Oxygen-requiring. Aerobic bacteria need oxygen to grow. Aerobic exercise requires the heart and lungs to work harder to meet the body's increased oxygen demand.
Low levels of growth hormone (GH)
Affect growth in children and can result in hypopituitary dwarfism
D
After initial compensation, what hemodynamic change should the nurse monitor for in a patient who has a reduction in the number of circulating erythrocytes? a. Increased viscosity of blood b. Decreased cardiac output c. Altered coagulation d. Hyperdynamic circulatory state REF: p. 501
Spleen
Aged red cells are sequestered and destroyed by macrophages of the MPS, primarily in the _______
Data processing deficits
Agnosia -Tactile, visual, auditory Dysphasia -Expressive -Receptive -Transcortical -Global Aphasia
Pneumothorax
Air in the plural space
Panhypopituitarism
All hormones are deficient
Self-Esteem needs
All humans have a need to feel respected; this includes the need to have self-esteem and self-respect. Esteem presents the typical human desire to be accepted and valued by others. People often engage in a profession or hobby to gain recognition. These activities give the person a sense of contribution or value. Low self-esteem or an inferiority complex may result from imbalances during this level in the hierarchy. People with low self-esteem often need respect from others; they may feel the need to seek fame or glory. However, fame or glory will not help the person to build their self-esteem until they accept who they are internally. Psychological imbalances such as depression can hinder the person from obtaining a higher level of self-esteem or self-respect.
Factors affecting degree of risk
All surgical procedures have risks, but certain health conditions increase these risks, such as infection, delayed wound healing, and anesthesia reactions. General health, medications, mental and cognitive status, nutrition, cardiac, blood coagulation, respiratory, and renal disorders, liver disease, diabetes mellitus, family history, and previous surgeries.
Kawasaki disease
Also known as mucocutaneous lymph node syndrome Acute, self-limiting systemic vasculitis that may result in cardiac sequelae Usually occurs in children under 5 years of age and in winter or spring
What is meningitis?
An infection of the meninges
Dysrhythmia
An irregular pattern of heartbeats
B
An oncologist is discussing multiple myeloma. Which information should the oncologist include? Multiple myeloma can be defined as a neoplasm of: a. T cells b. B cells c. Immature plasma cells d. Mature red blood cells REF: p. 518 | p. 520
What are Mycotic aneurysms?
Aneurysms caused by infection.
Which term should the nurse use to describe new collateral vessel formation in a client?
Angiogenesis New collateral vessels are formed through the process of angiogenesis. Cells of the larger vessels are nourished by the vasa vasorum, small vessels located in the tunica externa. A single tropomyosin molecule (a relaxing protein) lies alongside seven actin molecules. Automaticity, or the property of generating spontaneous depolarization to threshold, enables the sinoatrial and atrioventricular nodes to generate cardiac action potentials without any stimulus.
Transposition of the great arteries: mixed defects
Aorta arises from the right ventricle and the pulmonary artery arises from the left ventricle
Obstructive Defects
Aortic stenosis Coarctation of the aorta Valvular aortic stenosis Subvalvular aortic stenosis Pulmonic stenosis
What should the nurse monitor to determine a client's afterload?
Aortic systolic pressure Aortic systolic pressure is a good index of afterload. Temperature can help determine infectious processes, not afterload. Electrolyte tests can help determine fluid and electrolyte levels, not afterload. Arterial blood gases help determine pH of the blood.
A client has injured the endothelium of a blood vessel. Which area (see diagram) should the nurse choose to illustrate the damaged area?
Area 1 The tunica intima contains the endothelium, the innermost lining of the blood vessels. Elastic arteries have a thick tunica media with more elastic fibers than smooth muscle fibers. The smooth muscle is part of the tunica media. The adventitia is the outermost lining of the blood vessel.
A nurse is teaching a client about the anatomy of the heart. Which area (see diagram) should the nurse choose to illustrate the cardiac chamber with the thickest wall?
Area 4 The left ventricle's myocardium is several times thicker than that of the right ventricle because the left ventricle myocardium must be strong enough to pump against the high pressure of the systemic arterial pressure (92 mm Hg). The right ventricle must only pump against the lower pressure pulmonary arterial pressure (15 mm Hg). The two atria have the thinnest walls because they are low-pressure chambers.
Hemostasis
Arrest of bleeding
What is the most common aneurysm?
Arterial Venous Malformation. It looks like a bowl of spaghetti.
What is a Thrombotic Stroke?
Arterial occlusions caused by thrombi formed in arteries supplying the brain or in intracranial vessels Transient ischemic attacks
oxygen
As pressure decreases at the tissue level this dissociates from hemoglobin
A
Ask a trusted family member
Restrictive lung diseases
Aspiration, atelectasis, bronchiectasis, bronchiolitis, pulmonary fibrosis, inhalation disorders, pulmonary edema
A client has been in the hospital for the past 10 days following the development of an infection at her surgical incision site. Each morning the client reports overwhelming fatigue and has told the nurse, "I just can't manage to get any sleep around here." How should the nurse first respond to this client's statement?
Assess the factors that the client believes contribute to the problem.
What is an Intracerebral Hemorrhage?
Associated with MVA and falls Intracerebral hemorrhage and resultant hematoma acts as an expanding mass There is Increased ICP and compression of brain tissues with resultant edema
Atrial septal defects manifestatios
Asymptomatic at early age Pulmonary symptoms on exertion at later age
Patent ductus arteriosus manifestations
Asymptomatic or pulmonary overcirculation (dyspnea fatigue, poor feeding)
Manifestations of PDA
Asymptomatic or pulmonary overcirculation (dyspnea, fatigue, poor feeding)
Which of the following hormones is released from atrial tissue in response to increases in blood volume?
Atrial natriuretic peptide
Tricuspid atresia additional defects
Atrial septal defect Hypoplastic or absent right ventricle Enlarged mitral valve and left ventricle Pulmonic stenosis
Primary adrenal insufficiency hypocortisolism (Addison disease)
Autoimmune that causes destruction of cells in adrenal cortex leading to inadequate synthesis of cortisol. Hyperpigmentation due to ACTH, elevated potassium
Idiopathic Addison disease
Autoimmune. Associated with other autoimmune conditions and is usually inherited as autosomal recessive trait
Motor and sensory pathways regulating the body's internal environment through involuntary control of organ systems
Autonomic nervous system
What coordinates and maintains a steady state among visceral organs?
Autonomic nervous system
Cone-shaped process where the axon leaves the cell body
Axon hillock
Part of the neuron that carries nerve impulses away from the body
Axons
)Interval from onset of nonsepcific signs & symptoms to more specific symptoms. A) Incubation stage B Prodromal stage C) Full Illness stage D) Convalescent Stage
B
A foreign material capable of inducing a specific immune response is called: A) Antibody B) Antigen C) Disinfection D) Antimicrobial
B
Causes meningitis in young adults and uses kissing and sexual contact as a portal of exit. A) TB and Flu B) Neisseria Gonorrhea C) Tetanus D) Staph aureus
B
If an infectious disease can be transmitted directly from one person to another it is a: A) Susceptible host. B) Communicable disease. C) Port of entry to a host. D) Port of exit from the reservoir.
B
If there is an possible chronic infection, there is a decrease in iron levels from what normal range? A) 30 - 60g/100ml B) 60 - 90g/100ml C) 90 - 120g/100ml
B
The most significant and most commonly observed infection-causing agent is called what? A) Antigens B) Bacteria C) Disinfection D) Endemic
B
The natural habitat for the growth and multiplication of microorganism is called what? A) Colonization B) Reservoir C) Carriers D) Major route of transmission
B
What causes the decrease in body defenses and makes a person susceptible to C-Diff.? A) Multiple health conditions using up the immunity levels faster than the body can keep up. B) Elimination of normal flora C) Loss of fluoride on teeth D) Nutritional deficiency
B
What is the best method to serilize a straight urinary catheter and suction tuve in the home setting? A) Use an Autoclave. B) Use boiling water. C) Use ethylene oxide gas. D) Use chemicals for disinfection.
B
What is the ideal pH range for microbes in the human body? A) 4-5 B) 5-7 C) 7-8 D) 3-7
B
What measures the acidity of the environment? A) Temperature B) pH C) Sun Light D) Humidity
B
What participates in maintaining the bodies normal health? A) Vitamins B) Normal Flora C) Immunizations D) IgE
B
When a nurse is performing surgical hand asepsis, the nurse must keep hands: A) Below elbows. B) Above elbows. C) At a 45-degree angle. D) In a comfortable position.
B
Which is the most common mode of Indirect transimmion? A) Person to Person B) Inanimate objects C) Body fluids that travel D) Droplets or particles in the air E) Contaminated items F) Internal & External transmission.
B
Which of the following is not a topic the nurse can education the patient on to reduce the risk of infection. A) Nutrition B) Socializing with small children C) Immunizations D) Hygiene E) Rest & Relaxation & Exercise F) Control portals of exit and entry to the body
B
Who is risk for infection based on age? A) Pre-schooler B) Newborn C) Adult D) Adolecent
B
Which are signs and symptoms of a systemic infection? (Select all that apply) A) Increased appetite B) Aches C) Chills D) Pus E) Fever F) Nausea G) Vomiting H) Weakness
B, C, E, F, G, H
The normal range for neutrophis is 55 - 70%. Select possible findings below. (Select all that apply) A) Findings will vary depending on patients medications B) Increased levels indicates acute pus-forming infection. C) No change means the patient is dehydrated. D) Decreased levels with bacterial infections.
B, D
Name some illnesses that have a risk of droplet transmission. A) Cellulitis B) Flu C) Edema D) TB E) Chicken Pox F) Measles
B, D, E, F
What are the four infectious stages? A) Pre-exposure B) Incubation C) Transient D) Prodromal E) Full Illness F) Surgincal G) Convalescent
B, D, E, G
What are some types of Meningitis?
Bacterial meningitis Aseptic (viral, nonpurulent, lymphocytic) meningitis Fungal meningitis Tubercular (TB) meningitis
A nurse is discussing pressure receptors located in the aortic arch and carotid arteries that affect a client's heart rate and blood pressure. Which reflex is the nurse describing?
Baroreceptor reflex The baroreceptor reflex facilitates both blood pressure changes and heart rate changes. It is mediated by tissue pressure receptors (called pressoreceptors or baroreceptors) in the aortic arch and carotid arteries. Distention of the atria causes stimulation of atrial receptors (for example, when intravascular volume is increased by intravenous infusions). This causes activation of the Bainbridge reflex, which increases heart rate. The Frank-Starling and Poiseuille eponyms refer to various concepts, including laws, curves, and spaces, but not to reflexes. The Frank-Starling law of the heart describes the length-tension relationship of preload to myocardial contractility (as measured by stroke volume). The Poiseuille law shows the relationship among blood flow, pressure, and resistance. Resistance in a vessel is inversely related to blood flow—that is, increased resistance leads to decreased blood flow.
Extrapyramidal motor syndromes
Basal ganglia motor syndromes Cerebellar motor syndromes
Intraoperative phase
Begins when the patient enters the OR. This phase consists of the patient being anesthetized, monitored, prepped, draped, and surgical procedure is performed. A "time out" occurs for all surgical staff and it is documented. The nurse focuses on safety, infection prevention, and physiologic response to anesthesia. This phase ends when the patient is taken to the PACU.
What the risk factors for Subarachnoid Hemorrhages?
Being female, smoking, drug use(cocaine)
Second stage of General Anesthesia: Excitement
Beings with loss of consciousness, excitement of muscles, involuntary movement, muscles become tense, breathing may be irregular, and ends with regular breathing and loss of eyelid reflexes.
A client says that the mitral valve is diseased and wants to know where this valve is located. Which information by the nurse is the best response?
Between the left atrium and the left ventricle The mitral valve is located between the left atrium and the left ventricle. The valve between the right atrium and the right ventricle is the tricuspid valve, not the mitral valve. The aortic valve is between the left ventricle and the aorta. The pulmonic valve is between the right ventricle and the pulmonary artery. Test-Taking Tip: Relax during the last hour before an exam. Your brain needs some recovery time to function effectively.
What is a Subarachnoid hemorrhage?
Blood escapes from defective or injured vasculature into the subarachnoid space
Which of the following is an accurate statement regarding blood flow through the heart?
Blood flows from the right ventricle through the pulmonic semilunar valve.
Cellular structures that selectively inhibit certain harmful substances in the blood from entering the brain or CSF
Blood-brain barrier
"One Flew Over the Cuckoo's Nest" dates
Book 1962 Mive 1975
A client has a regular heart rate of 54 beats/min. How should the nurse document this finding?
Bradycardia Bradycardia is defined as a heart rate of less than 60 beats/min. Normal sinus rhythm is defined as an impulse rate between 60 and 100 per minute. Dysrhythmia is abnormal rhythms. Tachycardia is an abnormally fast heart rate of more than 100 beats/min.
Components of CNS
Brain and spinal cord
)Interval when patient presents specific signs & symptoms. A) Incubation stage B Prodromal stage C) Full Illness stage D) Convalescent Stage
C
A healthcare-associated infection (HAI): A) Infection the patient came into the hospital with and is being treated for. B) Infection passed from one patient to another when they share a room. C) Infection that was not present on admission to the hospital and develops during the course of treatment for other conditions (nosocomial).
C
A patient has an indwelling urinary catheter. Why does an indwelling urinary catheter present a risk for urinary tract infection? A) It keeps an incontinent patient's skin dry. B) It can get caught in the linens or equipment. C) It obstructs the normal flushing action of urine flow. D) It allows the patient to remain hydrated without having to urinate.
C
A patient is isolated for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but he knows that this is a normal response to isolation. Which is the best intervention? A) Provide a dark, quiet room to calm the patient. B) Reduce the leve of precautions to keep the patient from becoming angry. C) Explain the reasons for isolation procedures and provide meaningful stimunation. D) Limit family and other caregiver visits to reduce the risk of spreading the infection.
C
A patient's surgical wound has become swollen, red, and tender. You note that the patient has a new fever and leukocytosis. What is the best immediate intervention? A) Notify the health care provider and use surgical technique to change the dressing. B) Reassure the patient and recheck the wound later. C) Notify the health care provider and support the patient's fluid and nutritional needs. D) Alert the patient and caregivers to the presence of an infection to ensure care after discharge.
C
Describe a protective environment. A) Room with a window that can be opened to the outside of the building. B) Room that is sterilized between each patient. C) Room with positive airflow. Used for highly susceptible, immunocompromised patient such as Transplant and gene therapy.
C
Give an example of a Anaerobic microbe. A) TB and Flu B) Neisseria Gonorrhea C) Tetanus D) Staph aureus
C
Identify the interval when a patient progresses from nonspecific signs to manifesting signs and symptons specific to a type of infection. A) Illness stage B)Convalescence C) Prodromal stage D) Incubation period
C
If there are no white blood cells found on a gram stain culture of a wound, sputum or the throat, what does that tell you? A) The test needs to be repeated. B) The patient last ate clear liquids C) The presence of normal flora and not sign of infection. D) The procedure was not sterile.
C
Nonhuman carriers, such as mosquitoes, ticks, and lice, that transmit organisms from one host to another is called a what? A) Host passing B) Transient C) Vector D) Worms E) Parasite
C
The nurse has redressed a patient's wound and now plans to administer a medication to the patient. Which is the correct infection control procedure? A) Leave the gloves on to administer the medication. B) Remove gloves and administer the medication. C) Remove gloves and perform hand hygiene before administering the medication. D) Leave the medication on the bedside table to avoid having to remove gloves before leaving the patient's room.
