EXAM 1 NURS 1200
to consume enough vitamin a to support proper wound healing the nurse should recommend
1600 to 2000 retinol equivalents per day
which item would be required for a wound irrigation delivery system
19 gauge angiocatheter
a nurse explains the steps for adminstering a squeeze and breathe metered dose inhaler with out. a spacer to a patient the steps are in this order
1st administer the squeeze and breathe mdi canister into the holder 2nd remove the mouth piece cover from the inhaler 3rdly shake the inhaler vigorously 5 to 6 times 4th have the patient sit up take a deep breathe and exhale 5th tilt head back slightly and inhale slowly and deeply through mouth 6th remove mdi from mouth and exhale through pursed lips
how many words would the nurse ask the patient to recall when using the mini cog instrument to test the cognitive ability of a patient
3
if a patient has fair muscle strength and the muscles are at 50% normal condition which grade of muscle strength would the nurse assign
3
which nursing skill is involved in assessing a patients status after administering an intravenous med
evalution
which time frame will the nurse use for med administration if a patients prescription reads cefuroxime 1 gm intravenously TID
every 8 hours
lordosis is the
exaggeration of the anterior convex curve of the lumbar spine
gordens model is an
example of a structured database format
which assessment findng would reflect a keloid formation at the site of a previous surgery
excess scar tissue
which description is true regarding the disadvantage of med administration through the intraocular disk
expensive
after assessing the physician gives the nursing student a verbal order for a new med which action would the nursing student take first
explain to the physician that the prescription should be given to a rn
probing, leading and closed ended questions are used to
explore the history of the patinet after the assessment has started
which action by the nurse may lead to musculoskeletal injury when positioning a patient who had a syncope episode while walking
extending both legs of the patient to let them slide against the floor
the nurse is assessing a patient who reports joint pain which type of rom assessed by the nurse involves sagittal plane movement
extension dorsiflexion
Secondary intention healing
extensive tissue loss edges cant be closed repair time longer scarring greater susceptibility to infection greater
a trochanter roll prevents
external rotation of the hips when a patient is in the supine position
depression is manifested by
extreme sadness
odd is a mental health disorder seen in children who are
extremely irritable tend to lose their temper argue with adults disobey set of rules
which pain assessment tool is appropriate for a 2 yr old patient
face, legs, activity , cry and sonsolability scale
which pain assessment tool would the nurse use to evaluate the intensity of pain in a 6 yr old patient
faces pain scale
expression of feelings is a
factor related to situational context
full range of motion with gravity indicates
fair muscle strength and 50% normal condition which is considered grade 3 muscle strength
in developing a client plan of care the lpn can revise the plan if the client is not meeting expected goals
false
higher blood flow to the site
favors faster absorption of drugs
health care agencies establish individual policies to meet
federal, state and local regulations
which element of the communication process is the patient displaying when frequently nodding and saying i see as the nurse explains the steps of a dressing change
feedback
which nursing intervention would the nurse accurately measure the respiratory rate in an obese patient
feel the breaths by placing a hand on the patients abdomen
lanugo is
fine, downy hair that is present in the newborn for the first few months after birth
which part of the hand would the nurse use to assess the skin texture, swelling and the presence of lumps during palpation
fingertips
delusions are
firm, irrational and fixed false belief that occur despite real perceptions
German Measles (Rubella)
first appears on the face then spreads
athletes foot causes
fissures btwn the toes and sides of feet and soles
fibrous joints are
fixed joints the permit very little movement
a macule is a
flat circumscribed primary lesion of less than 1 cm in diameter
which primary muscle is used for the abduction of the wrist joint
flexor carpi radialis extensor carpi radialis brevis extensor carpi radialis longus
rapid skipping from 1 topic to another when the topics have recognizable associations is known as
flight of ideas
the thought process disorder in which the patient suddenly skips from one topic to another with recognizable associations to previous topics is known as
flight of ideas
which shirt term illness would explain a patients weight loss
flu
while carring for a patient with enteral feeding which precautionary measure taken by the nursing student indicates a need for correction
flushing tubes with at least 10 mL of water before and after giving one or more meds
Nursing Assessment
focus on the patient's response to health problems
according to maslows heirarchy of needs basic physical needs must be met first such as
food air and water
volume controlled infusions allow
for administration of meds that are stable for a limited time in solution
a propellant is used
for effective dispersion of the drug in the canister
transdermal routes are used
for prolonged systemic effects with limited side effects buy may not provide rapid relief
shaking an insulin vial can
form bubbles that can interefere with correct dosage
tinea corporis
form multiple circular lesions with clear centers on the abdomen chest and back of arms
a capsule is a
form of med that is encased in a gelatin shell this med is meant to be swallowed whole
which info regarding synovial joints would be correct
freely movable and lined with synovial membranes
synovial joints are
freely movable joints
eversion and inversion occur in the
frontal plane
abduction is a
frontal plane movement
which alteration in mental status would the nurse assess for in an older adult patient who has age related hearing loss
frustration social isolation suspicion
stage 4 pressure injury
full thickness tissue loss exposing bone tendon muscle
keratin has no
function un skin pigmentation
which exam visualizes neurochemical changes in the brain caused by nociception
functional magnetic resonance imaging
which observation would be considered correct when assessing the mobility of a patient walking across the room
gait
a patient should be adminstered o2 at a rate of 2 l/min via nasal cannula if the patient has impaired
gas exchange related to decreased cardiac output
which fluids if exposed to the skin pose the highest risk of skin breakdown
gastric secretions
which items would be required for wound irrigation
gauze dressing supplies
hydrogel dressings are
gauze or sheet dressings impregnated with water or glycerin based amorphous gells
the patient with class 2 obesity
generally has a bmi of 35-39
which assessment tool would the nurse use to assess the level of consciousness of an older adult with confusion
glasgow coma
which piece of equipment measures the rom of a shoulder joint
goniometer
the wider the base of the support the
greater the stability of the nurse
the lower the center of gravity the
greater the stanility of the nurse
which skin finding in a newborn would alert the nirse to fetal distress
greenish brown discoloration of the nails and cord
when a patient diagnosed with onychomycosis presents with nail clubbing and loosening of the nail plate for which additional finding would the nurse assess
greenish discoloration around the nail plate
based on the medical record of a patient diagnosed with gigantism which laboratory value would the nurse reviewq
growth hormone
which abnormal mental health finding would the patient be experiencing when they tell the nurse i often heat my dead grandfathers voice
hallucinations
which condition would involve the distal part of the great toe being directed away from the bodys midline
hallux valgus
intrapersonal communication
happens within the person
tympanic percussion note
has a loud intensity, high pitch and a drumlike musical quality
intramuscular and intravenous routes
have higher absorption rates
meds placed under the tounge
have quick absorption
patients with trigeminal neuralgia
have severe stabbing or piercing pain in the facial area
which nursing action is appropriate when the nurse only administers a partial dose of a narcotic
having a second nurse sign for the waste in the patients record disposing of the unused part of the narcotic in the presence of another nurse
to determine if a child has increased intracranial pressure which assessment would the nurse perform on a 7 month old infant who sustained a fall
head circumference
agility training may
help prevent falls
a wood light
helps to find scalp infections
intramuscular injections are preferred for meds such as
hep b, tetanus, diphtheria and pertussis immunizations
which condition would the nurse expect in a patient who after sustaining a fall reports severe back pain that shoots down to the legs and who is unable to perform hip flexion or extension during an assessment
herniated lumbar disc
a patient is lying supine with the leg relaxed the nurse slowly raises the foot keeping the knee straight until the patient complains of pain and then dorsiflexes the foot the nurse would be assessing for which condition
herniated nucleus pulposus
thigh bp is
higher than that of the arm
cell membrane has a lipid layer
highly lipid soluble meds cross cell membranes easily and are absorbed quickly
which activity is least appropriate for an older adult patients exercise program
hiit training
the presence of excessive hair growth on a females chest and face indicates
hirsutism
which neurotransmitter is released at the site of injury
histamine bradykinin prostaglandin
probing explores the