C
The practices designed to reduce the number and transfer of pathogens; synonym for clean technique: A) Sterilization B) Hand Hygiene C) Medical asepsis D) Asepsis
C
The process used to destroy microorganisms; destroys all pathogenic organisms except spores is called: A) Antigens B) Bacteria C) Disinfection D) Endemic
C
What are standard precautions? A) Organizational policies and procedures B) NANDA guidelines C) CDC precautions used in the care of all patients regardless of their diagnosis or possible infection status
C
What are the effects on the entire body, instead of a single organ called? A) Localized B) Manageable C) Systemic D) Virulence
C
When should the nurse change the dressing of a wound? A) Only when the doctor has ordered it. B) Twice a week C) When dressings become wet and/or soiled.
C
Which is not an example of a vehicle for infection? A) Contaminated items (MRSA) B) Water (Cholerae) C) Clothing (Chicken Pox) D) Drugs, solutions (Pseudomonas) E) Blood (hep. B & C viruses, HIV & syphilis) F) Food (Salmonella, E. coli, botulinum
C
Which is the most common mode of droplet transimmion? A) Person to Person B) Inanimate objects C) Body fluids that travel D) Droplets or particles in the air E) Contaminated items F) Internal & External transmission.
C
Which of the following are not considered part of personal protective equipment (PPE)? A) Gloves B) Gowns C) Pocket protector D) Masks E) Protective eye gear
C
Which of the following is not an element in the development or chain of infection? A) Means of transmission B) Infectious agent or pathogen. C) Formation of immunoglobulin D) Reservoir for pathogen growth
C
While preparing to do a sterile dressing change, a nurse accidentally sneezes over the sterile field that is on the over-the-bed table. Which of the following principles of surgical asepsis, if any, has the nurse violated? A) When a sterile field comes in contact with a wet surface, the sterile field is contaminated by capillary action. B) Fluid flows in the direction of gravity. C) A sterile field becomes contaminated by prolonged exposure to air. D) Non of the principles were violated.
C
Who is at risk for infections due to a disease process? A) Person in average good health. B) Pregnant woman. C) Person with AIDs, Leukemia or A-platic anemia D) Older Adult
C
Who is most at risk for infections due to nutritional status? A) Pregnant woman B) Athlete C) People with deficiencies in nutrients D) Vegitarians
C
Put the following steps for removal of protective barriers after leaving an isolation room in order: A) Untie top, then bottom mask strings and remove from face. B) Untie waist and neck strings of gown. Allow gown to fall from shoulders and discard. Remove gown, rolling it onto itself without touching the contaminated side. C) Remove gloves. D) Remove eyewear or goggles. E) Perform hand hygiene.
C, D, B, A, E
Which of the following would call for direct and indirect contact transmission protocol? (Select all that apply) A) Closed fractured arm B) TB C) VRE D) Strep throat E) MRSA F) C. Difficile G) Herpes
C, E, F, G
Transmission based precautions
CDC precautions used in patients known or suspected to be infected with pathogens that can be transmitted by airborne, droplet, or contact routes: used in addition to standard precautions
Standard Precautions
CDC precautions used on all patients regardless of their diagnosis or possible infectious this category combined universal and body substance precautions
Primary regulator for CNS blood flow
CO2
2000
COMPLETION A 35-year-old male was diagnosed with hepatitis B. Further tests revealed neutropenia characterized by a neutrophil count less than _____ per milliliter. REF: p. 509
100,000
COMPLETION A nurse realizes a patient has thrombocytopenia when the platelet count is below _____ platelets per cubic millimeter. REF: p. 532
Which drugs have a major effect in decreasing the strength of cardiac contraction?
Calcium channel blockers
Verbalization of steps
Can be an evaluation tool, but it is not as effective as a return demonstration when evaluating a psychomotor skill.
Which of the following is a difference between cardiac and skeletal muscle fibers?
Cardiac fibers have only one nucleus and skeletal muscle fibers have many nuclei.
2 Factors that Determine BOTH Systolic + Diastolic Pressure
Cardiac output + Peripheral Resistance (which reflects the viscosity or the thickness of the blood + also the changes int he RADIUS of the arterioles)
Perioperative nursing
Care that nurses provide to patients before, during, and after surgery. The perioperative nurse plans, directs, and coordinates the care of every patient going into and out of surgery. They are responsible for the patient outcomes resulting from perioperative nursing care..
Globulins
Carrier proteins and immunoglobulins (antibodies)
Implementing
Carrying out the plan of care
Secondary hyperthyroidism
Caused by TSH-secreting adenomas
Increased Intracranial Pressure
Caused by increase in intracranial content -Tumor growth, edema, excessive CSF or hemorrhage Stage 1-4
Pernicious anemia
Caused by vitamin b12 deficiency
Liver disease
Causes a broad range of hemostasis disorders: defects in coagulation, fibrinolysis, & platelet number/function
Erythropoietin
Causes an increase in red cell production and release from bone marrow
3 Components of the neuron
Cell body Dendrites Axons
What makes up the What makes up the hindbrain?
Cerebellum Pons Medulla
What makes up the forebrain?
Cerebral hemispheres
Clear, colorless fluid similar to blood plasma found in ventricles
Cerebrospinal fluid
Mental and cognitive status risks
Certain mental and cognitive conditions affect one's ability to interpret and understand medical information. Thus can increase surgical risks and interfere with the patient's ability to follow instructions and care for the surgical wound.
Fever in children + older adults (elderly)
Children: - A mild elevation in temp might indicate a SERIOUS infection in infants younger than 3 months of age Older adults: - Often have a LOWER baseline body temperature + therefore fever may be one of the LATER signs of illness, even in a serious infection, with the temperature elevations only slightly above normal.
What is CSF produced by?
Choroid plexus
Phenochromacytomas
Chromaffin cells (from adrenal gland) tumor that secretes catecholamines
What is Myasthenia Gravis?
Chronic autoimmune disease IgG antibody produced against acetylcholine receptors (antiacetylcholine receptor antibodies) Weakness and fatigue of muscles of the eyes and the throat, causing diplopia, difficulty chewing, talking, swallowing.
hyperplasia of globlet cells, bronchiectasis, pneumonia, hyoixia, and fibrosis
Chronic inflammation leads to what
Which of the following arteries travels in the coronary sulcus between the left atrium and the left ventricle?
Circumflex
A grade 4 concussion is what?
Classical Cerebral Concussion. Characteristics include Disconnection of cerebral systems from the brainstem and reticular activating system Physiologic and neurologic dysfunction without substantial anatomic disruption Loss of consciousness (<6 hours) Anterograde and retrograde amnesia Uncomplicated (no focal injury) Complicated (focal injury)
Total anomalous pulmonary venous connection
Classified by point of attachment Supracardiac Cardiac Infracardiac
Seizures and types
Classified by: -Clinical manifestations -Site of origin -EEG correlates -Response to therapy Epilepsy Prodroma Tonic Phase (contraction) Postictal phase Status epilepticus
Metabolic syndrome
Combination of central obesity, dyslipidemia, and preHTN that can put you at high risk for type 2 DM and cardiovascular disease
Test Card to
Combine
Graves disease
Common cause of hyperthyroidism. Autoimmune condition. STI antibodies form against TSH receptors in they thyroid overstimulating them to secrete TH.
Disseminated Intravascular Coagulation
Complex, acquired disorder in which clotting & hemorrhage simultaneously occur Result of increased protease activity in the blood caused by unregulated release of thrombin with subsequent fibrin formation & accelerated fibrinolysis
Surfactant
Compliance is ensured by an adequate production of what
Functions of the spinal cord
Connects the brain and the body Conducts somatic and autonomic reflexes Provides motor pattern control centers Modulates sensory and motor function
Branches of numerous neurons converging on one neuron
Convergence
What makes up the midbrain?
Corpora quadrigemina Tegmentum Cerebral peduncles
Pathways that function as lower motor neurons involved in precise motor control
Corticospinal and corticobulbar
Adrenocortocotropic hormone (ACTH) deficiency
Cortisol and aldosterone deficiency
Hemoptysis
Coughing up blood
Components of PNS
Cranial nerves Spinal nerves Efferent and afferent pathways
Status of tissue oxygenation
Cyanotic defects Acyanotic defects
A antibacterial agent that kills bacteria or suppresses their growth is called: A) Antibody B) Antigen C) Disinfection D) Antimicrobial
D
A family member is providing care to a loved one who has an infected leg wound. What would you instruct the family member to do after providing care and handling contaminated equipment or organic? A) Wear gloves before eating or handling food. B) Place any soiled materials into a bag and double bag it. C) Have the family member check with the doctor about need for immunization. D). Perform hand hygiene after care and / or handling contaminated equipment or material.
D
A protective vascular reaction that delivers fluid, blood products and Nutrients to an area of injury is called what? A) DVT B) Bacteriostasis C) Susceptibilty D) Infammantion
D
Give an example of a aerobic microorganism. A) TB and Flu B) Neisseria Gonorrhea C) Tetanus D) Staph aureus
D
Interval fwhen recovery from infection occurs. A) Incubation stage B) Prodromal stage C) Full Illness stage D) Convalescent Stage
D
Microorganism that uses the skin and mucous membranes as a portal of exit. A) TB and Flu B) Neisseria Gonorrhea C) Tetanus D) Staph aureus
D
Nosocomial refers to: A) Anti-social behavior of patient B) Wattery stools C) Abnormal lab results D) something originating or taking place in the hospital (i.e., infection)
D
Prevention of the growth and reproductin of bacteria by cold temperatures: A) Virulence B) Aerobic bacteria C) Anaerobic bacteria D) Bacteriostasis E) Bactericidal
D
Something that occurs with predictability in one specific region or population and can appear in a different geographical location refers to a: A) Antigens B) Bacteria C) Disinfection D) Endemic
D
The normal levels for Erythrocyte sedimentation rate is up to 15mm/hr for men and up to 20mm/hr for women. What does an increase in these numbers mean? A) Possibility of DVT developing B) Increased pain level C) Cyanosis D) Presence of inflammatory process.
D
The nurse wars a gown when: A) The patient's hygiene is poor. B) The nurse is assisting with medication administration. C) The patient has acquired immunodeficiency syndrome (AIDS) or hepatitis. D) Blood or body fluids may get on the nurse's clothing from a task that he or she plans to perform.
D
What can you expect to show an increase if the patient has a parasitic infection? A) Basophils B) Monocytes C) Lymphocytes D) Eosinophils
D
What does "virulence" mean? A) Healthy tissue B) Rejuvinated tissue after illness recovery C) Reported on the internet to educate patients D) Ability of pathogen to survive in the host or outside the body.
D
What is an infection in which the causative organism comes from microbial life the person harbors called? A) Exogenous B) Endemic C) Antigen D) Endogenous
D
What is bacteria that require oxygen to live and grow called? A) Carriers B) Reservoirs C) Anaerobic D) Aerobic
D
What is the infection that occurs as a result of a treatment or diagnostic procedure called? A) Antimicrobial B) Pathogenic C) Venerial D) Iatrogenic
D
Which is the most common mode of airborn transimmion? A) Person to Person B) Inanimate objects C) Body fluids that travel D) Droplets or particles in the air E) Contaminated items F) Internal & External transmission.
D
Which is the most likely means of transmitting infection between patients? A) Exposure to another patient's cough. B) Sharing equipment among patients. C) Disposing of soiled linen in a shared linen bag D) Contact with a health care worker's hands
D
Which of the following best describes an iatrogenic infection? A) It results from a diagnostic or therapeutic procedure. B) It results from an extended infection of the urinary tract. C) It involves an incubation perord of 3 to 4 weeks before it can be detected. D) It occurs when patients are infected with their own organisms as a result of immunodeficiency.
D
What is the proper order for applying Personal Protective Equipment (PPE)? A) Gloves B) Mask C) Fit Check 1 D) Hand hygiene E) Fit Check 2 F) Eye wear G) Gown
D, G, B, C, F, E, A
What are petichial hemorrhages common with?
DAI
Which head injuries cause the most deaths?
DAI diffuse anoxol injuries.
What happens to the nervous system with age?
Decrease # of neurons Slowing of neuro responses
Hypotension
Decreased Blood Pressure (slide 23 Chap 24) abnormally low blood pressure
A client has a drop in cardiac output. Which assessment finding does the nurse expect to observe?
Decreased mean arterial blood pressure A decrease in the cardiac output causes an immediate drop in the mean arterial blood pressure and arteriolar flow. An increase in cardiac output without a decrease in peripheral resistance will cause both arterial volume and arterial pressure to increase. Overall, the renin-angiotensin system is activated after volume depletion or hypotension (decreased cardiac output) and is suppressed after volume repletion.
Which condition will cause the client's body to activate the renin-angiotensin-aldosterone system (RAAS)?
Decreased perfusion to the kidney The primary factor that stimulates renin release is a drop in renal perfusion as detected by the juxtaglomerular cells. The RAAS is not activated by decreased perfusion to the brain, liver, or lungs.
Inherited metabolic disorders
Defects in amino acid metabolism - screening at birth -Phenylketonuria (PKU) --Hyperphenylalaninemia - inability to convert PKU to tyrosine Storage diseases -Lysosomal storage diseases - disorder of lipid metabolism (not included in newborn screening) -Tay-Sachs disease - example
Leukocytes (white blood cells)
Defend the body against infection and remove debris
Stages of greiving
Denial or Disbelief Anger Bargaining Resolution Acceptance
A learning objective
Describes what the learner will be able to do after successful instruction. Three types of reinforcers:
Assessing Peripheral Arterial Pulses + the 8 Arteries this Pulse Can be Detected
Detected in these arteries: 1.) Temporal 2.) Carotid 3.) Brachial 4.) Radial 5.) Femoral 6.) Popliteal 7.) Posterior Tibial 8.) Dorsalis Pedis - The radial pulse site is assessed most often in children + adults. - Carotid pulse site is used during EMERGENCY assessments such as for patients who are in shock or have had a cardiac arrest. When taking a carotid pulse, lightly palpate only ONE side at a tie to prevent any decrease in crebrovascular circulation. - Brachial pulse is most often used for infants
Mesenchymal stem cells (MSCs)
Develop into osteoclasts, fibroblasts, and adipocytes
Lillian Wald
Developed the first nursing service for occupational health (Metropolitan Life Insurance Company)
Development of Nervous System in Children
Develops from embryonic ectoderm in stages: -Formation of neural tube - (3 - 4 weeks gestation) -Development of forebrain (occurs 2-3 month gestation) -Neuron proliferation and migration (3 - 5 months gestation) -Formation of synapses (5 months to postnatally) -Myelinazation (birth to 4 years postnatally) Rapid development of brain during third, fourth, fifth gestational months Fontanelles "soft spot" = anterior closes 18 mos. Posterior closes 2-3 mos. Head growth -Hydrocephalus - CSF compartment enlarged (↑ICP, bulging font.) -Microcephaly - head circumfrance below 2% for age (genetics, toxins) Reflex responses -Neonatal reflexes disappear in predictable order - see box 17.1
What are characteristics of chronic Subdural Hematoma?
Develops over weeks to months Older adults Alcohol abuse 80% complain of chronic headaches and have tenderness at site of injury
What are characteristics of acute Subdural Hematoma?
Develops within 48 hours Often located at the top of the skull
A nurse is describing the part of the cardiac cycle in which the ventricles are filled during relaxation. What is the nurse discussing?
Diastole The heart muscle relaxes and allows blood to flow through it as it fills passively during diastole. The heart muscle contracts to move blood through the chambers during systole. Ventricular ejection refers to the blood being moved out of the ventricles. Mechanically, the isovolumic phase of ventricular systole is defined as the interval between the closing of the atrioventricular valves and the opening of the semilunar valves.
Ability of branching axons to influence many neurons
Divergence
Where is gray matter found in the spinal cord?
Dorsal horn Lateral horn Ventral horn
A nurse is teaching the client about the respiratory pump. Which information should the nurse include in the teaching session?
Downward movement of the diaphragm occurs The respiratory pump acts during inspiration (not expiration), when the veins of the abdomen are partially compressed by the downward movement of the diaphragm. The skeletal muscle pump occurs during skeletal muscle contractions. The heart valves are not affected by the respiratory pump; it is venous return and venous pressure that are affected.
Secondary hypocortisolism
Due to prolonged exogenous glucocorticoids like prednisone. Cant immediately stop taking because will result in adrenal crisis
Primary polydispia
Due to too much water intake, water intoxication.
Layers of meninges
Dura mater Arachnoid mater Pia mater
Orthopnea
Dyspnea when a person is lying down
A temperature or chemical that destroys bacertia: A) Virulence B) Aerobic bacteria C) Anaerobic bacteria D) Bacteriostasis E) Bactericidal
E
The expected outcome is the absence of signs and symptoms of infection. Which is not one of the ways the nurse can monitor the patient. (Select all that apply) A) Monitor patient pos-op, including surgical site, invasive site, & repiratory track. B) Examine all invasive & surgical sites. C) Monitor breathing. D) Review lab results. E) Review medicaion lists.
E
What is not a factor for a microbial proper environment? A) Food B) Oxygen/ or none C) Water /or none D) Temperature E) Low Immunity cells F) pH G) Light /or none,
E
Which is the most common mode of vehicles transimmion? A) Person to Person B) Inanimate objects C) Body fluids that travel D) Droplets or particles in the air E) Contaminated items F) Internal & External transmission.
E
Which of these is not a site of common health care-associated infections? A) Urinary tract B) Surgical or traumatic wounds C) Respiratory tract D) Blood Stream E) Digestive system
E
Pulmonary Veins
Each one drains several pulmonary capillaries, dispersed randomly throughout the lung, leave the lung at the hila and enter the left atrium
Alzheimer Disease (AD)
Early onset familial Non-hereditary (sporadic, late onset) Theories: -mutation for encoding amyloid precursor protein -Alteration in apolipoprotein E
E
Educate yourself about your illness
A nurse is discussing the tendency of the lungs to return to the resting state after inspiration. Which term should the nurse use to describe this process? 1 Collectins 2 Compliance 3 Elastic recoil 4 Surface tension
Elastic recoil
Classification by degree of urgency
Elective, urgent, and emergency surgery. This is determined by the surgeon. All presurgical screening examinations and diagnostic testing results are reviewed. Once this is done, the OR can be scheduled.
EHR
Electronic Health Record
Other Childhood Tumors
Embryonal tumors: -Neuroblastoma - most common cancer in infants less than 1 year of age -Retinoblastoma - eye tumor --Inherited - dx during first year of life --Acquired - dx during 2 - 3 years of age
Young or Middle Adult
Encourage participation in teaching plan by setting mutual goals. Encourage independent learning Offer information so they understands effects of health problem.
Which information from the client indicates teaching by the nurse was successful for the layers of the heart, beginning on the inside?
Endocardium, myocardium, and epicardium (serous pericardium) The three layers of the heart wall in order, beginning on the inside, are endocardium, myocardium, and epicardium (serous pericardium). The supracardium is not a layer of the heart wall. The mesocardium is not a layer of the heart. The ventricles of the heart are separated by the interventricular septum.
Epilepsy and Seizure Disorders
Epilepsy diagnosed when child has more than one unprovoked seizure Seizures -Neurologic -Systemic (DM) Febrile seizures -Benign
Parts of the Diencephalon
Epithalamus Thalamus Hypothalamus Subthalamus
Diagnostic procedures
Establishes or confirms a diagnosis EX: laparoscopy of the abdomen
Anemia classification
Etiology (cause) & morphology
Hydrocephalus
Excess fluid within the cerebral ventricles, subarachnoid space, or both Caused by interference in CSF flow -Decreased reabsorption -Increased fluid production -Obstruction within the ventricular system
Pulmonary edema
Excess water in the lungs
Cushing disease
Excessive anterior pituitary secretion of ACTH
Primary hyperparathyroidism
Excessive secretion of PTH from one or more parathyroid glands and mainly caused by parathyroid adenomas and results in hypercalcemia
Hyperkinesia
Excessive, purposeless mvmt
If a client has problems with the exchange of nutrients between the blood and the tissues, which vessels are affected?
Exchange of nutrients between the blood and the tissues takes place in the capillaries. Venules deliver blood into the veins. Arterioles branch into the capillaries. Lymphatic vessels remove excess fluid and protein that accumulate in the tissues. Capillaries
Factors Affecting Respirations
Exercise, respiratory + cardiovascular disease alterations in fluid/electrolyte/acid-base balances, medications, trauma, infection, pain + emotions.
Allergic alveolitis
Extrinsic allergic alveolitis (hypersensitivity pneumonitis)
Which is the most common mode of vector transimmion? A) Person to Person B) Inanimate objects C) Body fluids that travel D) Droplets or particles in the air E) Contaminated items F) Internal & External transmission.
F
Patent ductus arteriosus (PDA)
Failure of the ductus arteriosus to close Allows blood to shunt from the aorta to pulmonary artery, causing left-to-right shunt
Truncus arteriosus
Failure of the embryonic artery and the truncus arteriosus to divide into the pulmonary artery and the aorta The trunk straddles an always present VSD Types I, II, and III
What are causes of brain injury?
Falls 28% Motor vehicle crashes 20% Moving objects or moving against stationary objects 19% Assault 11% Sports-relBasilar skull fractureated events Blasts (military active duty
Bundles of myelinated axons in the PNS
Fascicles
Classic anemia symptoms
Fatigue, weakness, dyspnea (difficulty breathing), & pallor
The peripheral vascular system supplies blood to which area in a client's body?
Feet The peripheral vascular system is an imprecise term used to describe the part of the systemic circulation that supplies the skin and the extremities, particularly the legs and feet. Pulmonary circulation provides blood to the lungs. Coronary circulation carries blood to the heart. The carotid artery supplies blood to the brain. Test-Taking Tip: Start with answering all the questions that you feel confident in answering. If you cannot immediately think of the answer to a question, give it a few seconds of thought. If the answer comes to you, mark it and move on. If not, skip it, circle the number so you know to come back to it, and go to the next question.
Kawasaki Disease: Diagnosis (five of six major findings)
Fever for 5 or more days (unresponsive to antibiotics) Bilateral conjunctivitis without exudation Erythema of oral mucosa (strawberry tongue) Changes in the extremities, such as peripheral edema and erythema with desquamation of palms and soles Polymorphous rash Cervical lymphadenopathy
Cerebellum functions
Fine motor control, balance and posture
Prone
Flat on abdomen Type: Posterior thorax, spine, and back of legs
Supine (horizontal recumbent)
Flat on back Type: Thoracic, heart, and abdominal
Lithotomy
Flat on back and legs up in stirrups Type: gynecologic, perineal, rectal and genitourinary
Dorsal recumbent
Flat on back with knees flexed and hips externally rotated Type: Thoracic, heart, and vaginal
Trendelenburg
Flat on back, health down, feet elevated
The nurse has asked the client to grasp his overbed trapeze and pull his torso up off the surface of the bed. What movement will the client perform with his arms?
Flexion
Positive reinforcement
Follows feedback and involves the use of praise and acknowledgment of new attitudes, behaviors, or knowledge.
C
For a patient experiencing hypersplenism, the nurse expects the erythrocytes to be: a. Proliferated b. Activated c. Sequestered d. Infected REF: p. 521
What is a embolic stroke?
Fragments that break from a thrombus formed outside the brain.
Types of small cell lung cancer
From neuroendocrine tissue
Postoperative phase
From when the patient enters the PACU until they are completely recovered from the surgical procedure. The PACU nurse must complete priority nursing assessments, including assessing respiration, circulatory, and neuro status, pain level, BP, pulse ox, and cardiac.
Albumins
Function as carriers and control the plasma oncotic pressure
Development of an infection occurs in all of the following except which element? A) An infectious agent or pathogen B) Reservoir or souce C) Portal of exit from the reservoir D) Mode of transmission E) Portal of entry to a host F) Susceptible host G) Moist, wet lungs
G
Thick, fibrous band of tissue overlying the cranium for added protection to the skull
Galea aponeurotica
Respiration
Gas exchange between between the atmospheric air in the alveoli and blood in the capillaries
Which of the following is the correct description of the A wave?
Generated by atrial contraction
HAI- health care associated infection
HAI Data and Statistics. Healthcare-associated infections (HAIs)-infections patients can get while receiving medical treatment in a healthcare facility-are a major, yet often preventable, threat to patient safety.Oct 25, 2016 HAI Data and Statistics | HAI | CDC
Pyrexia
Have a fever
What is Blunt (closed, non-missile) trauma?
Head strikes hard surface or a rapidly moving object strikes the head The dura remains intact; brain tissues not exposed to the environment Causes focal (local) or diffuse (general) brain injuries
What are the two factors that determine cardiac output?
Heart rate and stroke volume
Fever helps the body respond to infectious processes by 4:
Heat increases lymphocytic transformation/motility facilitating the immune response
Adolescent
Help learn about feelings and need for self expression use teaching as collaborative activity allow them to make decisions about health and health promotion use problem solving to help adolescents make choices
Fever helps the body respond to infectious processes by 2:
Higher body temps decrease serum levels of iron, zinc, and copper (minerals needed for bacterial replication)
Regulation of Hormone Release
Hormones are regulated by chemical(blood glucose), hormonal (one gland working better than another), or neural factors -Negative feedback (glucose; spike in blood sugar, insulin released until blood sugar comes back down) -positive feedback(oxytocin when pregnant, builds up in body until contractions or normal and until baby is delivered)
Hormone Transport and Action
Hormones are released into the circulatory system by endocrine glands --Target cell(little cells that have the approbate lock on them and are specific to one hormone) --Up-regulation(if there are low concentrations on the hormones, we make more) --Down-regulation(we decrease the amount of hormone) --Hormone effects: --Direct effects --Permissive effects-less obvious, can make an maximum response itself
A
How should the nurse prepare a patient who is to receive a Schilling test for pernicious anemia? a. Administer radioactive cobalamin and measure its excretion in the urine. b. Measure antigen-antibody immune complexes. c. Measure serum ferritin and total iron-binding capacity. d. Administer folate and evaluate folate content in a blood serum sample. REF: p. 503
Hypoventilation
Hypercapnia (excessive carbon dioxide in the bloodstream,)
Disorder of expression
Hypermimesis Hypomimesis Dyspraxia/apraxia
Syndrome of inappropriate antidiuretic hormone secretion
Hypersecretion of ADH in the absence of normal stimuli for its release (retain water-prevent diuresis)
Hyperventilation
Hypocapnia ( a state of reduced carbon dioxide in the blood)
Diabetes Insipidus (DI)
Hyposecretion of ADH resulting in partial of total inability to concentrate the urine leading to polyuria (frequent urination) and polydyipsia (frequent drinking)
A nurse notes that a client admitted to a long-term care facility sleeps for an abnormally long time. After researching sleep disorders, the nurse learns that which area of this client's brain may have suffered damage?
Hypothalamus
hypothermia
Hypothermia = Lower limit of normal can also be 28C or 82.4F (slide 6 chap 24)
A client will be ambulating for the first time since his cardiac surgery. What should the nurse consider when assisting this client?
If an ambulating client whom a nurse is assisting begins to fall, the nurse should slide the client down his own body to the floor, carefully protecting the client's head.
Manifestations of pulmonic stenosis
If severe: cyanosis from right-to-left shunt through atrial septal defect; decreased CO
Pulmonic stenosis manifestation
If severe: cyanosis from right-to-left shunt through atrial septal defect; decreased CO
Tricuspid atresia
Imperforate tricuspid valve Lack of communication between the right atrium and right ventricle
Palliative procedures
Improves comfort and decreases pain or symptoms but does not cure EX: back surgery to decrease pressure
Cosmetic procedures
Improves personal appearance EX: liposuction
Systemic hypertension
In children defined as systolic and diastolic pressure that is over the 95th percentile for age and gender on at least three occasions
B
In disseminated intravascular coagulation (DIC), the nurse assesses for active bleeding after intravascular clotting because: a. Prothrombin is activated. b. Clotting factors are depleted. c. Inflammatory mediators are released. d. Tissue factor (TF) is inactivated. REF: p. 532
Tricuspid atresia manifestations
In newborn, cyanosis, tachycardia, dyspnea, poor feeding In older child, signs of chronic hypoxemia
lower, increases, 2-4 months
Incidence of SIDS is _______________in the first month, ___________ in the second month, and peaks at _____________
Material reinforcers
Includes food, toys, and music.
Which of the following actions does NOT cause a release of renin?
Increase in blood pressure at the renal artery
Cerebral edema
Increase in the fluid within the brain -Vasogenic -Cytotoxic -Interstitial
Secondary hyperparathyroidism
Increased PTH secretion due to chronic hypocalcemia, vitamin D deficiency, and kidney disease. Pulls calcium from the bones resulting in kyphosis, hypercalciurina, hypercalemia
Thyrotoxicosis/hyperthyroidism
Increased TH levels due to any cause
Hypercortisolism
Increased secretion of cortisol that leads to cushing disease and cushing syndrome.
Fever helps the body respond to infectious processes by 3:
Increased temp causes lysosomal breakdown and autodestruction of cells, preventing viral replication in infected cells
Manifestations of aortic stenosis
Infant: if significant faint pulses, hypotension, tachycardia, and poor feeding Older children: may have complaints of exercise intolerance Risk for bacterial endocarditis
Who are at-risk individuals for traumatic brain injury?
Infants 6 months to 2 years School-age children Adolescents and young adults 15 to 35 years of age People more than 70 years of age Men 1.5 times as likely to sustain a TBI Persons living in high-crime areas
Empyema
Infected pleural effusion; pus
What is radiculitis?
Inflammation of the spinal nerve roots.
What is Open (penetrating, missile) trauma?
Injury breaks the dura and exposes the cranial contents to the environment Causes primarily focal injuries
Coup injury?
Injury directly below the point of impact
What is Contrecoup?
Injury on the pole opposite the site of impact
Flail chest
Instability of a portion of the chest wall
Childhood obesity Risk
Insulin resistance, diabetes, cardiovascular disease Childhood nutrition, level of physical activity, and engagement of sedentary activities (TV, computer use, etc.)
What type of neuron transmits impulses from neuron to neuron?
Interneurons
Psychomotor
Involves acquiring motor skills that require coordination and the integration of mental and physical movements such as the ability to walk or use an eating utensil. • Demonstration • Practice • Independent projects, games
What are Plexus Injuries?
Involves the nerve plexus distal to the spinal roots but proximal to the formation of the peripheral nerves.
Hypothermia
Is a body temperature BELOW the lower limit of normal - Occurs when the compensatory physiologic responses meant to produce + retain heat are overwhelmed by unprotected exposure to cold environments - Chronic conditions such as alcoholism, malnutrition + hypothyroidism increase the risk of hypothermia - Patients in the perioperative period + newborn infants are also at increased risk - Death may occur when body temperatures fall below 95 F - Survival has been reported in isolated cases when body temps have fallen in the range of SEVERE hypothermia (below 82.4 F) as the rates of chemical reactions in the body are slowed, thereby decreasing the metabolic demands for oxygen.
Pulse Rhythm
Is the pattern of the beats + the pauses between them.
if you have a stroke, you have signs of _____________?
Ischemia
isolation
Isolation is defined as the voluntary or compulsory separation and confinement of those known or suspected to be infected with a contagious disease agent (whether ill or not) to prevent further infections. (In this form of isolation, transmission-based precautions are imposed.)
While teaching about arteries the nurse mentions the endothelium. A staff member asks what this is. What is the nurse's best response?
It forms the inner lining of the blood vessels. The blood vessels and heart are lined with highly specialized cells called endothelial cells, which compose a layer of tissue called the endothelium. The internal lining of blood vessels is not connective tissue, which is the outer lining. The muscular lining of blood vessels is the tunica media, which is the middle layer.
Positioning during surgery
It is important to maintain a proper position for the patient during surgery. Fail of doing so can result in short term and long term effects for the patient. Patient must be positioned to allow the nurse to monitor vitals, IV lines, and comfort level.