history of the patient without controlling the direction of the story and is meant to bring out as much info as the patient can give
while assessing a patient the nurse observes raised irregularly shaped skin eruptions with red margins which mild reaction does the nurse document in the medical record
hives or urticaria
Insulin syringe
hold 0.3 mL to 1 mL
a patient using a breath activated metered dose inhaler which action made by the patient ensures full med distribution
holding the breath for 5 to 10 seconds during inhalation
the 3 point technique involves
holding the thumb at the mouthpiece with the index and middle fingers at the top
the primary function of the pituitary gland is
hormone secretion and doesnt help thermoregulation
which type of dressing is provided to the patient that developed a deep pressure injury that has the presence of exudates
hydrogel
which dressing would the nurse use to protect and absorb moisture when providing care to a patient with a pressure injury
hydrogel covered with foam
which contributing factor of delirium would the nurse check for while collecting the medical history on a patient who has delirium
hypoglycemia hypotension head injury
excessive sweating in infants is associated with
hypoglycemia heart disease hyperthyroidism
which organ would be considered the thermostat of the human bosy
hypothalamus
which assessment finding indicates atelectasis that may result from immobility
hypoventilation
the registered nurse is teaching a nursing student about home care considerations to prevent the risk of pressure injuries which statment by the nursing student indicates effective learning
i should educate the patient about the signs of wound infection i should dicuss reactive surfaces that may increase pressure to the wound
which statement made by the nursing student indicates effective learning regarding methods to prevent aspiration
i will instruct the patient to hold and drink from a cup if possible i will crush and mix some meds with pureed foods for easy administration i will assess a patient for signs of dysphagia before administering meds
stretching is
ideal for enhancing circulation
thigh pressure should
ideally be measured in adolescents or young adults
pain originating from the musculoskeletal tissues or the body surface is
identified as somatic pain
which adverse effect involves overreaction or underreaction to a med effect (unpredictable)
idiosyncratic reaction
when preparing to measure a patients waist circumference which landmark would the nurse use when placing the measuring tape
iliac crest
the bones comprising nonsynovial joints are
immovable
protein quickens fibroplasia and acts as
immune function
t lymphocytes are cells that play an
important role in immunity
hirsutism is caused by
improper functioning of the endocrine glands or metabolic dysfunction
the effect of exercise on the musculoskeletal system includes
improved muscle tolerance to physical exercise
the effect of exercise on the cardiovascular system includes
improved mycardial contraction which strengthens the cardiac muscle
the human body absorbs meds
in a liquid state more readily than tabs and capsules
skin infection may result
in acute pain because of inflammation and tissure damage
the oral route of administration is contraindicated
in patients with gi disorders and motility
that patient with coronary disease experiences pain
in the neck then that patient indicates referred pain
which additional finding would the nurse monitor for in a child with attention deficit hyperactivity disorder who presents with excessive talking
inability to complete tasks
which nursing sensitive patient outcome is a component of quality health care
incidences of pressure injuries number of falls
isometric contraction causes an
increase in muscle tension or muscle work but no shortening or active movement of the. muscle
hyperemia is the
increased blood flow thorugh engorged arterioles skin changes to red or bright pink
kyphosis is the
increased convexity in the curvature of the thoracic spine which may be caused by rickets osteoprosis or tb of the spine
the reliability of a patients bmi would be afffected by which factors
increased muscular tone loss of muscle mass
the effect of exercise on the pulmonary system is an
increased respiratory rate and depth followed by a quicker return to the resting state
the patient with unilateral weakness may have an
increased risk of aspiration because of impaired swallowing
a patient is advised to be in supported fowler position which trouble area can cause the patients discomfort in this position
increased shearing force on the back and heels unprotected pressure points at the sacrum and heels pressure on the posterior aspects of the knees decreasing circulation to the feet
jaundice after 2 weeks of age may
indicate biliary tract obstruction
serum transferrin levels also
indicate protein status in the body
grade 2 muscle strenght is
indicated by full range of passive motion
daily
indicated that the med should be given every day
prn
indicated that the med should be given whenever it is needed
bmi of 37
indicates class 2 obesity
if thigh pressure is lower than the arm pressure it
indicates coarctation of the aorta
the question what aggravates the pain
indicates provocation/palliation criterion because the nurse is assessing the trigger for the pain
the question do you feel like that pain travels around
indicates the region/radiation criterion because the nurse is assessing radiation of the pain
the question does pain interfere with your activites
indicates the severity scale criterion because the nurse is assessing the severity of the pain
silver impregnated dressings are used for
infected wounds and should be discontinued when wounds are clean
scabies is an
infection caused by mites that cause elevated pruritic burrows on the fingers
objective data
information that is seen, heard, felt, or smelled by an observer; signs
which initial step would the nurse take if lateral violence occurs in the workplace
informing the manager to obtain support
which route of administration mainly uses meds in the form of aerosol sprays
inhalation
which route of drug administration may provide rapid relief to the patient with difficulty breathing
inhalation
which type of med is often described as a rescue or maintenance med
inhalational
maintenance meds are
inhaled and their effects last for long periods of time
gamma aminobuytric acid
inhibits and blocks the pain impulses through descending pathways from the brainstem to the spinal cord and prodcue an analgesic effect
which route is generally preferred for the administration of anesthetic agents during abdominal surgery
inhilation
Tertiary intention healing
initally left open edema, infection or exudare resolves then closed
parenteral administration
injecting a medication into body tissues
intramuscular
injection into a muscle
intravenous
injection into a vein
intradermal
injection into the dermis just under the epidermis
Subcuataneous
injection into tissues just below the dermis of the skin
which outcome is desired when the head of the bed is elevated to 60 degrees in the supported fowler position
inproves ventilation
which assessment technique includes looking at the patient in a well lighted room
inspection
patients using breath actuated metered dose inhalers are
instructed to coordinate the puffs with inhalation for an effective outocme
patients using dry powder inhalers are
instructed to inspire fast enough to administer the entire dose of meds
which action made by the nursing student may cause the patient to experience aspiration
instructing the patient to use straws while taking the liquid med positioning the patient in a relaxed sleeping position during administration
which action performed by the nurse would require correction when obtaining a patients height
instructs the patient to stand facing the wall
loudness or softness of sounds indicates the
intensity or amplitude of the sound
public communication is
interaction with an audience
which form of communication is appropriate to assess understanding and clarify misinterpretations when the nurse is teaching a patient about health concer
interpersonal
which injection is given to a patient receiving a tuberculin screening test
intradermal
which route of administration involves inserting a needle at a 5-15 degree angle from the surface of the skin without puncturing the patients subcuatenous tissue
intradermal
which injection is preferred for allergy skin testing
intradermal injection
which parenteral route of administration uses the z track method
intramuscular route because it will minimize local skin irritation by sealing the med in the the muscle tissue
the needle is inserted at an angle of 90 degrees from the skin surface when the
intramuscular route is used
which route if administration is beneficial in an emergency situation for an infant with poor access to intravascular space
intraossesous
the health care provider prescribed a med to be administered in the subarachnoid space of the patient ( or one of the ventricles of the brain). which route of administration is the health care provider prescribing for the patient
intrathecal
which action will the nurse take when conducting the reconcile phase of the med reconciliation process
investigate any discrepancies after comparing the new med prescription with the current list
buccal route of med administration
involves placing the med agains the mucous membrane of the cheek until the med dissolves
percussion
involves tapping the patients skin with short sharp strokes to assess the underlying structures
suppository for of a med
involves the insertion of pellets of meds in body cavities such as the vagina and rectum
the presence of concave shaped spoon like nails indicates
iron decficiency anemia
delusions are a patients
irrational and fixed false belief
a 35 ml syringe is used for
irrigating an open wound
Which mood and affect abnormality would be observed in a child with oppositional defiant disorder (ODD)?
irritability
a health promotion nursing diagnosis
is a clinical judgment of a person's, family's, or community's motivation, desire, and readiness to increase well-being and actualize human health potential as expressed in their readiness to enhance specific health behaviors such as nutrition and exercise
cheilosis
is a condition in which fissures occur at the corners of the mouth from excess moisture
achondroplastic dwarfism
is a genetic disorder causing a shortened height
the third korotkoff sound
is a knocking sound of longer duration of blood flow through the artery
troche
is a lozenge that is given orally
the visual analogue scale
is a pain assessment tool that helps identify the patients level of pain
aphasia
is a speech disorder in which the patient has difficulty understanding or producing language
the second sound of korotkoff sounds
is a swooshing sound of turbulent blood flow through a still partially occluded artery
loosening of assoications
is a thought process disorder in which the patient shifts from topic to topic while communicating and the topics are unrelated
incident pain
is a type of acute pain caused by certain body movments
malignant pain
is a type of chronic pain
a pulse that is 0
is absent
pain caused by kidney stones
is acute pain
insulin
is administered through intraperitoneal route
the brief pain inventory scale
is an assessment that uses graduated scales from 0-10
blanchable erythema
is an early indication of pressure in pressure ulcers
the modulation phase
is associated with alleviation of the pain stimulus because there is no release of bradykinin and prostaglandins from injured tissues
Cushing's syndrome
is caused by an overproduction of ACTH
which statement is true regarding piggybacks
is connected to a short tubing line the connects upper y port of a primary infusion line or to an intermittent venous access 25-250 mL of fluid
Meatcommunication
is factors that influence communication
auscultation
is listening to the sounds produced by body such as the heart, bvs, lungs and abdomen
a pulse that is 2+
is normal
Chronic nonmalignant pain
is often associated with musculoskeletal conditions such as arthritis and fibromyalgia
which characteristic behavior would the nurse find in a patient who is diagnosed with agoraphobia
is reluctant to leave home
postoperative pain
is somatic damage that causes nociceptive pain
tendinitis
is the inflammation of tendons which causes deep somatic pain
the brainstem
is the posterior part of the brain that regulates heartbeat, breathing and sleeping
liver metastasis
is visceral damage that results in nociceptive pain
a pulse that is 1+
is weak
vernix caseosa
is. a thick cheesy substance made of sebum and epithelial cellss
which characteristic of stage 2 pressure injry is the nurse likely to find during a wound assessment
it has reddish pink wound bed without slough
if the patient has pain resulting from damage to the skin surface
it indicates that the patient has cutaneous pain
if the patient has an injury at a particual site but experiences pain elsewhere
it indicates that the patient is having reffered pain
the nurse would use an adherent film dressing because
it will facilitate softening of the eschar to allow for debridement
which clinical sign or symptom is indicative of pruritus
itching of skin
the nurse has to adminster an alkaline med to a patient which route of med administration is preferred
iv
alkaline and other irritant meds are usually administer through
iv routes because they cause less discomfort
the nurse explains that exercises increases
joint mobility, cardiac output and basal metabolic rate
which nursing intervention would be appropriate for a patient who is at risk of skin break down because of moisture
keep the skin dry and free of maceration
which skin disease would the nurse consider when assessing patients with dark skin
keloids melasma pseudofolliculitis
the basal cell layer of the epidermis is mainlymade of
keratin
serum creatinine levels indicate
kidney function
collateral ligaments connect the
knee joint at both sides and prevents dislocation by giving medial and lateral stability
persistent repetition of words and actions is
knowns as perseveration
which term describes snide remarks or put downs btwn colleagues
lateral violence
which description would best illustrate the tripod position
leans forward with the arms braced on the arms of the chair
in which position would the nurse place the patient to admminister a rectal suppository
left side lying position
thomas test is
leg raising test that involves flexion of the hip joint
which complication would occur when the blood supply to the femoral epiphysis is decreased
legg calve perthes syndrome
duration refers to the
length of time the produced sound
confluent indicates the
lesions have run together
range of motion test would be used to test
limitations
zosteriform is a
linear arrangement along a unilateral nerve route
which topical med contains a soapy emollient
liniment
which topical med contains alcohol
liniment
which therapeutic communication technique would the nurse apply in attending to an agitated patient
listen actively share empathy ask relevant questions
topical routes primarily provide
local effects mainly related to skin problems
oral routes often produce
local or systemic effects but may not provide rapid relief for local respiratory problems as effectively as the inhalational route
hypperresonant
louder booming longer
enoxaparin
low molecular weight heparin that is administered in subcutaneous tissue of the abdomen at least 2 inched away from the umbilicus
which sound is auscultated with the bell of the stethoscope
low pitched
the health care provider advises a patient to dissolve the prescribed drug in his mouth for a long time without swallowing which form of a med is prescribed for this patient
lozenge
which blood cells are known as garbage cells
macrophages because they ingest bacteria, dead cells and debris from wounds
the epidermis or the outer layer is
made of tough fibrous protein called keratin
interview is used
mainly while taking the nursing health history
which action is a principle of proper body mechanics when lifting or carrying objects
maintain a wide base support
muscle tone helps
maintain functional positions such as sitting or standing without excess muscle fatigue
the inner ear helps in
maintaining balance by allowing a person to change positions suddenly without losing balance
oral, buccal and parenteral meds can be
maintenance meds used on a daily schedule they arent typically considered rescue meds as they take longer to absorb
the equilibrium of an object is
maintianed as long as the line of gravity passes through its base of support
examining is the
major method used in the physical health assessment
according to erikson establishing trust is the
major rask of an infant during development
developing a sense of industry is a
major task in a school age child because at this age the child develops basic competency
intraarterial med administration
managed by the nurse who continuously infuses the clot dissolving agent and carefully monitors the integrity of the infusion
a nurse finds that a patient who has urinary incontinence scores 11 on the braden scale which nursing action is most appropriate to prevent from developing pressure injuries
managing moisture
during the mental status exam which finding is expected when the nurse is assessing a patient with parkinsons disease
masklike expressin monotonous speech
stage 1 pressure injury
may be discoloration of skin warmth edema hardness pain
a drug with a slow onset of action
may show a delayed effect
the nurse instructs the patient ro flex the knee joint while performming the
mcmurray test to determine the presence of a torn meniscus
a leading question is
meant to control the direction of the story
an electronic thermometer with a blue tipped probe
measures oral temp
ac indicates
med should be taken before meals
qh indicates
med should be taken every hr
bid indicates
med should be taken twice a day
federal medication laws control
medication sales and distribution
which route causes meds to be absorbed slowly after administration
meds placed on the skin
time critical meds are
meds that should be administered with in 30 minutes before or after the scheduled time
feedback is the
message the receiver returns that indicates understanding
which clinical manisfestation would the nurse expect when assessing a patient diagnosed with achondroplastic dwarfism
midface hyplasia thoracic kyphosis lumbar lordosis
the nurse would develop a care plan focused on which medical condition if a patient scores a 12 on the patient health questionnaire 9
minor depression
insulin glargine should nit be
mixed with any other insulin
which finding from a mental status exam of an adolescent patient is considered normal
moderate pace of convo clear articulation abstract thinking ability
hydrocolloid gauze provides a
moist environment for the wound to heal
which equipment is used to test the loss of protective sensation in a patients foot
monofilament
according to the circular transactional model the referent
motivates one person to communicate with another initiating the communication process
which area would the nurse inspect for the presence of koplik spots in a child with suspected measles
mouth
which instruction would the nurse provide the patient to assess the trigeminal nerve
move the jaw forward and laterally
adduction involves
moving a limb toward the midline of the body
Isometric exercises are activities that involve
muscle contraction without body movement
hydralazine is a
muscle relaxant indicated in emergency conditions
arthritis, fibromyalgia and low back pain are all
musculoskeletal disorders associated with severe nerve and tissue damage which may result in chronic nonmalignant pain
Somatic pain originates from
musculoskeletal tissues or body surface
rapid acting insulin mixed with NPH insulin
must be given 15 mins nefore meals and for max benefit
a cuff size that is too
narrow for the patient yields a false high bp because it takes extra pressure to compress the brachial artery
proprioceptors present in the
nerve endings of muscles joints and tendons monitor proprioception
which type of pain does the nurse document in the medical record for a patient with herpes zoster who reports a pain level 10/10
neuropathic
which type of pain is being experienced by a patient who states i have numbness and tingling and occasionally shooting pain when asked what hteir pain feels like
neuropathic
which landmarks would the nurse use to ensure accuarate chest circumference of a 12 month old infant
nipple line
normal saline is a
noncytotoxic topical fluid that can be used to clean a pressure ulcer
about which condition would the nurse educate a patient wanting a tattoo
nontuberculous mycobacterial infections
cartilage is
nonvascular and it supports ct that sustain weight and serve as a shock absorber btwn articulating bones
cartilage is
nonvasculat supporting ct
muscle tone is the
normal state of balanced muscle tension
bmi of 18.5 to 24.9 indicates
normal weight
pitch or frequency indicates the
number of vibrations per second low or high
during the consider and compare phase
nurse reviews what the patient was taking at home or preadmission and makes sure that the lise of meds, dosages and frequencies is accurate and then compares this list to the current ordered meds and treatment plan
serum prealbumin is the best indicator of
nutritional status not only reflecting what the patient has ingested but also what the body has metabolized
different types of data collection
observing interviewing examining
the nurse flushes the injection port with normal saline to prevent