A coworker asks a nurse how cardiac output is determined. How should the nurse respond?
It is the product of stroke volume and heart rate The product of the stroke volume and the heart rate provides the amount of cardiac output. None of the other options (MAP, SVR, or pulse pressure) are factors in cardiac output.
What are the 3 grades of concussions?
I—confusion, disorientation, and momentary amnesia II—momentary confusion and retrograde amnesia III—confusion with retrograde and anterograde amnesia
Infant
Keep routines hold them firmly while smiling and speaking softly to convey sense of trust have infant touch different textures
K
Know which medicines you take and why
Left front lobe
Language, speaking, reading, writing, understanding language Positive emotions Logical/analytical: problem solving through step by step
Macrocyclic-normochromic anemia
Large RBCs & normal hemoglobin concentration
Spleen
Largest secondary lymphoid organ
Nurse Practice Act
Law established to regulate nursing practice
Analogy
Learning occurs when an educator translates complex language or ideas into words or concepts that a patient understands.
Which of the four chambers has the thickest wall?
Left Ventricle
Atrioventricular canal defect manifestations
Left-to-right shunt and pulmonary overcirculation
A client's muscular arteries constrict. How should the nurse interpret this finding?
Less blood flow through the vessels Contraction narrows the vessel lumen (the internal cavity of the vessel), which diminishes flow through the vessel (vasoconstriction). When the smooth muscle layer relaxes, more blood flows through the vessel lumen (vasodilation). The same amount and no change in blood flow do not occur with vasoconstriction.
Lymphocytopenka
Less than normal
Alterations in Arousal
Level of consciousness changes Pattern of breathing (PHVA and CSR) Pupillary reaction -Oculomotor responses -Motor responses -Vomiting, yawning, hiccups
Pineal Gland
Located near center of brain Secretes melatonin
Follicle-stimulating hormone (FSH) and luteinizing hormone (LH) deficiency
Loss of secondary sex characteristics
What happens with Neurogenic shock?
Loss of sympathetic outflow Vasodilation Hypotension Bradycardia Hypothermia
The nurse is preparing a client to be turned in bed. In what position would the nurse place the client to begin this procedure?
Lying flat
Which of the following is the appropriate equation for mean arterial pressure?
MAP = diastolic + 1/3 (systolic - diastolic)
Medications + Lifestyle Changes to Control Hypertension
MEDICATIONS: Diuretics (to DECREASE fluid volume), beta-adrenergic blockers (o block sympathetic stimulation + decrease cardiac output), vasodilators + calcium channel blockers (to relax smooth muscles of arterioles + decrease peripheral vascular resistance) + angiotensin-converting enzyme (ACE) inhibitors (to prevent vasoconstriction by angiotensin II + decrease circulatory fluid volume by reducing aldosterone production). LIFESTYLE CHANGES: Following a low calorie + low fat diet, losing excess weight, limiting alcohol intake, stop smoking, reducing salt intake + exercise.
What is an example of a demyelinating disorder?
MS Multiple Scerosis.
A, B, D, E
MULTIPLE RESPONSE A 15-year-old male is diagnosed with infectious mononucleosis. Which of the following assessment findings would he most likely demonstrate? (Select all that apply.) a. Lymph node enlargement. b. Fever and sore throat c. Rash on the trunk and extremities d. Fatigue e. Enlargement of liver and spleen REF: p. 511
A, B, C
MULTIPLE RESPONSE A patient has microcytic hypochromic anemia. Which of the following pathogenic mechanisms may cause anemia in this patient? (Select all that apply.) a. Decreased erythrocyte life span b. Failure of mechanisms of compensatory erythropoiesis c. Disturbances of the iron cycle d. Increased basal metabolic rate e. Swelling in the tissues REF: p. 501
C, D, E
MULTIPLE RESPONSE A patient wants to know about risk factors for acute leukemia. Which of the following should the nurse include? (Select all that apply.) a. Cytomegalovirus (CMV) infection b. Eating genetically modified food c. Chemotherapy treatment for other cancers d. Excessive ultraviolet radiation exposure e. Ovarian cancer REF: p. 513
Clotting factors
Mainly fibrinogen
Hypothalamus
Maintains wakefulness Located below thalamus and above brainstem
Congenital Heart Defects
Major cause of death in the first year of life other than prematurity
Valvular aortic stenosis
Malformed or fused cusps Progressive obstruction with episodes of ischemia Strenuous activity limited
Leukemia
Malignant disorder of the blood and blood forming organs
Cushing syndrome
Manifestations resulting from chronic exposure to excess cortisol
Splenic pulp
Masses of lymphoid tissue containing macrophages and lymphocytes and lymphoid follicles
Prenatal, environmental, and genetic risk factors of congenital heart defects
Maternal rubella or increased age Diabetes Alcoholism PKU Drugs Hypercalcemia Antepartal bleeding Prematurity Chromosome aberrations
Prenatal, environmental, and genetic risk factors for congenital heart defects
Maternal rubella or increased age, type 1 diabetes, alcoholism, PKU, drugs, and hypercalcemia Antepartal bleeding Prematurity Chromosome aberrations
Ventricular septal defect manifestations
May be asymptomatic If severe: increased pulmonary blood flow from left-to-right shunt; pulmonary hypertension (Eisenmenger syndrome)
Caring
McDonough, RN, MSN, EdD. Florence Nightingale (1860) defined nursing as having "charge of the personal health of somebody...and what nursing has to do...is to put the patient in the best condition for nature to act upon him." ... And at the very core of nursing practice is the act of caring.
Which of the following is NOT correct regarding autoregulation?
Mechanism is well documented and is related to the sympathetic system
Posterior pituitary
Median eminence Pituitary stalk Pars nervosa
Heart Failure
Medical Definition of congestive heart failure. : heart failure in which the heart is unable to maintain adequate circulation of blood in the tissues of the body or to pump out the venous blood returned to it by the venous circulation—compare coronary failure. ??
TITLE XVIII or Social Security Act passed in 1965
Medicare
Protective membranes surrounding the brain and spinal cord
Meninges
Infections
Meningitis - is an inflammation (swelling) of the protective membranes covering the brain and spinal cord known as the meninges -Aseptic - could be viral but not bacterial -Bacterial -Viral Viral encephalitis - inflammation of the brain -direct invasion of virus or post infection as a result of an autoimmune disease
Trial and Error problem solving
Method of problem solving that involves testing any number of solutions until one is found that works for that particular problem.
Malformation of Brain Development
Microcephaly -True (primary) microcephaly - autosomal recessive genetic or chromosomal -Secondary (acquired) microcephaly - infection, trauma, metabolic, maternal anorexia
Diabetic nephropathy
Microvascular disease of chronic DM. Damage to glomerularous in kidneys and tubular atrophy, andglomerulosclerosis
Diabetic retinopathy
Microvascular disease of chronic DM. Leading cause of blindness.
Diabetic neuropathies
Microvascular disease of chronic DM. Peripheral nerve damage, decreased nerve GF, ischemia
Classification by degree of risk
Minor surgery, major surgery, factors affecting the degree of risk
A nurse is describing blood flow through the heart and describes the valve that directs blood flow from the left atrium to the left ventricle. Which term, if used by the client, will indicate to the nurse that the teaching about the valve was successful?
Mitral The mitral valve directs blood from the left atrium to the left ventricle. The aortic valve lies between the left ventricle and the aorta. The pulmonic valve lies between the right ventricle and the pulmonary arteries. The tricuspid valve directs blood from the right atrium to the right ventricle.
Lymphocytosis
More than normal
Hypothyroidism
Most common and results in the deficient production of TH by the thyroid gland
Type 1 Diabetes Mellitus
Most common pediatric chronic disease. Slowly progressive autoimmune T-cell mediated disease that destroys beta cells of the pancreas. Environmental and genetic. Hypoinsulinemia which increases glucagon
Primary hypothyroidism
Most common, results from autoimmune thyroiditis
For the last 3 weeks, a nurse in a long-term care facility has administered a sedative-hypnotic to a client who complains of insomnia. The client does not seem to be responding to the drug and is now lying awake at night. What is the most likely explanation?
Most sedative-hypnotics lose their effect after 1 or 2 two weeks of administration.
Type 2 Diabetes Mellitus
Mostly affects Indian and Alaskan adults with risk factors including obesity, age, HTN, physical inactivity, and gentians. Starts with pancreas beta cell resistance to insulin then eventually hypoinsulinemia and hyperglycemia
What type of neuron transmits impulses from the CNS to an effector organ?
Motor neurons
The nurse adjusts a client's bed to a comfortable working height in order to turn a patient. What would be the nurse's next action?
Move the client to edge of the bed opposite the side that client will be turning.
Alterations in neuromuscular function
Muscle tone -Hypotonia -Hypertonia (spasticity, gegenhalten, dystonia, rigidity)
A nurse teaches the staff about the metabolic hypothesis of autoregulation. Which information from the staff indicates teaching was effective about the location of where autoregulation originates?
Myocardium The metabolic hypothesis of autoregulation proposes that the autoregulation of coronary vessels originates in the myocardium, not the endocardium or the visceral or parietal pericardium.
Eupena
NORMAL respiration
Aortic stenosis
Narrowing of the aortic outflow tract Caused by malformation or fusion of the cusps Causes increased workload on left ventricle and left ventricular hypertrophy Various types
Coarctation of the aorta
Narrowing of the lumen of the aorta that impedes blood flow
Coarctation of the aorta
Narrowing of the lumen of the aorta that impedes blood flow Almost always in a juxtaductal position
Pulmonic stenosis
Narrowing of the pulmonary outflow tract Abnormal thickening of the valve leaflets Narrowing of the valve with resistance to flow from right ventricle to pulmonary artery Right ventricular hypertrophy Pulmonary semilunar valve atresia
After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client to sit up on the side of the bed?
Near the client's hip, with legs shoulder-width apart and one foot near the head of the bed
Teaching Environment
Needs to be conducive to learning
NPWT
Negative-pressure wound therapy: activity that promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed, reduction in bacteria in the wound, and the removal of excess wound fluid
Structural Malformations
Neural tube defects Anterior midline defects Spina bifida - most common -Anencephaly - bone and part of brain missing (stillbirth) -Encephalocele - Herniation of portion of brain and meniges -Meningocele - saclike cysts of meninges filled with spinal fluid -Myelomeningocele - hernia protrusion (meninges, spinal fluid, spinal cord with nerves)
What supports the neurons of the CNS?
Neuroglia
The nurse is caring for new parents. During her education session, the nurse instructs the parents on a newborn's sleep patterns. Which statement is accurate about a newborn's sleep patters?
Newborns sleep 16 to 17 hours per day.
Regular interruptions of the myelin sheath
Nodes of Ranvier
Right front lobe
Non verbal: music, art, perception, space, face, pattern, recognition, language skills Negative emotions, expressing them and perception Synthetic: problem solving by combining whole forms
Hydrocephalus
Noncommunicating hydrocephalus -Internal -Intraventricular Communicating hydrocephalus Acute hydrocephalus Normal-pressure hydrocephalus
What occurs with spinal shock?
Normal activity of the spinal cord ceases at and below the level of injury; sites lack continuous nervous discharges from the brain Complete loss of reflex function (skeletal, bladder, bowel, sexual; thermal control; autonomic control)
Normal-normochromic anemia
Normal size RBCs & normal hemoglobin
First field of certified Nurses
Nurse anesthetists became the first nursing specialty to certify practitioners in 1946
Fever / Hyperthermia: Nursing INTERVENTIONS + Nursing OUTCOMES
Nursing INTERVENTIONS: - Monitor temperature - Monitor blood pressure, pulse + respirations - Monitor intake + output Monitor for fever-related complications - Administer antipyretic medication Nursing OUTCOMES: - Vital signs - Hydration - Thermoregulation - Risk control: hyperthermia
Iron deficiency anemia
Nutritional iron deficiency
Medication risks
OTC, prescribed, or herbal medications can increase surgical risks and affect how the patient responses to the stress of undergoing surgery or anesthesia. During assessment, the nurse questions the patient about all medications taken at home. Potential adverse reactions occur with: diuretics, anticoagulants, tranquilizers, corticosteroids, medications that affect CNS, and herbal medications.
National Council of State Boards of Nursing (NCSBN)
Organization whose memberships consists of the board of nursing of each state or territory.
When assisting a client from the bed into a wheelchair, the nurse assesses the client for signs of dizziness upon standing. For what adverse condition is the nurse assessing the client?
Orthostatic hypotension
Major types of atrial septal defects
Ostium primum Ostium secundum Sinus venosus
Polycythemia
Overproduction of RBCs
Hemoglobin
Oxygen-carrying protein of the erythrocyte
Defects with increased pulmonary blood flow
PDA, atrial septal defect, VSD
Korotkoff Sounds Phases 1 - 5
PHASE 1: Characterized by the first appearance of faint but clear tapping sounds that gradually increase in intensity, the FIRST tapping sound is the SYSTOLIC pressure PHASE 2: Characterized by muffled or swishing sounds. These sounds may temporarily disappear, especially in hypertensive people. The disappearance of the sound during the latter part of phase one + during phase two is called the AUSCULATORY GAP + may cover a range of as much as 40 mm Hg. Failing to recognize this gap may cause serious errors of underestimating systolic pressure or overestimating diastolic pressure PHASE 3: Characterized by distinct, loud sounds as the blood flows relatively freely though an increasingly open artery PHASE 4: Characterized by a distinct, abrupt, muffling sound with a soft, blowing quality. In adults, the onset of this phase is considered to be the FIRST diastolic pressure PHASE 5: The LAST sound heard before a period of continuous silence. The pressure at which the last sound is heard is teh SECOND diastolic pressure.
Which of the following represents the measure of time from the onset of atrial activation to the onset of ventricular activation?
PR interval
Division of ANS that conserves energy and the body's resources
Parasympathetic
Which of the following is the cardioinhibitory center?
Parasympathetic excitation
Anterior pituitary
Pars distalis Pars tuberalis Pars intermedia Secretes tropic hormones
(u)P
Participate in all decisions about treatment.
Aspiration
Passage of fluid and solid particles into the lungs
Defects Increasing Pulmonary Blood Flow
Patent ductus arteriosus (PDA Atrial septal defect Ventricular septal defect Atrioventricular canal defect Tetralogy of Fallot Tricuspid atresia
Anger
Patient blames and complains and often directs anger toward nurse or others. Do not argue with patient but listen to concerns Teach patient present tense. Reassure family and significant others that patients anger is normal.
First stage of General Anesthesia: Analgesia
Patient is awake, becomes drowsy, and loses consciousness. Experiences analgesia or a loss of pain sensation
What is Kernig's sign?
Patient lays down, bring leg up and straighten it, when you straighten it they have pain.
General health risks
Patients have a careful review of their health prior to surgery. When a patient is in a poor state of health, surgery may be delayed or cancelled.
P
Pay attention
Bronchiectasis
Persistent abnormal dilation of the bronchi
person-centered care
Person-centred care is a way of thinking and doing things that sees the people using health and social services as equal partners in planning, developing and monitoring care to make sure it meets their needs.
PHR
Personal Health Records: Information sheets that contain the individual's medical history, including diagnoses, symptoms, and medications
Fever helps the body respond to infectious processes by 5:
Phagocytosis is enhanced, and production of antiviral interferon is augmented
The nurse would like to elevate the client's arms to promote ventilation in a client with chronic obstructive pulmonary disease. What intervention should the nurse implement?
Place a small pillow under each arm.
Jackknife
Placed on abdomen, head lowered, feet lowered, buttocks up Type: rectal
Thrombocytopenia
Platelet count less than 150,000 platelets/uL of blood
thrombopoietin, 10
Platelet levels are regulated by ________. Platelets circulate for__ days before losing their functional capacity.