occulsion of the intravenous access divices
pressure injuries can
occur on the sacrum
acromegaly
occurs because of an overproduction of growth hormone in adulthood
hypopituitary dwarfism
occurs from a growth hormone deficiency in childhood
breakthrough pain
occurs in patients who undergo opioid therapy
which action by the nurse indicates a need for correction regarding med adminstration
offering a snack rich in fats after administering acidic meds you want to offer non fat foods because foods rich in fats delay med absorption
which action describes an independent nursing intervention
offering counseling for coping initiating early mobility protocols instructing patients on side effects of meds positioning patients to prevent pressure injry formation
which nontherapeautic communication technique is the nurse using when saying dont worry youll be fine to a patient
offering false reassurance
which nursing intervention is beneficial while administering a bitter med to a child
offering the child a frozen jucie bar
a gauze dressing is
often used for clean stage 2 or 4 pressure injury
which topical med preparation may involve more than 1 med
ointment
which group of patients is most at risk of severe injuries related to falls
older adults
maintenance meds are used
on a daily basis to prevent acute respiratory distress
precipitating factors are the
ones that worsen the primary symptom
a stuporous or semi comatose patient responds
only to pain or persistent vigorous shaking
the nurse intends to use a med that can give immediate relief to a patient which parameter of the drug would the nurse check to determine whether the drug can provide immediate relief to the patient
onset of action
which type of question is used when starting the assessment of a patient
open ended
nurses uses
open ended questions when beginning the assessment of a patient
which class of drugs if administered to the patient with out a prescription is punishable under the controlled substances act
opioid analgesics
opioids activare
opioid receptors in the spinal cord during the transmission phase to block the signal of pain and inhibt the perception of pain
which route of drug administration is appropriate for patient with hemophilia
oral
which route of drug administration is most economical and convenient
oral
which route of med administration is easiest and most desirable
oral
which parameter is the nurse assessing when the patient is asked about the date and time
orientation
the nurse sets the tome for the relationship by adopting a warm empathetic caring manner during the
orientation phase
which diagnosis in the medical record relates to the older patients report of increase hip pain
osteoarthritis
isotonic exercises promote
osteoblastic activity rather than osteoclastic activity
which question would the nurse ask when using the patient health questionnaire 2
over the past 2 weeks have you felt little intreest or pleasure in doing things
hemoglobin levels indicate the
oxygen carrying capacity of the blood
carpal tunnel syndrome results in
pain burning and numbness it occurs because of the atrophy of the median nerve of the wrist and hand
which action would the nurse perform before initially inflating the cuff during a blood pressure assessment
palpate the brachial artery
which supply would the nurse obtain to administer the mini mental state exam
paper pencil
red tender and swollen nail folds along with inflammation along the base of the nail or where it meets the skin on the sides indicates
paronychia
the cerebellum is the
part of the brain that controls and coordinates all voluntary movements particularly highly skilled movements
stage 2 pressure injury
partial thickness loss of dermis shallow open ulcer with a red pink wound bed without sloguh
receptive aphasia (Wernicke's aphasia)
patient can talk but it is difficult understanding language and receiving language
misinterpretation of an actual existing stimulus indicates that the
patient has illusions
intermittent venous access increases
patient mobility safety and comfort
which patient care goal is a ling term goal for a newly diagnosed medically unstable patient with diabetes
patient will achieve glucose control as demonstrated by decrease in hemoglobin a1c level
6 rights of medication administration
patient, time, dose, route, medication, documentation
heat therapy is used for
patients recovering from rectal surgery or experiencing hemorrhoids and vaginal inflammation
which phase of nociceptive pain signifies the conscious awareness of a painful sensation
perception
implementation involved
performing hand hygiene, putting on gloves, explaining the procedures and administering meds
the sender is the
person who encodes and delivers a message
the receiver is the
person who receives and decodes a message
the patient holds the hands back to back while flexing the wrists during the
phalen test this test helps to determine carpal tunnel syndrome
according to the institute for safe medication practices guidelines who is recommended to us a pill splitting device to split tabs in half
pharmacist
the rate and extent of distribution depends on the
physical and chemical properties of the medication and the physiology of the person taking it
central poststroke pain, carpal tunnel, and complex regional pain syndrome are
physiologic disorders assoicated with neuropathic pain
pain is the
physiologic factor that influences a patients activity tolerance
serosanguineous drainage is
pink
how can the nurse administer meds to a patient with unilateral weakness without causing aspiration
place the med in the stronger side of the mouth
plateau concentration
plasma concentration attained and maintained after repeated fixed doses
while caring for a patient who is receiving a jejunal tube feeding the nursing student administers iron through the tube which outcome is expected
poor bioavailability
the parenteral route of administration aids patients who have
poor peripheral perfusion
which action is correct by the nurse when performing a wound irrigation
positioning the patients wound vertical to the collection basin
which med form is commonly prepared for administration by parenteral routes ( meds put into tissue and circulatory system by injection)
powder and solution
a tablet is a
powdered med compressed into a hard disk and is meant to be swallowed whole
which term describes side effect
predictable often unavoidable occur at the usual therapeutic dose
side effect is
predictable and unavoidable adverse effect that is produced at a usual therapeutic dose
only oral syringes should be used when
preparing meds for the enteral route to prevent accidental parenteral administration
STAT
prescription indicated that the med should be administered immediately
which characteristics is associated with c fibers
presences of diffused sensations
the tibiotalar joint is
present in the ankle and feet it permits extension and flexion of the foot in plane
the radiocarpal joint is
present in the wrist it permits flexion and extension of the wrist
folliculitis barbe
presents with multiple pustules and white heads with hair visible at the center of an erythematous base usually on a males face and neck
seborrheic dermatitis
presents with thick yellow to white greasy scales with mild erythema on an infants scalp
the nurse notes a quarter sized area of blancable erythema over the patients sacral area which factor likely caused this finding
pressure
improperly fitted or applied devices and weight of the body on certain bony prominences can cause
pressure on the adjacent skin and underlying tissue result in ulcer and skin breakdown
the nurse is caring for a patient diagnosed with a spinal cord injury at t7 for which area of care would the nurse seek out a physical therapists for assistance
preventing the development of any postural abnormalities assisting the patient in ambulation prescribing exercise to strengthen trunk musculature
the patient is the
primary source of info
which type of assessment is the nurse performing when using a finger to apply light pressure just above the iv site and asking the patient if any tenderness is felt after noting inflammation at the site
problem focused
the effect of exercise on the matabolic system includes and
production of body heat
what is an advantage of summarizing
promotes recall of previous discussions participants focus on key issues useful in the terminal phases of the patient relationship
which anesthetic drug is contraindicated in patients with an allergy to soy producls
propofol
when assessing a patients mobility which info would the nurse document if the patient has difficulty stopping during ambulation
propulsion
which explanation provided the rationale for using a 19 gauge angiocatheter for irrigating a wound with a wide opening
providing ideal pressure for cleanig
a patiwnt with severe muscle cramp tells the nurse the pain is a little better when i massage the muscle or apply a cold pack which criterion of the pqrst method of pain is addressed in the patients statement
provocation/ palliation
which cognitive function would the nurse be assessing when asking the patient to describe childhood teachers and important dates in life such as an anniversary date
remote memory
debridement is the
removal of nonliving tissue and rids the wound of a source of infections, improves visualization of wound and provides a clean base to promote healing
which statment is true regarding an inhaler containing rescue meds
rescue meds provides immediate relief
inhalation meds are often described as
rescue or maintenance meds
inhaled meds are also often described as
rescue or maintenance meds
which findings would the nurse monitor for in a preschooler with autism spectrum disorder who demonstrates strict adherence to routines
resistance to change poor eye contact repetitive speech
which factor would render older women more susceptible to fractures
resorption and osteoporosis
the cerebrum is
responsible for the regulation of voluntary movements and sensory perception
exercise decreases the
resting heart rate and the return to resting state becomes quicker
inflammation of the mucous membrane lining the nose
rhinitis
which finding would lead the nurse to suspect arthritis
rigid spine and neck moving as one unit when the patient turns
there are 3 types of nursing diagnoses
risk problem focused health promotion
dividing balanced activity btwn the arms and legs reduces the
risk of a back injury
a dysphagia screening tool is used to assess the
risk of aspiration
an older adult who was in a car accident and fractured their femur has been immobilized for 5 days which nursing diagnosis is related to patinet safety when the nurse assists this patient out of bed for the first time
risk of inability to tolerate activity
volume controlled infusions reduce the
risks of rapid dose infusion by iv push
factors the influence absorption
route ability of the med to dissolve blood flow to the site body surface area lipid solubility of the med
intermittent venous access
saline lock iv catheter capped off on the end with a small chamber covered by a rubber diaphragm or a specially designed cap
which body fluid places the patient at the lowest risk of skin breakdown
saliva serosanguineous drainage
which location would the nurse assess to confirm jaundice in dark skinned patient
sclera hard/soft palate junction palms
which skin structure would be altered with dryness of the scalp forehead face and chin
sebaceous glands
family and significant others are
secondary sources of info
inappropriate attention span and impulsiveness are
seen in a patient with attention deficit hyperactivity disorder
which level of consciousness is the patient displaying if they are responding only to touch with persistent and vigorous shaking and they withdraw both hands when pressure is applied to the nail beds
semi coma
receiver provides feed back to the
sender
communication channels are means of
sending and receiving messages through visual auditory and tactile senses
hallucinations refer to
sensory perceptions in the absence of an external stimuli
the bones in a synovial joint are
separated from each other and are enclosed in the synovial cavity with synovial fluid inside
which parameter would be measured to determine the protein deficiency in the patient with a wound
serum albumin serum transferrin serum prealbumin
volume control administration
sets are small (150mL) containers that attach just below the primary infusion bag or bottle
the environment is the
setting for sender receiver interaction
which action will the nurse take during bedside hand off at shift change
share info about the patients condition
rescue meds are
short acting and are taken to immediately relieve acute respiratoey distress
rescue meds
short acting and are taken to immediately relieve acute respiratory distress
rescue meds are
short acting provide immediate relief
non time critical meds
should be administered with in 1 hour of the scheduled time
proton pump inhibtors
should be given on an empty stomach you should wait at least 30 minutes before feeding
oral disintegrating meds
should be placed on the patients tongue and should not be chewed
the glenohumeral joint is present in the
shoulder it permits movement of the arm on many axes
a diabetic patient with peripheral neauropathy
shows symptoms of burning pain in the feet bilaterally which worsens during the night
which instruction would the nurse provide the patient to assess the integrity of of the spianl cord
shrug the shoulders
which clinical manifestation would the nurse expect when performing a general survey on a patient diagnosed with marfan syndrome
tall and thin pectus excavatum hyperextensible joints
percussion is
tapping the patients skin with short sharp strokes which produce a palpable vibration and a characteristic sound that depicts the location, size and density of the underlying organ
which activity does the nurse carry out while maintaining a zone of personal distance
teaching or educating a patinet
which intervention perfomed by the nurse is an independent nursing intervention
teaching the patient about deep breathing exercises assistin the patient in taking a bed bath repositioning a patient for relief from pain
bells palsy involves
temporary paralysis of one side of the face
sticking out the lower jaw checks the proper functioning of the
temporomandibular joint
which structure connects muscle to bone
tendon
the nurse is teaching a group of nursing students about tendons which statment about tendons is true
tendons are fibrous bands connecting muscles to bone tendons are strong, flexible and inelastic
lateral violence is a
term to describe workplace bullying such as snide remarks or put downs btwn colleagues
which stage of the interview consists of the nurse saying i have just 2 more questions for you when assessing a patient with complaints of chest pain
terminating the interveiw
which phase of the helpong relationship is represented when the nurse recalls a funny shared experience with a patient shortly before the patient is transferred to another unit
termination
attention span
tested by giving a set of instructions to the patient and observing whether the patient and observing whether the patient follows them properly
intestinal pain and severe stomach cramps indicate
that the patient has visceral pain
lower back pain while standing indicates
that the patient is having incident pain
visceral pain results from
the activation of nociceptors of the visceral organs
negative pressure wound therapy is
the application of subatmospheric pressure to a wount through suction to facilitate healing and collect wound fluid
during modulation phase
the body slowly reduces the pain by stopping the processing of a painful stimulus
proprioception is required by
the body to maintain proper posture
touching the chin toward each shoulder and lifting the chin toward the ceiling tests the function of
the cervical spine
obsession referes to
the constant preoccupation with unwanted or intrusive thoughts
congenital hip dislocation refers to
the displacement of the femoral head out of the acetabulum
the rash of measles first appears behind
the ears then spreads over the face then the neck trunk arms and legs
the pure food and drug acts
the first american law to regulate meds
dependent nursing interventions require
the health care providers prescriptions to treat a medical diagnosis
polycythemia is
the increased red blood cell count that results in ruddy blue colored skin
while using a breath actuated inhaler
the inhaler should not be shaken
Scoliosis
the lateral s or c shaped spinal column with vertebral rotation
during perception
the limbic system interprets the noxious stimuli and elicits emotional responses to pain in the patient
a fractured clavicle can occur during birth and may result in
the loss of moro reflex in the affected side and limited arm range of motion and a lump in the clavicle region
trough is
the minimum blood serum concetration of a med reacched just before the next scheduled dose
initial pain assessment
the nurse askes the questions concerning location, intensity and duration pain
mcgill questionnaire
the nurse asks the patient to rank a list of descriptors in terms of their intensity and to give an overall intensity rating of pain
which message does the nurse convey to a patient when sitting at an angle facing the patient
the nurse is interested in what the patient is saying
according to hippa
the nurse should maintain confidentiality about the health info of the patient
in the beginning of an interview or while setting the stage
the nurse uses introductory questions and statements
self confidence is important because
the nurse who conveys confidence and comfort while communicating can more readily establish an interpersonal caring relationship
to assess the correct body position of the patient
the nurse will ask the person to sit comfortably with the arms relaxed at the sides and the head turned toward the nurse
when using the numeric rating scale
the nurse would ask the patient to chose a number to rate the pains intensity
palpation applies
the nurses sense of touch to assess factors such as swelling, vibration or pulsation, rigidity or spasticity, crepitation, the presence of lumps or masses and the presence of thenderness or pain
which statement describes the advantage of administering meds by the oral route
the oral route is easy to adminster the oral route rarely causes anxiety the oral route is convenient and comfortable
during the transduction phase
the pain signals are transmitted from the site of injury to the spinal cord
during the transmission phase
the pain signals move from the spinal cord to the brain
the presence of depressed skin at the site of the surgery indicates
the patient has an atrophic scar caused by the loss of tissue
the presences of tightly packed papules at the site of the surgery indicates
the patient has linchenificaation caused by prolonged or intense scratching
in the perception phase
the patient shoes an emotional response to the pain stimulus
open ended questions encourage
the patient to talk more
for the most accurate bp reading
the patients feet mmust be flat on the floor
arthritis and mechanical back pain are
the physiological disorders associated with nociceptive pain
the melanocytes intercalated along the basal cell layer produce
the pigment melanin which gives brown tones to skin
a positive tinel sign refers to
the presence of tingling or buring in reaction to percussion over the median nerve at the wrist which indicates carpal tunnel syndrome
in the modulation phase
the release of a third set or neurotransmitters from the brain will show analgesic effect
in the transduction phase
the release of neurotransmitters from the injury site to the spinal cord takes place
the skin is
the sentry that guards the body from environmental stresses such as trauma, pathogens and dirt and adapts it to other environment influences
during an assessment the questions focus on
the signs and symptoms of the patient
circumlocution
thought process abnormality in which the patient substitutes a word or phrase such as thing to denote an object
an adequate balance in the body is maintained by the nervous system specifically
through the cerebellum and inner ear
the preinteraction phases involves the
time before the nurses inital interaction with the patient
duration is
time during which med is present in consentration great enoguh to produce a respnse
onset
time it takes after a med is administered for it to produce a response
which safety measures would the nurse implement to prevent aspiration when administering oral meds
time the meds with meals choose a different route if the risk of aspiration increases recommend self administration if possible
which microorganism would cause athletes foot
tinea pedis
if an older adult patient reports pain and swelling at the base of the thumb which test would the nurse perform to further assess for carpal tunnel
tinel
mottling or pallor may occure because of
tissue hypoxia that alters circulation
primary intention healing
tissue surfaces closed minimal or no tissue loss formulation of minimal granulation and scarring
once a med enters the blood stream its carried throughout the
tissues and organs
the cries scales is used
to assess the pain intensity in postoperative or preterm infants
which statment explains the nurses action of flushing the intravenous lock with normal saline by pushing slowly on the l=plunger
to clear the intravenous lock of blood
while teaching a patient about metered dose inhalers the nurse discusses the 3 point position which statement describes the rational for this nursing intervention
to help the patient activate the canister
the finger tips are best
to palpate skin texture, fluid accumulation and presence of abnormal body mass because of the concentration of the sensory nerve endings
membrane permeability refers to the ability of a med
to pass through tissues and membranes to enter the target cells
the nurse instructs a patient to rinse his or her mouth with water after using a corticosteroid inhaler which statment describes the rationale for this instruction
to prevent a fungal infection
whihc reason would the nurse have for cleaning a wound with normal salin using an irrigating syringe
to remove wound debris
the mini cog test is used
to screen whether the patient has cognitive impairment
for which patient would the nurse straighten the ear canal by pulling the auricle down and back when administering eardrops
toddler
inappropriate removal of tape can cause the
top layer of skin to be pulled and the separation of epidermis from dermis this can cause blisters
which condition would involve the accumulation of sodium urate crystals int eh joint space
tophi with chronic gout
which abnormal hair condition would motivate the nurse to ask about cancer and chemo treatments
toxic alopecia
the older client is at risk for which effect of meds
toxic effect
which topical medication may lead to respiratory depression in the case of an overdose
transdermal patch
which phase of nociceptive pain response involves the release of bradykinin and prostaglandins
transduction
cutis marmorata
transient mottling in the trunk and extremities is caused by low environmental temp
cutis marmorata is
transient mottling, reticulated red or blue patter in the trunk and extremities in response to cooler room temps.