Viral URI
Pneumonia is usually proceeded by _______ ___
Physical Effects of Hypothermia
Poor coordination, slurred speech, poor judgment, amnesia, hallucinations + stupor - Respirations increase, the pulse becomes weak + irregular + blood pressure is lowered.
A nurse is preparing to turn a hospitalized client age 65 years. Which action is a recommended guideline for performing this skill?
Position a friction-reducing sheet under the client.
Perioperative period
Preoperative, intraoperative, and postoperative
Acute leukemia
Presence of undifferentiated or immature cells
Which of the following is the correct definition of preload?
Pressure generated by the end-diastolic volume
Functions of the Pericardium
Prevents displacement of the heart during gravitational acceleration or deceleration, physical barrier that protects the heart against infection and inflammation, contains pain receptors and mechanoreceptors that affect blood pressure
Temporal lobe function
Primary auditory cortex
Frontal lobe function
Primary motor area
Occipital lobe function
Primary visual cortex
POMR
Problem Oriented Medical Record or POR documentation system organized according to the person's specific health problems: includes database. problem list, plan of care. and progress notes
A new client in the medical-surgical unit complains of difficulty sleeping and is scheduled for an exploratory laparotomy in the morning. The nursing diagnosis is Sleep Pattern Disturbance: Insomnia related to fear of impending surgery. Which step is most appropriate in planning care for this diagnosis?
Provide an opportunity for the client to talk about concerns.
Entrusting
Provides a patient the opportunity to manage self-care.
Medicare
Provides hospital insurance, part A, and medical insurance, part B, to all people age 65 and older who are eligible to receive social security benefits; ppl with total, permanent disabilites; and ppl with end-stage renal disease/
The nurse is caring for a client who is on bed rest and was just turned to the left side. Which action should the nurse take next to decrease the risk of impaired skin integrity?
Pull the shoulder blade forward and out from under the client.
ANS
Pulmonary circulation is innervated by what
A 45-year-old woman is admitted after undergoing a hysterectomy. She has been immobile for 2 days. She has a 20-year history of smoking. She also takes oral estrogen to manage her hot flashes. As a nurse assesses the client, she notices that the client's left leg is dark purple and measures 2 inches (5.08 cm) larger than her right leg. What is the client most at risk for?
Pulmonary embolism
Total anomalous pulmonary venous connection (TAPVC
Pulmonary veins connect to the right side of the heart, directly or indirectly through one or more systemic veins that drain into the right atrium
Henry Street Settlement
Purpose to provide well baby care, health education, disease precention, and treatment of minor illnesses.
The nurse is assisting a patient from the bed into a wheelchair. Which of the following is a recommended guideline for this procedure?
Raise the head of the bed to a sitting position.
Fever helps the body respond to infectious processes by 1:
Raising of body temp kills many microorganisms and adversely affects their growth and replication
Which of the following is TRUE regarding the thoracic duct?
Receives lymph from most of the body
Anemia
Reduction in the total nimber of RBCs in the circulating blood or decrease in the quality or quantity of hemoglobin
PND (Paroxysmal nocturnal dyspnea)
Refers to attacks of severe shortness of breath and coughing that generally occur at night
Clinical Judgment
Refers to the result (outcome) of critical thinking or clinical reasoning; the conclusion, decision, or opinion a nurse makes.
Activity reinforcers
Relies on the principle that a person is motivated to engage in an activity if he or she has the opportunity to engage in a more desirable activity after completion of the task..
Ablative procedures
Removes a part of the body that is diseased EX: removal of a gangrenous toe
Transplantation procedures
Replaces dysfunctional body part EX: heart/kidney
Cognitive
Requires thinking and encompasses the acquisitions of knowledge and intellectual skills.
Resident bacteria
Resident: found in creases in skin, requires friction with brush to remove Table 23-2 [pg. 541]
Fourth stage of General Anesthesia: Medullary paralysis
Respiratory centers in the medulla oblongata of the brain (controls breathing and other vital functions) ceases to function, complete respiratory depression, CPR need, and death can occur.
Which two items are related in the Frank-Starling law of the heart?
Resting sarcomere length to tension generation
Reconstructive or restorative procedures
Restores function or appearance of traumatized or malnourished tissues EX: skin graft for a burn victim
Constructive procedures
Restores functioning that has been lost or reduced EX: cleft lip or palate
Chylothorax
Results from lymph formed in the digestive system called chyle accumulating in the pleural cavity due to either disruption or obstruction of the thoracic duct
Atrioventricular canal defect
Results from nonfusion of the endocardial cushions Demonstrates abnormalities in the atrial and ventricular septa and atrioventricular valves Complete, partial, and transitional AVCs
Transposition of the great arteries: mixed defects
Results in two separate, parallel circuits Unoxygenated blood circulates continuously through the systemic circulation Oxygenated blood circulates continuously through the pulmonary circulation
Network of connected nuclei that regulate vital reflexes, such as CV function and respiratory function
Reticular formation
Pathway that modulates motor movement by inhibiting and exciting spinal activity
Reticulospinal pathway
The nurse is performing range-of-motion exercises on a client's arm. The nurse starts by lifting the arm forward to above the head of the client. Which action would the nurse perform next?
Return the arm to the starting position at the side of the body.
Occipirtal lobes
Right controls left vice versa
Hemodynamic alterations
Right-to-left shunt, left-to-right shunt
Complications of PDA
Risk for bacterial endocarditis
Patent ductus arteriosus complications
Risk for bacterial endocarditis
Standards
Rules or guidelines that allow nurses to carry out professional roles, serving as protection for the nurse, the patient, and the institution where health care is given
Creating a set
SET
Respiratory infections
SIDS could have a possible relationship to what
Males
SIDS is more common in what gender
The nurse is assisting a client to ambulate following knee surgery. What is a key concern when assisting clients with activity?
Safety
Flow of ions between segments of myelin rather than along the entire length of the axon
Saltatory conduction
Sanguineous drainage
Sanguineous drainage is bright red and indicates active bleeding
What is myelin formed and maintained by?
Schwann cells in the PNS
Viral pneumonia
Seasonal and usually self-limiting
What is myelin?
Segmented layer of lipid material that speeds up impulses
Alterations in awareness
Selective attention -Ability to select from available, competing environmental and internal stimuli -Sensory inattentiveness (extinction and neglect syndrome) -Selective attention deficit Memory Amnesia -Retrograde -Anterograde -Image processing Executive attention deficits -ADHD
What type of neuron transmits impulses from sensory receptors to the CNS?
Sensory neurons
Clara Barton
Served on the front line during the Cilvil War and operated a war relief program to provide supplis to the battlefileds and hospitals.
Clara Barton
Set up a postwar service to find missing soldiers and is credited with founding the American Red Cross.
Parkinson disease
Severe degeneration of basal ganglia (corpus striatum) involving the dopaminergic nigrostrital pathway -tremors, rigidity, bradykinesia -Postural disturbances -Autonomic and neuroendocrine symptoms -Cognitive-affective symptoms **Secondary parkinsonism
Poikolocytosis
Shapes
Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client's weight?
Shift their weight back and forth, from back leg to front leg.
Lateral
Side lying Type: thoracic, kidney, and hip
Which part of the heart is responsible for electrical impulse stimulation?
Sinus node
Anisocytosis
Sizes
Microcytic-hypochromic anemia
Small RBCs that contain low amounts of hemoglobin
Motor and sensory pathways regulating voluntary motor control of skeletal muscle
Somatic nervous system
Parietal lobe function
Somatic sensory input
Gait disorders
Spastic Scissors Cerebellar Basal ganglion Senile Front lobe ataxic
Where is white matter found in the spinal cord?
Spinal tracts
Consciousness
State of awareness of oneself and the environment Arousal is state of awakened Most critical clinical index of NS function, with changes indicating either improvement or deterioration
Subvalvular aortic stenosis
Stricture caused by a fibrous ring below a valve Konno procedure used to correct
2 Factors that Determine the CARDIAC OUTPUT
Stroke Volume + Heart Rate
What are Cerebrovascular accidents (CVAs) and what are two kinds?
Strokes. Thrombotic Stroke and Embolic Stroke.
Basophils
Structurally and functionally similar to mast cells
epidermis
Superficial layer of the skin (Book) Top or outermost part of the skin. (sld 2 ch 31)
Common positions used in surgery
Supine or dorsal recumbent, prone, lithotomy, sitting, lateral, Trendelendburg, and jackknife.
The nurse is assisting a client with limited mobility to turn in bed. After successfully turning the client to the side, where would the nurse place an additional pillow?
Supporting the client's back.
Classification by purpose
Surgical procedures are grouped by their purpose. Terms used classify surgical procedures are diagnostic, ablative, constructive, reconstructive or restorative, transplantation, palliative, and cosmetic.
What happens proximal to the injury in Wallerian degeneration?
Swelling Increase in metabolic activity New terminal sprouts project
What happens distal to the injury in Wallerian degeneration?
Swelling appears Neurofilament hypertrophy Shrinkage of myelin sheath Axon degenerates
A nurse is recommending aerobic exercise for a client who is overweight. Which exercise might the nurse suggest?
Swimming
Division of ANS that responds to stress by mobilizing energy stores and prepares the body to defend itself (Fight or flight response)
Sympathetic
Divisions of Autonomic Nervous System
Sympathetic Parasympathetic
Region between adjacent neurons
Synapses
Tetralogy of Fallot
Syndrome represented by four defects: - Ventricular septal defect (VSD) - Overriding aorta - Pulmonary valve stenosis - Right ventricle hypertrophy
Tetralogy of Fallot
Syndrome represented by four defects: Ventricular septal defect (VSD) Overriding aorta Pulmonary valve stenosis Right ventricle hypertrophy
School-Age Child
Teach psychomotor sikkels needed to maintain health offer opportunities to discuss health problems and answer questions
Older Adult
Teach when patient is alert and rested Involve patient in discussion or activity Focus on wellness and person's strength Use approaches that enhances patient's reception of stimuli when they have a sensory impairment Keep teaching sessions short Teach when patient is alert and rested Involve adult in discussion or activity Focus on wellness and person's strength Use approaches that enhances patient's reception of stimuli when they have a sensory impairment Keep teaching sessions short
The nurse should intervene immediately when observing the nursing assistive personnel (NAP) performing which activity with a stable client?
Teaching a client range of motion exercises
hyperpyrexia
Temp > or = to 41C (106F) is hyperpyrexia medical emergency - body must be cooled to prevent brain damage
What is a classical concussion?
Temporary axonal disturbances causing attention and memory deficits but no loss of consciousness
What is a mild concussion?
Temporary axonal disturbances causing attention and memory deficits but no loss of consciousness
Defects decreasing pulmonary blood flow
Tetralogy of Fallot
5 steps nursing process
The 5 Steps of the Nursing Process 1.Assessment Phase 2.Diagnosing Phase 3.Planning Phase 4.Implementing Phase 5.Evaluation Phase The nursing process is a scientific method used by nurses to ensure the quality of patient care. This approach can be broken down into five separate steps. 1.Assessment Phase The first step of the nursing process is assessment. During this phase, the nurse gathers information about a patient's psychological, physiological, sociological, and spiritual status. This data can be collected in a variety of ways. Generally, nurses will conduct a patient interview. Physical examinations, referencing a patient's health history, obtaining a patient's family history, and general observation can also be used to gather assessment data. Patient interaction is generally the heaviest during this evaluative phase. 2.Diagnosing Phase The diagnosing phase involves a nurse making an educated judgment about a potential or actual health problem with a patient. Multiple diagnoses are sometimes made for a single patient. These assessments not only include an actual description of the problem (e.g. sleep deprivation) but also whether or not a patient is at risk of developing further problems. These diagnoses are also used to determine a patient's readiness for health improvement and whether or not they may have developed a syndrome. The diagnoses phase is a critical step as it is used to determine the course of treatment. 3.Planning Phase Once a patient and nurse agree on the diagnoses, a plan of action can be developed. If multiple diagnoses need to be addressed, the head nurse will prioritize each assessment and devote attention to severe symptoms and high risk factors. Each problem is assigned a clear, measurable goal for the expected beneficial outcome. For this phase, nurses generally refer to the evidence-based Nursing Outcome Classification, which is a set of standardized terms and measurements for tracking patient wellness. The Nursing Interventions Classification may also be used as a resource for planning. 4.Implementing Phase The implementing phase is where the nurse follows through on the decided plan of action. This plan is specific to each patient and focuses on achievable outcomes. Actions involved in a nursing care plan include monitoring the patient for signs of change or improvement, directly caring for the patient or performing necessary medical tasks, educating and instructing the patient about further health management, and referring or contacting the patient for follow-up. Implementation can take place over the course of hours, days, weeks, or even months. 5.Evaluation Phase Once all nursing intervention actions have taken place, the nurse completes an evaluation to determine of the goals for patient wellness have been met. The possible patient outcomes are generally described under three terms: patient's condition improved, patient's condition stabilized, and patient's condition deteriorated, died, or discharged. In the event the condition of the patient has shown no improvement, or if the wellness goals were not met, the nursing process begins again from the first step. All nurses must be familiar with the steps of the nursing process. If you're planning on studying to become a nurse, be prepared to use these phases everyday in your new career.
Pulse Pressure
The DIFFERENCE between the systolic + diastolic pressures
Hand off communication
The PACU nurse must receive a hand off report from the OR nurse and the anesthesiologist. This should include the status of the patient and any medications that were given.
Primary purpose of Licensure of Nurses
The Protection of the public
Remittent Fever
The body temperature does NOT return to normal + fluctuates
Sustained or Continuous Fever
The body temperature remains ABOVE normal with MINIMAL variations.
Intermittent Fever
The body temperature returns to normal AT LEAST ONCE every 24 hours
Relapsing or Recurrent Fever
The body temperature returns to normal for ONE or more days with one or more episodes of fever, each as long as SEVERAL days.
The client is ambulating in the room and walks around a bedside table. What is the best explanation for why the client does not bump into the table?
The client is aware of spatial relationships to avoid the table.
The client is an active, healthy 2-year-old child. His mother asks a nurse what she can expect developmentally from the boy over the next few years. What is the nurse's best response?
The client will continue to grow rapidly and will refine both gross and fine motor skills.
The heat conserving mechanism Step 3
The hypothalamus relays information to the cerebral cortex about cold and voluntary responses result (individuals bundle up, keep moving, or curl up into a ball to decrease the amount of skin surface area available for heat loss)
The heat conserving mechanism Step 1:
The hypothalamus stimulates the sympathetic nervous system, which stimulates the adrenal cortex and results in increased skeletal muscle tone, initiating the shivering response and producing vasoconstriction
Prodromal Stage
The incubation period is the time interval between the initial infection and the first appearance of signs and symptoms. Prodromal period - characterized by the appearance of the first mild signs and symptoms. Period of illness - the disease is at its height, and all disease signs and symptoms are apparent.
The nurse teaches a client about the lymphatic system. Which information from the client indicates teaching was successful?
The lymphatic system allows for leakage from the vascular system to be reabsorbed into the body's circulatory system. Capillary outflow exceeds venous reabsorption by about 3 L/day, so some fluid lags behind in the interstitium. To maintain sufficient blood volume in the cardiovascular system, this fluid must eventually rejoin the bloodstream; this is the function of the lymphatic system. Lymphatic vessels are thin walled with valves and thus most resemble veins. Lymph consists primarily of water and small amounts of dissolved proteins, mostly albumin, that are too large to be reabsorbed. It is a pumpless system.
Endomitosis
The megakaryocyte breaks up into fragments
A nurse is assisting client from a bed to a wheelchair. Which nursing action is appropriate?
The nurse uses assistive devices when lifting more than 35 pounds of client weight.
Using proper body mechanics, which motions would the nurse make to move an object?
The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling.
C
The nurse will check which of the following tests to directly measure iron stores? a. Serum ferritin b. Transferrin saturation c. Bone marrow biopsy d. Total iron-binding capacity REF: p. 504
Preparing the surgical site
The patient must shower/clean with a microbial agent the day before the procedure, must remove any hair if required, and documentation must occur. Once in the OR, the skin is cleaned and dried with a sterile towel.