in which phase of nociception do opioids block the signal of pain
transmission
histamine, bradykinin, prostaglandins
transmit a pain message or action potential along the sensory afferent nerve fibers to the spinal cord
which type of dressing is used for stage 1 pressure ulcer
transparent film dressing
the patient with beau lines has a
transverse depression across the nail extending to the nail bed because of acute illness or trauma
pronation occurs in the
transverse plane
which type of syringe is used to administer a small and precise amount of meds subcutaneously in infants and newborns
tuberculin syringe
which of the following nursing interventions are crucial in preventing negative effects of immobility
turning the client every 2 hours assisting with coughing and deep breathing exercises performing rom exercisses
pronation
turning the palm downward
repetitive speech is
typical in a child who has autism spectrum disorder
after a med is absorbed it is distributed within the body to tissues and organs and
ultimately to its specific site of action
the patient with late clubbing may have elevation of inner edge of nails because of an
underlying condition such as hear tor lung disease
the bones in nonsynovial joints are
united by fibrous tissue or cartilage
c fibers are
unmyelinated sensory fibers that cause pain signals to be more diffuse
allergic reaction
unpredictable response of meds that occurs with repeated administration
a pressure injury covered in eschar is an
unstageable pressure injury
jaundice that occurs immediately
upon birth or within the first 24 hours of like is pathologic jaundice and may indicate hemolytic disease
raised, irregularly shaped skin eruption with a reddened margin and pale center is
urticaria
maintenance meds are
used on a daily schedule to prevent acute respiratory distress
the gnasc tool is
used to asses stage 1 pressure injuries in patients with dark skin
palpation is
used to assess texture, temp and swelling
Nursing Diagnosis
used to evaluate the response of the whole person to actual or potential health problems
an electronic thermometer with a red tipped probe is
used to measure rectal temp
the generalized anxiety disorder scale
used to screen for anxiety and anxiety disorders
which statement accurately describes the unit dose system
uses carts for distribution has labeled drawers
the nurse can use 2 approaches for comprehensive assessment this include
using a structured database format and a problem oriented approach
which action by the nursing student indicates a need for correction regarding administration of a liquid form med through small bore feeding tubes
using an intravenous syringe to prepare the med
the brief pain inventory scale the patient can rate the pain
using these graduations based on the effect of pain on mood, walking =, functional ability and sleep in the past 24 hours
immobility can cause which of the following urinary problems
uti
which health pattern describes the patients spiritual attitude according to gordons model
value belief pattern
how fast a med reached a site depends on the
vascularity of the carious tissues and organs
the sender also seeks both
verbal and nonverbal feedback
which parameter is assessed when using the glasgow coma scale
verbal response motor response eye opening response
flat percussion note
very soft high a dead stop of sound, absolute dullness very short
ligaments are
white shiny flexible bands of fibrous tissue that bind joints and connect bones with cartilage
albinism would cause a
whitish pink color in a light skinned patient
the braden scale is a
widely used tool for risk assessment of pressure injury development and is composed of six subscales
fibromyalgia syndrome manifests as
widespread pain in the muscles
the patient who falls under the category class 3 obesity
will have a bmi of more than 39.9
a patient with normal gait
will have a smooth and even walk cylce
a patient who has delirium
will have incoherent convos
1st exposure to an allergen
will sensitize the immune system
the nurse checks for the trendelenburg sign in a patient
with congenital hip disorders
which though process abnormality is the patient exhibiting if during a convo the nurse finds that a patient has jumbled language is illogical and uses words that have no real meaning
word salad
consider using silicone dressings as a
wound contact layer to promote atraumatic dressing change
calcium alginate dressings are used for
wounds with excessive drainage, the dressing forms a gel when it comes in contact with the wound fluid
which skin color would the nurse observe in a child being fed vitamin A supplements regularly
yellowish orange
closed end questions usually have a
yes or no response and dont allow the patient to explain his condition freely
a patient prescription calls for 30 mL of a med to be taken which info would the nurse provide regarding the administration of the med according to a household measurement
you should take 2 tbsp of the med
a patient says to the nurse i have been drinking 4 glasses of whiskey daily for the past 2o yrs and i never had any problems i dont know why my health care provider has asked me to stop drinking how would the nurse paraphrase this statement
your not convinced that you need to stop drinking
which intervention would the nurse perform before obtaining the weight of a 6 month old infant on a platform scale
zero out the scale
Nursing Implementation
Formally begins after a plan of care is developed. The nurse initiates interventions that are designed to achieve the goals and expected outcomes needed to support or improve the patient's health status.
Expressive aphasia (Broca's)
The inability to produce language ( despite being able to understand language)
a spacer is
a 10 to 20 cm long tube that attaches to the pressurized metered dose inhaler and allows the med particles to slow down and separate into smaller pieces
osteoporosis is
a bone disorder characterized by a decrease in bone mass and density which increases the risk of fractures
a large or oval patch of light brown pigmentation present at birth is know as
a cafe au lait spot
which statment is accurate regarding orally administered meds
a capsule is a med encased in a gelatin shell acidic meds pass through the gastric mucosa more rapidly oral meds have a more prolonged effect than parenteral meds the oral route is the most commonly used route of med administration
which statement is accurate regarding orally administered medixation
a capsule is a medication encased in a gelatin shell acidic meds pass through the gastric muscosa more rapidly oral meds haave a prolonged effect than parenteral meds the oral route is the most commonly used route of med administration
the unit does system uses
a cart with a 24 hr supply of meds for each patient
which prescription might the nurse anticipate for a patient with new onset bowel incontinence that is causing compromised skin integrity
a change in dietary prescription
erythema toxicum is
a common skin rash associated with red macules on the cheeks and trunk ( flea bite rash) appears in the first 3 to 4 days of like
maintenance meds are used on
a daily schedule to prevent acute respiratory distress
hallux valgus is
a deformity in which the great tow deviates away from the medial prominence of the head of the first metatarsal
a troche is
a flat tab that should be dissolved in the mouth for med release
the simple descriptor scale consists of
a list of words such as no pain mild pain moderate pain severe pain
developing initiative is
a major task for a preschooler
thigh pressure is preferably measured in
a prone position it can also be measured in supine
standing orders allow
a quick response to a rapidly changing clinical situation
small, raised and reddened vesicles are
a rash
Verbal Descriptor Scale
a rating scale on which people are asked to describe their pain by choosing the phrase that most closely resembles the pain that they are experiencing
ointment
a semisolid preparation, usually oily, for external application to the skin or mucous membranes and usually containing a medicinal substance
a papule is
a solid elevated circumscribed primary lesion less than 1 cm in diameter appears because of superficial thickening of the epidermal layer of the skin
Mini-Mental State Examination (MMSE)
a test of the cognitive functions of the mental status examination (memory, orientation to time and place, naming, reading, copying or visuospatial orientation, writing, and the ability to follow a three-stage command
blocking is
a thought process disorder in which a patient suddenly becomes silent or abruptly stops speaking in the middle of a convo
a beau line is
a transverse furrow or groove across the nail and extends down to the nail bed
gyrate indicates
a twisted coiled sprial or snakelike configuration
nonpersonal is not
a type of communication
a bulla is
a type of primary lesion that appears superficially in the epidermal layer of the skin
the lateral meniscus is
a wedge shaped cartilage that cushions the tibia and femur and protects them from external pressure
which angular motion would involve moving the arm away from the midline of the body
abduction
facing the direction of movement prevents
abnormal twisting of the spine
respiratory airways and mucous membranes have many bvs so meds are
absorbed most quickly after administration
a child who is
abused in the home may lack parental bonding and therefore may show no sepaaration anxiety if the parents are out during the assessment
which type of pain is the patient experiencing when after an appendectomy the nurse notes that the patient has pain, hypertension, tach, stoic face and breathing difficulty
acute
for which condition would the nurse first assess a patient curling over in the fetal position while sitting on the exam chair
acute abdominal pain
when meds should be given as desired
ad lib
effervescent meds arE
added to a glass of h2o and immediately given before dissolving
the nurse is providing care to a patient with a pressure injury that is covered in eschar which dressing prescription will the nurse use for this patient
adherent film
chemotherapeutic agents, insulin and antibiotics are
administered through the intraperitoneal route
chemotheraputic agents are
administered through the intrapleural route