B
The people from which country have the lowest risk for Hodgkin lymphoma? a. United States b. Japan c. Denmark d. Great Britain REF: p. 517
Hematopoiesis
The process of blood cell production
Korotkoff Sounds
The series of sounds for which the nurse listens when assessing the blood pressure - ONLY heard when useing a stethoscope to assess blood pressure - The FIRST sound is the SYSTOLIC pressure - The SECOND sound is the DIASTOLIC pressure, notes where the SOUNDS DISAPPEAR completely. - In situations in which sounds were heard all the way down to zero, for example pregnant women, patients with arteriovenous fistulas + children, the blood pressure recording would include phase IV. - The RADIAL artery is used to ausculate the Korotokoff sounds when assessing blood pressure in the forearm. Forearm measurements tend to be higher than the upper arm measurements. The accuracy of readings with forearm monitors is affected by the position of the wrist relative to the heart. This can be avoided if the wrist is always at HEAR LEVEL when the reading is taken.
A man reports that he had to have a pacemaker put in because his normal pacemaker would not work. This client asks the nurse what the normal pacemaker is. Which information by the client indicates teaching was successful?
The sinoatrial node The sinoatrial node is considered the pacemaker of the heart. The bundle of His helps conduct electrical impulses down the inner ventricles. The coronary sinus is a vein that drains blood from the cardiac veins into the right atrium, and it does not contain autorhythmic myocardial cells. The atrioventricular node initiates a signal that is conducted through the ventricular myocardium by way of the bundle of His and Purkinje fibers.
therapeutic relationship
The therapeutic relationship (also therapeutic alliance, the helping alliance, or the working alliance) refers to the relationship between a healthcare professional and a client (or patient). It is the means by which a therapist and a client hope to engage with each other, and effect beneficial change in the client.
Middle range theory
Theory of unpleasant symptoms
Chemoreceptors
These sense the effectiveness of ventilation by monitoring the PH status of cerebrospinal fluid and oxygen content of arterial blood
Larynx
This connects the upper and lower airways
Diffusion ceases
This happens when alveolar and capillary oxygen pressures equiliberate
Pulmonary circulation
This has a lower pressure than systemic circulation
Acute epiglottitis
This is a severe, rapidly progressive, life-threatening infection of the epiglottis and surrounding area, historically caused by Haemophilus influenzae type B
Croup
This is an acute laryngotracheaobronchitis, common in children from 6 months to 5 years of age, commonly caused by a virus (parainfluenza), and causes subglottic edema
Cystic Fibrosis
This is an autosomal recessive inherited disease
SIDS
This is defined as sudden death of an infant under 1 year of age that remains unexplained
Alveolocapillary membrane
This is formed by the shared alveolar and capillary walls and gas exchange occurs across this membrane
Carbon dioxide
This is more soluble in plasma compared to oxygen
Spasmodic Croup
This is seen in older children, has a sudden night onset without prior illness
Which information from the client indicates teaching by the nurse was successful for systolic blood pressure?
This is the blood pressure when the ventricles contract The systolic blood pressure is the arterial blood pressure during ventricular contraction or systole. The diastolic blood pressure is the arterial blood pressure during ventricular filling or diastole. If the ventricles stopped there would be no blood pressure. Test-Taking Tip: After you have eliminated one or more choices, you may discover that two of the options are very similar. This can be very helpful, because it may mean that one of these look-alike answers is the best choice and the other is a very good distractor. Test both of these options against the stem. Ask yourself which one completes the incomplete statement grammatically and which one answers the question more fully and completely. The option that best completes or answers the stem is the one you should choose. Here, too, pause for a few seconds, give your brain time to reflect, and recall may occur.
compliance
This is the ease with which the lungs and chest wall expand during inspiration
Ventilation
This is the process by which air flows into and out of the gas-exchange airways and is controlled by sympathetic and parasympathetic division of the ANS
Elastic Recoil
This is the tendency of the lungs and chest wall to return to their resting state after inspiration. The forces of the chest wall and lungs are in opposition and pull on each other creating the normal negative pressure of the pleural space
Trachea, Bronchi, and Terminal bronchioles
This is what consists of the lower airways
Neuroreceptors
This monitors the mechanical aspects of ventilation
Epilepsy
Thought to be caused by genetic mutations interacting with environmental effects
C
Thrombocytopenia may be: a. Transient or consistent b. Normal or abnormal c. Congenital or acquired d. Active or inactive REF: p. 523
Autoimmune thyroiditis
Thyroid autoantibodies and autoreactive T lymphocytes infiltrate and destroy thyroid gland
Thyroid-stimulating hormone (TSH) deficiency
Thyroid deficiency
An elderly client is complaining of disturbed sleep during the night because of excessive urination. What information should the nurse address with the client as a possible cause related to the complaint?
Timing of diuretic medication
Convulsion
Tonic-clonic (jerky, contract-relax) movements associated with some seizures
Acute confusional states (ACS)
Transient disorders of awareness that result from cerebral dysfunction -Secondary to drug intoxication, metabolic disorder, or conditions that affect the brain -Delirium (hyperkinetic or hypokinetic)
Hyperosmolar hyperglycemic nonketotic syndrome (HHNKS)
Type 2. Higher glucose resulting in severe dehydration, polyuria, and loss of electrolights. Normal pH
Hypersecretion of prolactin
Typically caused by prolactinomas
UAP
Unlicensed assistive personnel (UAP): individual who is trained to function in an assistive role to the licensed registered nurse in the provision of patient activities as delegated by and under the supervision of the registered professional nurse
Sitting
Upright or semi-reclining with legs elevated to the level of the heart Type: Breast, thoracic, head, and neck
Which of the following peptides has the function of regulation of sodium and water balance?
Urodilatin
U
Use a reputable facility
Toddler
Use play to teach procedure offer picture books that describe story of children in hospital or clinic use simple words
Preschooler
Use role play, imitation, and play to make learning fun encourage questions and offer explanations encourage children to learn through pictures and short stories about how to perform hygiene
Hypersecretion of growth hormone (GH)
Usually associate with hyperpituitarism and is usually caused by GH-secreting pituitary adenomas
Which of the following is the source of nutrients for the blood vessels?
Vasa vasorum
What is the effect of angiotensin II?
Vasoconstriction
The heat conserving mechanism Step 2:
Vasoconstriction of peripheral blood vessels shunts centrally warmed blood away from the periphery to the core of the body where heat can be retained (in subcutaneous fat tissue)
Respirations
Ventilation. The movment of gasses in and out of the lungs.
What motor pathway is responsible for rapidly contracting extensor muscles?
Vestibulospinal pathway
Third stage of General Anesthesia: Surgical anesthesia
Vital signs and reflexes are depressed, skeletal muscles relax, breathing is regular, and operation begins
Accreditation
Voluntary process by which schools of nursing are approved to conduct nursing education programs.
Degeneration of a nerve fiber that has been separated by injury or disease
Wallerian degeneration
This is normally passive, however abdominal and internal intercostal muscles do help
What are the accessory muscles of expiration
Sternocleidomastoid and Scalene muscles
What are the accessory muscles of inspiration
Ventilate the alveoli, diffuse gases into and out of the blood, perfuse the lungs so the body recieves oxygen
What are the functions of the pulmonary system
Diaphragm and External intercostals
What are the major muscles of inspiration
Mucous plugging, chronic inflammation, and chronic infection of the small airways
What are the typical features of CF lung disease
humoral factors
What are vasoconstriction and vasodilation controlled by
even distribution of ventilation and perfusion within the lungs
What does efficient gas exchange depend on?
Nasopharynx and Oropharynx
What is contained in the upper airways
Diaphragm and External intercostals
What is the major muscles of inspiration
Visceral Pleura
What is the name of the membrane that encases the lung
Parietal Pleura
What is the name of the serous membrane that lines the chest wall
Emergency airway and antibiotics
What is the treatments for Acute epiglottitis
Type II alveolar cells
What produces the surfactant
Lungs, digestive tract, and reproductive organs
What systems does Cystic Fibrosis affect
Facts and knowledge
What will be presented in the teaching session.
B
When a nurse is reviewing lab results and notices that the erythrocytes contain an abnormally low concentration of hemoglobin, the nurse calls these erythrocytes: a. Hyperchromic b. Hypochromic c. Macrocytic d. Microcytic REF: p. 501
Social
When a nurse works with a patient, most reinforcers are social and are used to acknowledge a learned behavior (e.g., smiles, compliments, words of encouragement).
D
When a patient wants to know why vitamin B12 and folate deficiencies cause anemia, how should the nurse respond? a. Red blood cells are unable to differentiate into erythrocytes. b. Red blood cells have malformed hemoglobin molecules. c. Red blood cells have decreased O2-carrying capacity. d. Red blood cells have a shorter life span. REF: p. 506
night
When does SIDS normally occur
Minor surgery
When surgical alteration of the body is minimal and there is low risk to the life of the patient. Typically require little to no anesthesia and respiratory assistance. Most minor procedures develop postoperative complications. EX: cataract surgery and breast biopsy
B
When the nurse sees a diagnosis of hereditary hemochromatosis on the chart, the nurse knows this is a disorder of: a. Intravascular coagulation b. Iron overload c. Leukocytosis d. Granulocytosis REF: p. 508
Preoperative phase
When the patient decides to have surgery. This includes all preoperative activities, such as diagnostic tests, forms, and anesthesia risk assessment. This is lasts until the patient is sent to the operating room.
Major surgery
When there is a higher risk to the life of the patient and surgery involves reconstruction or alteration of a body part. Anesthesia and respiratory assistance are usually required. Can be a complicated or prolonged procedure with a large amount of blood loss involving vital organs, and it may have a higher risk of postoperative complications. EX: mastectomy and a bowel reconstruction
What is a Brudzinski sign?
When you flex the head and there is pain. Example - Meningitis.
Alveoli
Where does gas exchange occur
C
Which of the following individuals should the nurse assess first for a vitamin B12 deficiency anemia? a. 3-year-old female who is a fussy eater b. 26-year-old female in the second trimester of her first pregnancy c. 47-year-old male who had a gastrectomy procedure (removal of the stomach) d. 64-year-old male with a history of duodenal ulcers and gastrointestinal bleeding REF: p. 503
First University to offer Vaccalaureate degree
Yale University in 1924
Smoking
__________ is related to cancers of the larynx, oral cavity, esophagus, and urinary bladder
Mary, a 15-year-old, has come for a school physical. During the interview, the examiner is told that menarche has not occurred. An explanation to be explored is: a) nutritional deficiency b) alcohol intake c) smoking history d) possible elevated blood sugar
a
Clara Maas
a 25yr old nurse who died after deliberately obtaining two carrier mosquito bites so that she coul continue providing care to soldiers with yellow fever in the Spanish-American war.
Which type of mobility aid would be most appropriate for a client who has poor balance?
a cane with four prongs on the end (quad cane)
Conductive hearing loss
a change in the outer or middle ear impairs conduction of the sound from the outer to the inner ear
Restless Leg Syndrome
a common sensorimotor disorder associated with unpleasant sensations (prickling, tingling, crawling) that occurs at rest and is worse in the evening or at night; there is a compelling urge to move the legs for relief with a significant effect on sleep and quality of life
Arterial Blood Gas
a diagnostic test examining arterial blood: used to determine the pressure exerted by oxygen and carbon dioxide in the blood
Somnambulism (sleepwalking)
a disorder primarily of childhood and usually resolves within a few years; not usually associated with dreaming and the child has no memory of the event on awakening —sleepwalking in adults often associated with sleep disordered breathing and can include rearranging furniture and eating
What is a Cerebral hemorrhage?
a hemorrhagic stroke
Capnography
a method to monitor ventilation and, indirectly. blood flow through the lungs
Creative Thinking
a process involving imagination. intuition. and spontaneity- factors that underpin the art of nursing.
Acute pain
a protective mechanism that alerts the individual to a condition or experience that is immediately harmful to the body and mobilizes the individual to take prompt action to relieve it; transient and usually lasts seconds to days; begins suddenly and is relieved after the chemical mediators that stimulate pain receptors are removed
Clinical reasoning
a specific term usually referring to ways of thinking about patient care issues (determining . preventing. and managing patient problems): for reasoning about other clinical issues (e.g.• teamwork. collaboration. and streamlining workflow): nurses usually use critical thinking.
Angina
a temporary imbalance between the amount of oxygen needed by the heart and the amount delivered to the heart muscles
The Cloze test
a test of a reading comprehension, asks patients to fill in the blanks in a written paragraph.
eschar
a thick, leathery scab or dry crust that is necrotic and must be removed for adequate healing to occur (book) thick leathery scab or dry crust that is dead necrotic tissue (sld 27 ch 31)
Simulation
a useful technique for teaching problem solving, application, and independent thinking.
Virulence
ability to produce disease
Paroxysmal dyskinesias
abnormal, involuntary mvmts that occur as spasms
REM (rapid eye movement) sleep
accounts for 20-25% sleep time, and occurs about every 90 minutes beginning 1 to 2 hours after non-REM sleep begins —also known as paradoxical sleep because the EEG pattern is similar to the normal awake pattern; the brain is very active with dreaming —associated with loss of temperature regulation; altered heart rate, BP/RR; release of steroids, erection, cerebral blood flow increase
NREM (Non-REM slow wave) sleep
accounts for 75-80% sleep time, and is initiated when inhibitory signals released from the hypothalamus creating a reduced activity state —basal metabolic rate falls, temp decreases, heart rate/RR/BP and muscle tone decreases, reflexes absent, cerebral blood flow decreases, GH released, corticosteroid and catecholamine levels depressed
exogenous
acquired from other people
Inspiration
act of breathing in (book) the active phase of ventilation Involves movement of muscles and the thorax to bring air into the lungs (slide 7 ch 38)
Expiration
act of breathing out. Synonym is- exhalation (Book) the passive phase of ventilation Movement of air out of the lungs (Sld 7 Ch 38)
Validation
act of confirming or verifying
Percussion
act of striking one object against another for the purpose of producing a sound; used to assess the location. shape. size. and density of body tissues (Book)
nursing diagnoses
actual or potential health problem than an independent nursing intervention can prevent or resolve 1. actual problem: is present 2. possible problem: may be present but more data is needed to confirm 3. potential problem: may occur actual or potential health problem that an independent nursing intervention can prevent or resolve. Actual problem is present. Possible problem may be present. but more data are needed to confirm or disconfirm the problem. Potential problem may occur; defining characteristic s are present as risk factors.
collaborative problems
actual or potential health problem that may occur from complications of disease. diagnostic studies. or the treatment regimen; the nurse works together with Other members of the health care team toward its resolution
Anaerobic
adjective BIOLOGY relating to, involving, or requiring an absence of free oxygen. "anaerobic bacteria" relating to or denoting exercise that does not improve or is not intended to improve the efficiency of the body's cardiovascular system in absorbing and transporting oxygen.
Social Security Act
affected health care & provided avenues for public health nursing
Ischemic edema
after infarction and has components of vasogenic and cytotoxic edema
Dysrhythmia
an abnormal cardiac rhythm An irregular pattern of heartbeats is called a (Slide 12 Ch 24)
goal
an aim or an end
HIE
an electronic system that allows physicians, nurses, pharmacists, other health care providers. and patients to appropriately access and securely share a patient's vital medical information
Spirometer
an instrument used to measure lung capacities and, one type is used to encourage deep breathing (incentive spirometer)
Therapeutic hypothermia
an intentional cooling of core temperature used to slow metabolism and preserve ischemic tissue during surgery, after cardiac arrest (may be desired outcome in open heart surgery when heart must be stopped), or following neurologic surgery —immunosuppression and the slowing of drug metabolism —heart and respiratory rate slowing —peripheral vasoconstriction (e.g. limb reimplantation)
What is the most common cause of Subarachnoid hemorrhages?
aneurysms.
The client is scheduled for a polysomnography to determine if the client has obstructive sleep apnea (OSA). The nurse instructs the client to:
anticipate sleeping overnight at a health care center.
Family
any group of people who live together and depend on one another for physical. emotional. or financial support (book) any group of people who live together and depend on one another for physical, emotional, and financial support- related/unrelated: biologically/ legally/ same gender/ span different generations. (Slide 14 ch4)
pressure ulcer
any lesion caused by unrelieved pressure that results in damage to underlying tissue (Book)
progress note
any of a variety of methods of notes that relate how a patient is progressing toward expected outcomes
nursing intervention
any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance patient outcomes; there are nurse-initiated, physician-initiated. and collaborative interventions
A-delta fibers
are medium size thinly myelinated fibers that transmit sharp, well localized "fast" pain sensations (these fibers are responsible for causing reflex withdrawal of the affected body part from the stimulus before a pain sensation is perceived
C fibers
are smaller, unmyelinated fibers that slowly transmit dull, aching, or burning sensations that are poorly localized and often constant
Tracheostomy
artificial opening made in the trachea through which a tracheostomy tube is inserted
Afferent
ascending
Pain Transmission
ascends to the thalamus (the major relay station of sensory information), brain stem, and cerebral cortex for further processing and interpretation
Thoracentesis
aspiration of fluid or air from the pleural space
Children with systemic hypertension are commonly
asymptomatic
Transient bacteria
attached loosely on skin, removed with relative ease Table 23-2 [pg. 541]
Older adults are at risk for alteration in nutritional status. From the individuals described below, select the individual(s) who appear(s) least a risk. a) an 80-year-old widow who lives alone b) a 65-year-old widower who visits a senior center with a meal program 5 days a week c) a 70-year-old with poor dentition who lives with a son d) a 73-year-old couple with low income and no transportation
b
The nutritional needs of a patient with trauma or major surgery: a) are met by rat reserves in obese individuals b) may be two to three times greater than normal c) can be met with intravenous fluids, supplemented with vitamins and electrolytes. d) are met by glycogen reserves
b
Which assessment finding indicated nutrition risk? a) BMI = 24 b) serum albumin = 2.5 g/dL c) current weight = 200 pounds d) BMI = 19
b
Why should the examiner ask about the use of medications when assessing nutritional status? a) Medication allergies are on the rise and a major health concern b) Many drugs can interact with nutrients and impair their digestion, absorption, metabolism, or utilization c) Patients readily discuss their daily use of vitamin and mineral supplements when asked d) The use of anabolic steroids can reduce muscle size and physical performance.
b
The 24-hour recall of dietary intake: a) is an anthropometric measure of calories consumed. b) is a questionnaire or interview of everything eaten within the last 24 hours. c) is the same as a food frequency questionnaire. d) is a form of food diary.
b is a questionnaire or interview of everything eaten within the last 24 hours.
Infectious agent
bacteria [most significant and common], viruses [smallest], fungi [plant like (mold/yeast]
Nurse Reinvestment act of 2002
because of Nursing Shortage, this was signed by President Bush;funded at $20million; provides nursing scholarships, public service announcements promoting nursing as a career, faculty loan cancellation programs, geriatric trainging grants, and nurse retention and safety enhancement grants.
Afferent Pathway
begin in the PNS travel to the spinal gate in the dorsal horn and then ascend to higher centers in the CNS
Pain Transduction
begins when tissue is damaged by exposure to chemical, mechanical, or thermal noxious stimuli; this causes activation of nociceptors (free nerve endings in the afferent PNS that selectively respond to different types of stimuli)
Infratentorial
below tentorium cerebelli
What is a Hemorrhagic stroke (ICH)?
bleeding into the brain tissue
Hemothorax
blood that develop s in the pleural space
cyanosis
bluish / grayish discoloration response to inadequate oxygenation
What is a Cerebral infarction?
brain tissue death at the sit of the stroke
DPI - Dry powder inhaler
breath-activated delivery of medications (slide 35 ch 38) Dry powder inhalers (DPI): types of breath-activated delivery methods for inhaled medications
Orthopnea
breathing is easier when sitting or standing (slide 18 ch 24) type of dyspnea in which breathing is easier when the patient sits or stands
Sanguineous
bright red blood- indicates fresh bleeding (slide 32 ch 31)
Nursing Shortage
by 2020 the UX is projected to need 1,016,900 more RNs than will be available
Body weight as a percentage of ideal body weight is calculated to assess for malnutrition. Severe malnutrition is diagnosed when current body weight is: a) 80% to 90% of ideal weight b) 70% to 80% of ideal weight c) less than 70% of ideal body weight d) 120% of ideal body weight
c
The examiner is completing an initial assessment for a patient being admitted to a long-term care facility. The patient is unable to stand for a measurement of height. To obtain this important anthropometric information, the examiner may: a) measure the waist-to-hip circumference. b) estimate the body mass index c) measure arm span d) obtain a mid-upper arm muscle circumference to estimate skeletal muscle reserve.
c
Which BMI category in adults is indicative of obesity? a) 18.5 - 24.9 b) 25.0 - 29.9 c) 30.0- 39.9 d) <18.5
c
Current dietary guidelines recommend that complex carbohydrates make up ____% of total calorie intake. a) 30 b) 40 c) 60 d) 75
c 60
Which of the following are normal, expected changed with aging? a) increase in energy needs b) increase in body water c) decrease in height d) increase in AP diameter of the chest
c decrease in height
The balance between nutrient intake and nutrient requirements is described as: a) undernutrition b) malnutrition c) nutritional status d) overnutrition
c nutritional status
Which of the following data would be obtained as part of a nutritional screening? a) temperature, pulse, and respiration b) blood pressure and genogram c) weight and nutrition intake history d) serum creatinine levels
c weight and nutrition intake history
The nurse is teaching a new graduate nurse about the most common causes of back injuries. The nurse knows that the new graduate understands the concepts of back injuries when she states that back injuries:
can occur when repositioning uncooperative clients.
Mixed hearing loss
caused by combination of conductive and sensorineural hearing loss
Sensorineural hearing loss
caused by impairment of the organ of Corti or its central connections, and may occur suddenly or gradually
Interstitial edema
caused by transependymal movement of CSF from ventricles into extracellular spaces of the brain tissues
Activation of nociceptors
causes ion channels to open, creating electrical impulses that travel through two primary nociceptors (A-delta and C fibers)
Night Terrors
characterized by sudden apparent arousals in which the child expresses intense fear or emotion, but the child is not awake and can be difficult to arouse; once awakened the child usually has no memory of the event, and so it is said to not be associated with dreaming —although occurring most often in kids, adults may experience with corresponding daytime anxiety
Serous drainage
clear,watery, fluid
Serous
clear/ serous portion of blood (slide 32 ch 31)
Ecchymosis
collection of blood in the subcutaneous tissues- purplish color
Cones
color and detail receptors and are densest at the center
Endogenous
comes from microbial life harbored in the person
Performance Improvement
commitment to healthcare patients quality care, reduced costs, and making a difference; accomplished by discovering a problem , planning a strategy, implementing a change. and assessing the change to see if the goal is met
health problem
condition related to health requiring intervention if disease or illness is to be prevented or resolved and coping and wellness are to be promoted
Eustachian tube
connects the middle ear with the thorax (normally flat and closed and opens with swallowing or yawning to equalize pressure of middle ear with atmospheric pressure); the mucus membrane of the Eustachian tube is continuous with mucosal lining of the throat
Vestibule
contains receptors essential to the body's sense of static equilibrium; as the head moves, otoliths move in a gel-like material in response to changes in the pull of gravity
Wheezes
continuous. high-pitched squeak or musical sound made as air moves through narrowed or partially obstructed airway passages (book) continuous sounds heard on expiration and sometimes on inspiration as air passes through airways constricted by swelling, secretions, or tumors Classified as sibilant ["hissing"] or sonorous [snoring/ gurgling] (sld 27 ch 38)
Marasmus is often characterized by: a) severely depleted visceral proteins b) elevated triglycerides c) hyperglycemia d) low weight for height
d
When reviewing the laboratory report (shown below) of a patient, the examiner realizes this patient is demonstrating: a) no evidence of protein depletion b) mild visceral protein deficiency based on serum albumin c) moderate protein depletion based on the serum transferrin d) moderate protein loss based on the serum prealbumin Laboratory Report: Serum Albumin --- 4.0 g/dL Serum transferrin --- 200 mg/dL Serum prealbumin --- 9 mg/dL
d
To support the synthesis of maternal and fetal tissue during pregnancy, a weight gain of _____ pounds is recommended. a) 25 to 35 b) 28 to 40 c) 15 to 25 d) Recommendation depends on BMI of mother at the start of the pregnancy.
d Recommendation depends on BMI of mother at the start of the pregnancy.
Focus charting
data (D), action (A), response (R) a documentation system that replaces the problem list with a focus column that incorporates many aspects of a patient and patient care: the foc us may be a patient strength or a problem or need: the narrative portion of focus charting uses the data (D), action (A), response (R) format
Affective
deals with expression of feelings and development of values, attitudes, and beliefs and acceptance of attitude, opinions, or values. • Role play • Discussion (group and one on one)
A 45-year-old man is interested in starting an exercise program. The nurse informs him that exercise does not:
decrease appetite.
Bradypnea:
decrease in respiratory rate (slide 18 ch 24) slow rate of breathing
Hypoventilation
decreased rate or depth of air movement into the lungs (book) decreased rate or depth of air movement into the lungs (Sld 16 Ch 38)
ischemia
deficiency of blood in a particular area
desiccation
dehydration: the process of being rendered free from moisture. (Book)
MDI- metered-dose inhaler
deliver a controlled dose of medication with each compression of the canister (Sld 35 ch 38) an instrument that delivers a controlled dose of medication to narrowed airways with each compression of the canister
Efferent Pathways
descend from the CNS back to the dorsal horn of the spinal cord
Efferent
descending
Surfactant
detergent - like phospholipid that reduces surface tension of the fluid lining the alveoli
Lillian Wald
developed a ciable practice for public health nursing (THE HENRY STREET SETTLEMENT) located in the Lower East Side of NYC
Pulse deficit
difference between the apical and radial pulse rates
Dyspnea
difficult labored breathing
dyspnea
difficult labored breathing
Dyspnea:
difficult or labored breathing (book) difficulty breathing- most common symptom of hypoxia(increase BP, increased P, R, pallor and cyanosis) (Sld 16 ch 38)
Means of transmission
direct contact, indirect contact, airborne route
Intuitive Problem Solving
direct understanding of a situation based on a background of experience, knowledge, and skill that makes expert decision making possible
Pathogens
disease producing microorganism
infection
disease state resulting from pathogens in or on the body
Dyssomnias
disorders of initiating and maintaining sleep or excessive sleepiness
Nebulizers
disperse fine particles of liquid medication into the deeper passages of the respiratory tract (Sld 35 ch 38) an instrument that disperses fine particles of medicine into the deeper passages of the respiratory tract where absorption occurs.
Nasal cannula
disposable, plastic device that delivers oxygen via two protruding prongs for insertion into the nostrils
Which activity for rest break should not be incorporated into care planning for clients to aid in healing and recovery?
drinking an 8 oz cup of a caffeinated beverage
Semicircular Canal
equilibrium receptors that respond to changes in direction of movement; as the head rotates, the endolymph moves in the direction opposite to the head's movement
Outcome evaluation
evaluation that focuses on measurable changes in the health status of the patient or the end results of nursing care
critical thinking indicators (CTI)
evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics. and skills that promote critical thinking in clinical practice
Diffusion
exchange of O2 and CO2 between alveoli and circulating blood (slide 16 ch 24) tendency of solutes to move freely throughout a solvent from an area of higher concentration to an area of lower concentration until equilibrium is establised
Perfusion
exchange of O2 and CO2 between circulating blood and tissue cells (Slide 16 Chap 24) ?process by which oxygenated blood pass e s through body tissues
Patient outcome
expected conclusion to a patient health problem in the event of a wellness diagnosis, an expected conclusion to a patient's health expectation
What is a fusiform aneurysm?
explosion along the whole artery.
Referred pain
felt in an area removed or distant from its point of origin; the area of referred pain is supplied by the same spinal segment as the actual site of pain (impulses from many cutaneous and visceral neurons converge on the same ascending neuron, and the brain cannot distinguish between the different sources of pain
Crackles
fine crackling sounds made as air moves through wet secretions in the lungs intermittent sounds occurring when air moves through airways that contain fluid Classified as fine, medium, or coarse (Sld 27 ch 38)
Upper motor neurons control...
fine motor movements and spinal reflex arcs
Static encephalopathies
fixed lesion without ongoing disease Cerebral palsy - disorder of muscle tone or posture caused by injury or abnormal development before, during, or after birth up to 1 year
Smell + taste=
flavor
Pleural effusion
fluid in the pleural space
A nurse applies padded boots to maintain the foot in dorsiflexion on a client who is comatose. The nurse is protecting the client from:
footdrop.
contact precautions
for patients confirmed or suspected of having CDI. This includes a private room, and use of gown and gloves when entering the room and during patient care. (Sld 21 Ch 23)
Shearing
forces tearing or injuring blood vessels when one layer of tissue slides over another layer (Slide 28 ch 31)
gluconeogenesis
formation of glucose from noncarbohydrate sources
Nursing Practice at the Henry Street Settlement
formed the basis for public health nursing in the United States
What is a Compound fracture?
fractures exposed through the skin
Turgor (Skin Turgor)
fullness or elasticity of skin assessed on sternum or under the clavicle by lifting a fold of skin with thumb and first finger.
Cell bodies in the PNS are...
ganglia
PPE- personal protective Equipment
gloves. gowns. masks. and protective eye gear designed to minimize or prevent the health care worker's exposure to infectiousmaterial
Electrocardiogram (ECG)
graphic record produced by the electrocardiograph (book) electrodes detect electric currents and transmits them from heart conduction (Sld 28 ch 38)
Alopecia
hair loss or balding
When moving a client up in bed with the assistance of another caregiver, the nurse should:
have the client fold the arms across the chest.
Hyperthermia
high body temperature
Impact of Medicare reimbursement on nursing
hospital occupancy increases, resulting in an increased need for hospital nurses; nursing embraces the hospital setting ast he usualy praactice site; home health movement was initiated
Temperature regulation (thermoregulation) is mediated by the?
hypothalamus
Antibody
immunoglobin produced by the body in response to a specific antigen
Hypoxia
inadequate amount of oxygen available to the cells (anxiety, restless, confused, drowsy) (sld 16 ch 38) lack of oxygen to cells (sld 26 ch 31)
Extended family
includes aunts, uncles, and grandparents nuclear family and other related people
Atelectasis
incomplete expansion or collapse of a part of the lungs
Vasogenic edema
increased permeability of the capillary endothelium
iatrogenic infection
infection that occurs as a result of a treatment or diagnostic procedure
Pediculosis
infestation with lice
Gingivitis
inflammation of the gingivae or gums
Retina
innermost layer, containing millions of rods and cones (special photoreceptors that convert light energy into nerve impulses)
Concept Mapping
instructional strategy that requires learners to identify. graphically display. and link key concepts. "A concept map is an active learning strategy that promotes critical thinking, clinical judgment, and helps increase clinical competency." (Jamison & Lis, 2014; George, et al., 2014) (Slide 2 CDmaking)
Collaborative interventions
interdependent nursing actions performed jointly by nurses and other members of the health care team
What neurons transmit impulses from neuron to neuron?
interneurons
Pain Perception
interpretation of pain is influenced by many factors including cultural preferences, male and female roles, and life experience
Tardive dyskinesia
involuntary mvmt of the face, lip, tongue, trunk, and extremities usually occurs as a side affect of prolonged anti-psychotic drug therapy
Motivation
is a force that acts on or within a person (e.g., an idea, an emotion, a physical need) to cause the person to behave in a particular way.
granulation tissue
is built to fill the wound space and forms a scar - tissue easily bleeds (Sld 15 ch 31) new tissue that is pink/red in color and composed of fibroblasts and .,mall blood vessels that fill an open wound when it starts to heal (Book)
Morning Care
is categorized as self care, partial care [bedside/sink], or complete care
When an older adult client walks with her knees slightly flexed and body leaning, the nurse determines that the client:
is demonstrating a common gait for the older adult.