which nursing interventions avoids aspiration in childrent
administering medications in liquid form
the prescription order for a patient contains morphine sulfate, 2mg IV q2h prn, for incisional pain which intervention by the nurse would be appropriate for this patient
administering the med only when the patient requires it
the aspects of a patient behavior that would be assessed during a general survey include
affect speech pattern facial expressions personal hygiene
which factor would directly affect bp
age race sex stress level
when administering enoxaparin
air within the syringe shouldnt be expelled because doing so can effect the dosing
which condition would cause the skin tone of a light skinned patient to be whitish pink in color
albinism
the nurse compares leg lengths of the patient while performing the
allis test to assess for hip dislocation
a patient develops buccal irritation after the administration of a buccal med for 3 days which nursing instruction would have prevented this irritation
alternating the cheeks with each dose
duration
amount of time for which the drug produces its effect and doesnt provide info regarding onset of action
the fourth korotkoff sound is
an abrupt muffling sound that occurs when the artery no longer closes in any part of the cardiac cycle
when patient is exposed to the same allergen for the 2nd time
an anaphylactic reaction may occur
Dysarthria
an articulation disorder in which the patients speech sounds are distorted and unintelligible
toxic effect
an effect that occurs after prolonged intake of meds
a cyst is
an encapsulated fluid filled cavity in the dermis or subcutaneous layer
pain felt by the patient while changing position is
an indicator of incident pain
itermittent venous access also called saline lock is
an intravenous cathered capped off on the end with a small chamber covered by a rubber diaphragm
chloasma is
an irregular brown patch of hyperpigmentation on the face that occurs with pregnancy or in women taking oral contraceptive pills
which method of iv med administration involves introducing a concentrated dose of a med directly into the systemic circulation
an iv bolus
Nursing Planning
an organized nursing care plan based on the nursing Dx, goals and interventions are set by both patient and nurse
a patient develops sudden onset of bronchiolar constriction, edema of the pharynx and larynx and sob after administration of a med which type of reaction is this
anaphylactic reaction
perception is the third phase of nociception
and is associated with conscious awareness of a painful sensation
vancomycin is an
anitbiotic
deliberate fasting and self induced vomiting can occur in
anorexia nervousa bulimia
closed ended questions are
answered only with a yes or no response
which behavior fosters the development of trust
answering the nurse call system promptly answering the questions honestly demonstrating competence when implementing treatment
cruciate ligaments provide
anterior and psoterior stability and help control rotation of the knee
vitamin c acts as an
antioxidant
administration of meds through a parenteral route often causes
anxiety
lorazepam is an
anxiety drug
which instruction given by the nurse would be appropriate if a pressurized metered dose inhaler was prescribed to the patient
apply approximately 5 to 10 lbs of pressure to the top of the canister to administer the med
which responsibility can be delegated to an assistive personnel during wound care
applying an elastic bandage reporting any movement restrictions of the patient
which task can be delegated to. assistive personnel in caring for a patient who has pressure ulcers
applying an. elastic bandage
hydrogel covered with foam is
appropriate for a pressure injury that requires protection and absorption of moisture
adherent film dressings are
appropriate for unstagebale pressure injuries
patients taking meds through the sublingual route
are instructed not to swallow or drink water until the tab dissolves
transdermal disks
are meds that are absorbed through the skin slowly over a long period
Phase IV Korotkoff sounds
are muffled softer sounds and indicates diastole
intravenous injections
are primarily used for fluid replacement in patients who are unable ti take oral fluids
diarrhea, tachy and restlessness
are signs and symptoms of generalized anxiety disorder
cherry angioma
are small smooth slightly raised bright red dots that commonly appear on the trunk of all adults older than 30 years of age
5 mL and 3 mL syringes
are used ofr large volumes of parenteral meds administration
subcutaneous inections
arent to be given over bony prominences because it can cause injury
when would the nurse begin to assess a newborn for physiologic jaundice
around the 4th day of life
the knee joint is an
articulation of three bones femur tibia patella
recent memory can be tested by
asking a question the nurse can corroborate such as asking the patient what he or she had for breeakfast
which patient condition may be caused by poor precationary measures taken by the nursing student while adminstering medication through the oral route
aspiration
the nurse accidently gives a patient a med at the wrong time which action would the nurse take first
assess the patient for adverse effects
the bwat is used to
assess the wound status
different types of problem solving in nursing
assessment diagnosis planning implementation evaluation
acrocyanosis is
associated with bluish discoloration of the skin on mainly hands and feet and is caused by hypothermia
puncture wounds are
associated with the risk of internal bleeding and infection
the tympanic membrane helps in
auditory function
toddler displays explorative behavior and desires to be independent thus developing
autonomy is a major task for a toddler
the health care provider instructs the nurse to administer a booster dose of tetanus toxoid to a 7 yr old patient which nursing action is appropriate
avoiding injections when the patient is asleep having the parent hold the child in a position of confort
which phrase best explains the term propriception
awareness of the position of the body and its parts
skin tags or acrochordons frequently occur on the
axilla
neutrophils ingest
bacteria and small debris
paronychia is caused either by
bacterial or fungal infection
factors of communication that influence the nature of the relationship among participants include the
balance of power and control and a shared history of the participants
syringe pump
battered operated and contains a very small amount of fluid
subcutaneous injections shouldnt
be given over large underlying muscles because the medicine can be accidently injected into muscles
insulin should never
be mixed with aany other meds because it can hamper the effectiveness of the insulin
talipes equinovarus or club foot occurs
because of genetic or environmental factors
spina bifida occurs
because of incomplete closure of the posterior vertebrae
decreased estrogen levels and increased resorption also causes bones to
become porous
which term is used to describe deteriorated skin condition related to prolonged unrelieved pressure on a body part
bed sore pressure sore pressure ulcer decubitus ulcer
oral disintegrating tabs
begin to dissolve immediately therefore they shouldnt be pushed through th e foil
cutaneous pain
begins in the skin surface and subcutaneous tissues
flexion involves
bending a limb at a joint
the iv route is the
best route for establishing constant therapeutic blood levels
serum alumin is a
biochemical indicator of protein deficiency and malnutrition
rapid mood swings indicate
bipolar disorder
laceration wounds tend to
bleed profusely depending on the depth of the wound
hypoventilation may occur because of atelectasis resulting from
blockage of bronchioles by secretions and the collapse of distal lung tissue
which thought process abnormality would the nurse report on a patient with schizophrenia who starts to communicate then abruptly stops speaking in the middle of a convo
blocking
plateau is
blood serum concentration of med reached and maintained after repeated fixed doses
koplik spots are
bluish white red based elevations of 1 to 3 millimeters located in the mouth
which term is used to explain the relationnship of one body part to another along a horizontal or vertical line
body alignment
weight bearing and other exercises help slow
bone loss
which site would the nurse use to administer a med through the intraosseous route
bone marrow
a joint is the connection btwn
bones
a ltcf encourages nurses to assess patients at risk of developing pressure injuries based on 6 subscales: moisture sensory perception activity mobility nutrition and friction or shear force which tool is the ltcf using for risk assessment of pressure injury development
braden scale
during the transduction phase
bradykinin and prostaglandins are released from injured tissues these chemicals transmit pain signals from the injury site to the spinal cord
which statement is accurate regarding the steps involved administering meds by inhilation
breath actuated metered dose inhalers dont use a spacer
while using the painad assessment tool the nurse would monitor 5 parameters
breathing vocalization consolability facial expression body language
which color would be sanguienous drainage on a patients dressing
bright red
the patient with reflective sympathetic dystrophy has
brittle nails and the skin appears pale, dry and shiny
the prepatellar bursa lies
btwn the patella and the skin prevents friction and thus helps the muscles and tendons glide smoothly over the bone
which test would the nurse be performing when firmly stroking the medial aspect of the knee 3 times and then taping lateral aspect of the knee
bulge sign
which type of primary lesion would be superficial in the epidermis more than 1 cm in diameter and rupture easily
bulla
straightening the ear canal
by pulling the auricle upward and outward is performed in children 3 yrs of age and older
which dressing would the nurse use for a patient with a clean stage 3 pressure injury
calcium alginate
mixing insulin detemir with any other insulin
can make it ineffective
medication encapsulated in a gelatin to be swallowed is a
capsule
glutamate
carries the pain impulse across the synaptic cleft to the dorsal horn neurons
ligaments connect bones to