Interpersonal Communication
is necessary for the teaching/learning process, but describing what the learner will be able to do after successful instruction constitutes learning objectives.
Computer instructions
is use of a programmed instruction format in which computers store response patterns for learners and select further lessons on the basis of these patterns (programs can be individualized). Computer instruction is a teaching tool.
Chronic/Persistent Pain
lasts more than 3 to 6 months, or pain lasting well beyond the expected normal healing time; serves no purpose, and often appears to be out of proportion to any observable tissue injury; it may be ongoing (low back pain) or intermittent (migraines)
Dermis
layer of the skin below the epidermis. second layer with a framework of elastic connective tissue, which rests on the subcutaneous tissue that anchors the skin layers to the underlying tissues of the body. (adipose tissue)(sld 2 ch 31)
NCLEX
licensure exam...taken by BSN, diploma, and ADN
Hyperopia (farsightedness)
light rays are focused behind the retina when a person is looking at a near object
Myopia (nearsightedness)
light rays are focused in front of the retina when the person is looking at a distant object
Auscultation
listening for sounds within the body (Book)
Subdural
located below dura mater
Interpretative centers
located in the brainstem, midbrain, diencephalon, and cerebral cortex
issue with pineal gland
look at sleep cycle melatonin levels
Hypothermia
low body temperature
When logrolling a client, the nurse should use supportive devices in turning the client in order to:
maintain the natural alignment of the client's body.
Single-parent family
may be separated, divorced, widowed, or never married
Evaluating
measurement of the extent to which the patient has achieved the goals specified in the plan of care; factors that positively or negatively influenced goal achievement are identified, and the plan of care is terminated or revised
Rods
mediate peripheral and dim light vision and are densest at the periphery
Bronchodilators
medication that relaxes contractions of smooth muscles of the bronchioles open narrowed airways (Sld 35 ch 38)
SOAP Format
method of charting narrative progress notes: organizes data according to subjective information (S), objective infonnation (0) assessment (A), and plan (P)
Cilia
microscopic. hair-like projections that propel mucus toward the upper airway so that it can be expectorated
Serosanguinous
mixture of serum and RBC's- light pink to blood tinged (slide 32 ch 31)
Hyperventilation
more than the normal amount of air entering and leaving the lungs (slide 18 chap 24)
Pulmonary ventilation
movement of air (gases) into and out of the lungs
One of the most common injuries/risks associated with exercise in a healthy person is:
muscle injury.
Lower motor neurons have a direct influence on...
muscles
Susceptible host
must overcome resistance mounted by host's defenses
Preganglionic cells are ______ Postganglionic cells are _____
myelinated unmyelinated
Reservoir
natural habitat of the organism
Can you do a Lumbar puncture with someone who has a brain tumor?
no. because it will herniate.
Open gate
nociceptive transmissions on these large myelinated A-delta fibers "open" the spinal gate and increase the perception of pain
Korotkoff sounds
non-invasive BP - arterial sounds heard through a stethoscope applied to the brachial artery distal to the BP cuff that changes with varying cuff pressure- determines your Systolic/ diastolic BP: Table 24-9 - page 601
Closed gate
non-nociceptive transmissions that serve to "close the gate" decrease pain perception
Pulse Oximetry
noninvasive technique that measures the oxygen saturation (SaO2 of arterial blood).
Bronchovesicular sounds
normal breath sounds heard over the upper anterior chest and intercostal area
Vesicular (breath) sounds
normal sound of respirations heard on auscultation over peripheral lung areas
Eupnea
normal, unlabored respirations (Slide 18 Chap 24) normal respirations
Cell bodies in the CNS are...
nuclei
Evidenced based practice
nursing care provided that is supported by sound scientific rationale
increased incidence of primary hypertension in older children is related to
obesity
Reflective practice
occurs when the caregiver has a profound awareness of self, and one's own biases, pre judgments, prejudices, and assumptions, and understands how these may affect the therapeutic relationship
Halitosis
offensive breath
What is coup-contra coup head injury?
one that occurs either front to back or side to side.
Myocardial infarction
one type of acute coronary syndrome characterized by the death of heart tissue due to lack of oxygen: also known as a hean attack
Parasite
organism that lives on or in a host and relies on it for nourishment
Extracerebral
outside of the brain tissue
Maceration
overhydration, softening through liquid (book)
Gate Control Theory
pain transmission is modulated by a balance of impulses conducted to the spinal cord, where cells in the substantia gelatinosa function as a "gate" that regulates the nociceptive (pain) transmission to higher centers in the CNS
Pallor
paleness
Dehiscence
partial or total separation of wound layers as a result of excessive stress on wounds that are not healed
Denial
patient avoids discussions of illness, withdraws from other, and disregards physical restrictions. Nurse: provide support, empathy, and careful explanation of all procedures while they are being done.
Apnea
periods of no breathing (slide 18 chap 24) Absence of breathing
Serosanguineous drainage
pink (light red), watery, and a mixture of serum and blood
Fungi
plant-like organisms (molds and yeasts) that can cause infection
Portal of entry
point at which organisms enter a new host
Portal of exit
point of escape for the organism
Endotracheal tube
polyvinyl-chloride airway that is inserted through the nose or the mouth into the trachea, using a laryngo scope as a guide
The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk?
predisposition to renal calculi
hypothalamus
president of endocrine system then pituitary gland is vice president, carrying out orders from hypothalamus
Narcolepsy
primary hypersomnia of central origin characterized by hallucinations, sleep paralysis, and rarely cataplexy (spells of muscle weakness)
Antigen
process of rendering a person immune or resistant 10 particular antigenic agents or bacteria
Nociception
processing of potentially harmful (noxious) stimuli through a normally functioning nervous system
American Association of Colleges of Nursing (AACN)
provide details about #s and types of programs, students, and graduates for BSN and higher degree programs.
Tachycardia:
rapid heart rate 100-180 beats/min Decreases cardiac filling time which decreases stroke volume and cardiac output (Slide 11 ch 24)
Tachypnea
rapid rate of breathing
BMI
ratio of height to weight (Book)
erythema
redness of skin caused by dilation of superficial blood vessels
Visceral pain
refers to pain in the internal organs and lining of body cavities; tends to be poorly localized with an aching, gnawing, throbbing, or intermittent crampy quality—carried by sympathetic fibers and associated with N/V, hypotension, and sometimes shock—often radiates
Turgor
removal of devitalized tissue and foreign material
QI
represents an invisible flow of energy that circulates through plants, animals. and people, as well as the earth and sky
Sputum
respiratory secretion expelled by coughing or clearing throat
Obstructive Sleep Apnea (OSA)
results from upper airway obstruction recurring during sleep with excessive snoring and multiple apneic episodes lasting 10 seconds or longer; the periodic breathing usually produces arousal which interrupts sleep cycle, reducing total sleep time and producing sleep and REM deprivation —produces hypercapnia and low O2 saturation and eventually leads to pulmonary and systemic HTN, stroke, CHF, dysrhythmias —associated conditions include obesity, decreased sensitivity to CO2 and O2 tensions, and upper airway obstruction
Standard Precautions
rules or guidelines that allow nurses to carry out professional roles, serving as protection for the nurse, the patient, and the institution where healthcare is given
purulent drainage
s/s- purulent ( WBC's, debris, bacteria) drainage, pain, redness, swelling, elevated WBC (Sld 20 Ch 31) comprised of white blood cells liquefied dead tissue debris, and both dead and live bacteria (book) thick, foul odor, could be dark yellow to green (Sld 32 Ch 31)
Clara Mass stamp was during the
sexual revolution of the 1970s, but was a positive effect on Nursing
Cue
significant information that is helpful in making decisions
Integument
skin, nails, hair and scalp
memorize what table
slide 11
Bradypnea
slow rate of breathing
Alveoli
small air sacks at the end of the terminal bronchioles that are the site of gas exchange (book) at the terminal bronchioles, small air sacs (slide 5 ch38)
Petechiae
small hemorrhagic spots caused by capillary bleeding
Virus
smallest of all microorganisms
Basic Human Needs
something essenial to the health and survival humans; common to all people
Nosocomial
something originating or taking place in the hospital (i.e., infection) It can be exogenous (acquired from other people) or endogenous ( comes from microbial life harbored in the person). If iatrogenic infection- resulted from a treatment or diagnostic procedure.
Endemic
something that occurs with predictability in one specific region or population and can appear in a different geographical location
Speak up Pay attention to the care you get Educate yourself about your illness Ask a trusted family member. Know which medicines you take and why Use a reputable facility Participate in all decisions about treatment.
speak up
Community
specific population or group o f people living in the same geographic area under similar regulations and having common values. interests. and needs
expected outcome
specific, measureable criteria used to evaluate weather the outcome criteria has been met.
criteria
specified behavior: for example. the measurable criteria in a patient goal specifies how the patient must perform the desired behavior
QSEN competencies
standards for Quality and Safety Education for Nurses, a project for preparing future nurses with the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the health care systems within which they work Quality and Safety Education for Nursing 2005
medical diagnoses
statement about a specific disease process using terminology from a well-developed classification system accepted by the medical profession
The nurse has been educating the client about how to use a walker safely. The nurse knows the education has been effective when the client:
steps into the walker when walking.
Surgical Asepsis
sterile technique: keeps an object or area free from all microorganisms non pathogenic and pathogenic.
What is a Lacunar stroke?
stroke in the deeper structures
Somatic pain
superficial and arising from the skin; typically well localized and described as sharp, dull, aching, or throbbing
Pain tolerance
the greatest intensity of pain that a person can endure—generally decreases with repeated exposure to pain, fatigue, anger, boredom, apprehension, sleep deprivation
The heat producing mechanism Step 1:
the hypothalamus releases thyrotropin-stimulating hormone releasing hormone (TSH-RH) and it stimulates the anterior pituitary to release thyroid-stimulating hormone (TSH) which acts on the thyroid and stimulates the release of thyroxine
Insomnia
the inability to fall or stay asleep; may be transient or chronic and related to acute stress, depression, EtOH, chronic pain, obesity, drugs, aging
Functional hearing loss
the individual does not respond to voice and appears not to hear; thought to be caused by emotional or psychologic factors
inference
the judgment reached about a cue
Pain threshold
the lowest intensity of pain that a person can recognize
Attentional Set
the mental state that allows the learner to focus on and comprehend a learning activity. Discomfort ,anxiety etc. influence the ability to focus. Learning occurs when the patient is actively involved in the educational session.
Bacteria
the most significant and most commonly observed infection causing agents
Blended competencies
the set of intellectual, interpersonal, technical, and ethical/legal capacities needed to practice professional nursing
Other excitatory neuromodulators include substance P, histamine, glutamate, and calcitonin-related peptide
these substances sensitize nociceptors in the PNS or CNS, leading to an increased responsiveness and reduced threshold of nociceptors that cause them to fire with increased frequency, resulting in hyperalgesia (increased sensitivity to painful stimuli) and allodynia (the perception of innocuous stimuli)
Purulent
thick, foul odor, could be dark yellow to green (slide 32 ch 31)
Bronchial sound
those heard over the trachea: high in pitch and intensity, with expiration be ing longer than inspiration
Critical Thinking
though that is disciplined. comprehensive. based on intellectual standards. and. as a result, well-reasoned: a systematic way to form and shape one's thinking that functions purposefully and exactingly
The heat producing mechanism Step 2:
thyroxine then acts on the adrenal medulla, causing the release of epinephrine into the bloodstream, which causes vasoconstriction, stimulates glycolysis, and increases metabolic rate, thus increasing heat production
Assessing
to systematically and continuously collect, validate. and communicate patient data
Nuclear family
traditional family; two parents and their children (Slide 14 ch4) family unit, family of marriage, parenthood. or procreation, and their immediate children(book)
A home care nurse visits a client with Parkinson's disease. The nurse observes that the client has rhythmic, repetitive movements of the hands. The home care nurse documents this as:
tremor
Blended family
two parents and their unrelated children from previous relationships (slide 14 ch4) Two single parent families joined together to form a new family unit.(book)
Pleura
two-layered membranes: the visceral pleura covers the lungs, and the parietal pleura lines the thoracic cavity (book) lungs are lined with a serous membrane (Slide 5 ch 38)
What is a Basilar skull fracture?
underneath the base of the skull. Battle's Signs and Raccoon Eyes are an example.
Parasomnias
unusual behaviors occurring during sleep
Telling
used when teaching limited information. If the pt. is anxious but it is vital information.
Cytotoxic edema
when toxic factors cause active transport systems to fail
Intracerebral
within the brain tissue
Evisceration
wound completely separates, with protrusion of viscera through incisional area
plan of nursing care
written guide that directs the efforts of the nursing team as the nurses work with patients to meet health goals; it specifies nursing diagnoses. outcomes. and associated nursing interventions
Myocardial Ischemia
www.mayoclinic.org/diseases-conditions/myocardial-ischemia/basics/.../con-2003509... Jul 25, 2015 - Myocardial ischemia occurs when blood flow to your heart is reduced, preventing it from receiving enough oxygen. The reduced blood flow is usually the result of a partial or complete blockage of your heart's arteries (coronary arteries).
Jaundice
yellow skin color resulting from elevated bilirubin n blood with liver/ gallbladder diseases
External ear
—sound waves enter the external auditory canal and hit the tympanic membrane (eardrum) causing it to vibrate —the tympanic membrane separates the external ear from the middle ear
Cochlea
—sound waves that reach the cochlea through vibration of the tympanic membrane, ossicles, and oval window set the cochlear fluids in motion —receptor cells on the basilar membrane are stimulated when the hairs are bent or pulled by fluid movement, and once stimulated, the hair cells transmit impulses along the cochlear nerve to the auditory cortex of the temporal lobe of the brain (this is where interpretation of sound occurs)
Middle ear
—the stapes presses against the oval window (a small membrane of the inner ear) and this movement sets the inner ear fluids in motion
Which exercises would the nurse recommend when planning isometric exercise for a client? Select all that apply.
• Contracting the quadriceps • Kegel exercises • Contracting and releasing the gluteal muscles
Stages of Infection
• Incubation period: organisms enter, grow and multiply • Prodromal stage: person is most infectious, vague and nonspecific signs of disease • Full stage of illness: presence of specific signs and symptoms of disease • Convalescent period: recovery from the infection
A 90-year-old widower lives alone in her home. The nurse knows that older clients are at increased risk for falls. What other factors contribute to increased risk for falls in clients? Select all that apply.
• ataxic gait • history of a fall 5 years ago • diuretics
A nurse is assessing a client's mobility status. What data would the nurse document as normal findings? Select all that apply.
• independent maintenance of correct alignment • head, shoulders, and hips aligned in bed • full range of motion
A nurse is conducting a home assessment of a 90-year-old male client with a history of several minor strokes that have left him with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client? Select all that apply.
• removal of clutter on the floor • placing a nightlight in the bathroom and the hallways • moving the bedroom to the ground floor
Which clients will develop mobility issues in the future? Select all that apply.
• the 35-year-old computer programming technician • the 55-year-old clinical secretary who is to retire after 30 years working the same job
A client describes difficulty falling asleep and difficulty maintaining sleep, and reports daytime fatigue and inability to concentrate. The nurse suggests which noninvasive techniques that may help promote restful sleep? Select all that apply.
• waking at the same time every morning • removing bedtime distractions such as watching television in bed • practicing relaxation techniques