cartilage
delayed administration of time critical meds
cause harm or subtherapeutic responses
erbs palsy is
caused by a briachial plexus injury
which clinical manisfestation would the nurse anticipate in a patient with a history of cushing syndrome
centripetal obesity
which statement by the parent would indicate effective learning about preventing diaper rash
change my babys diaper frequently
addisons disease is
characterized by cortisol deficiency which stimulates the production of melanin and results in bronzed or tanned skin
osteoarthritis is
characterized by hard nontender heberden and bouchard nodules
scoliosis is
characterized by lateral curvature of the thoracic and lumbar segments of the spine
chickenpox is
characterized by the presence of small tight vesicles that first appear on the trunk and then spread to the face arms and legs
assessment involves
checking the accuracy and completeness of each med administration record with the health care providers med prescription
compulsion
checks and rechecks things repeatedly even though its not necessary
which finding would when assessing a the nurse expect when assessing a dark skinned patient diagnosed with carbon monoxide poisioning
cherry red nail beds with carbon monoxide poisioning
which condition would the nurse anticipate after observing a patient leaning forward and bracing themselves on the arms of the chair
chronic obstructive pulmonary disease
which condition would be suspected in a patient with swan neck deformity and ulnar deviation of the fingers
chronic rheumatoid arthritis
rapid infusion of the iv fluid may cause
circulatory overload in patients on tv therapy
when an individual is unable to think of an objects name and substitutes it with a phrase to describe that object is referred to as
circumlocution
which thought process abnormality is the patient exhibiting if when the nurse asks when a fall occured the patient responds with a discussion about how much it snowed last night, where the patient went and what the patient was wearing
circumstantiality
which thought process abnormality would the patients speech indicate if the patient tells the nurse id like to go to my room, broom, tomb, loom, doom. id like to have dinner now, cow, how, wow
clanging
the nurse asks a patient when you tell me that youre having a hard time living up to expectation are you talking about your family expectations which therapeutic communication technique does this illustrate
clarifying
a bmi of 30 to 24.9 indicates
class 1 obesity
hydrocolloid dressings for
clean category stage 2 pressure injuries in body areas where they will not roll or melt
After the nurse dresses a patient's wound, which nursing intervention would help prevent the contamination of that previously cleaned wound?
cleaning the wound from the center to the surrounding skin
serous drainage is
clear
elixr is
clear fluid containing water and or alcohol that is given orally
inspection involves
close careful scrutiny first of the patient as a whole and then of each body system
the medication in dry powder inhalers may
clump in humid climates
which structure would connect the knee joint at both sides and prevent its dislocation
collateral ligaments
planning involves
collecting the medication administration record as well as taking steps to avoid interruptions
tophi are
collections of sodium urate crystals that appear in and around the joint
isotonic contraction is
combination of concentric and eccentric muscle actions for active movement
the mongolian spot is
common variation of hyperpigmentation in african american, asian, american indian and latino newborns
intraosseous route
commonly used for infants and toddlers who have poor intravascular access (bone marrow)
communicating and verifying meds changes with the patient occurs during the
communication phase
nonverbal communication describes
communication without verbal messages
which assessment includes a thorough interview health history review of systems and extensive head to toe
comprehensive assessment
extract
concentrated form of meds that is made by removing the active part of a med from its other components and is given orally
dysphonia
condition in which the patient has difficulty talking because of voice impairment and has an abnormal pitch or volume of speect
falsification of events to fill in memory gaps indicates
confabulation
talipes equinovarus refers to
congenital and fixed malposition of the foot
the nurse checks for the ortolani sign in a patient with
congential hip disorders
while taking an interview open ended questions generally strengthen the
connection btwn the nurse and patient which encourages listening on the nurses part
which intervention performed by the nurse is an interdependent intervention
consulting with a physiotherapist for postoperative exercises collabing with the home health department to ensure the patient will have home health visits conferring with the unit discharge coordinator to help the patient return home
a canister is a
container that consists of the drug and propellant
the message is the
content of the communication
oral medication administration is
contraindicated when a patient is unconscious, has gastric suction or is awaiting surgery
the nurse in the palliative care unit is administering a higher than prescribed dose of opioid analgesic to a patient with terminal stage cancer to relieve pain which act or law does this nurses action violate
controlled substance act
if a patients heart rhythm is regular
counting the pulse for 30 seconds and multiplying by 2
the dermis or inner supportive layer consists mostly of
ct or collagen
which critical thinking attitude motivates the nurse to communicate and know more about the patient
curiosity
when gathering history the nurse should focus on the
current complaints and the body system currently involved
us food and drug administration is the
current monitoring body for maintaining the standards of meds
povidone iodionine, hydrogen peroxide and sodium hypochlorite are
cytotoxic fluids that are used to clean highly colonized wounds
which statment is true regarding dry inhalers
dpis can be activated by a patients breath dpis clump if the patient is in a humid climate dpis created an aerosol when a patient inhales
foam dressings are preferred around
drainage tubes to absorb the drainage
which patient behavior would be assessed when administering the mini cog. screening exam
drawing a clock face
elastic net should be used for
dressing extremities
which option describes a hydrocolloid dressing
dressing that forms a gel that interacts with the wound surface
a lethargic or somnolent patient will
drift off to sleep when not stimulated
which finding would the nirse observe in a patient who is lethargic
drifts off to sleep when not stimulated
which type of inhaler requires less manual dexterity
dry powder inhaler
if the patient with impaired hand function has chronic hyperplasia of the palmar fascia which diagnosis would the nurse anticipate
dupuytren contracture
pressure reduction reduces the
duration and magnitude of pressure over vulnerable areas of the body and contributes to comfort hygiene dignity and functional ability
gathering info from patient about all current prescriptions, otc meds and homeopathic products occurs
during the obtain, verify document phase
which sign or symptom would be observed in a patient experiencing a panic attack
dyspnea sweating increased heart rate
which speech abnormality would the nurse monitor for in patient with brocas aphasia who understands what is being said but has difficulty using the language appropriately
dysrthria
repetition of words said by others in a mumbling and mocking tone is
echolalia
right sided heart failure causes
edema and jugular vein distension
while transferring and handling a patient the height of the be should be at
elbow level
which thermometer would measure the oral temp of a child within 25 seconds
electronic thermometer with blue tipped probe
crossed legs artifically
elevate the bp
which function would pressure dressings perform when applied with an elastic bandage
eliminates the dead space in underlying tissues to allow healing
the pituitary is an
endocrine gland that is located at the bottom of the hypothalamus
during the transmission phase
endogenous opioids are released which activate opioid receptors and block the transmission of pain impulses
an accurate nursing diagnosis helps
ensure effective and efficient nursing interventions
the centers for medicare and medicaid services program doesnt
ensure testing of drugs
which statement is true regarding enteral syringes
enteral syringes are a different color than parenteral syringes
coated tablets that dissolve in the intestine are
enteric coated tabs
which route is used for the administration of regional analgesia for surgical prcedures
epidural
vitamin a promotes
epithelialization wound closure inflammatory response angiogenesis collagen formation
clustering, collecting and interpreting data are common sources of
errors in the nursing diagnostic process
the rn determines if the patients goals are met examines effectiveness of interventions in which step
evaluating
grade 0 muscle strength is used to
document no muscle contraction
which total score using the generalized anxiety disorder 7 scale indicates the patient has moderate levels of anxiety
10
which score on the 4 unrelated words test would alert the nurse to the possibility of a diagnosis of alzheimer dementia
0 to 1
prescription of 240 mL indicates
1 cup
prescription of 960 mL indicates
1 quart
prescription of 5 mL indicates
1 tsp
which age would the nurse test an infants language development and ability ti use one word sentence
1 yr
how far beyond the wound edges would the nurse extend the transparent film when framing the periwound area of a patient for negative pressure therapy
2.5 to 5 cm which is 1 to 2 inches
at which age would the nurse begin routine monitoring of bp in children at low risk of hypertension
3 yrs
how would the nurse document pedal pulses of a patient which are determined to be full and bounding
3+
what would the mx score that can be given to a patient when using the mini mental stat exam
30
enteral tubes whould be flushed with at least
30 mL of water before and after giving meds
the needle is inserted at an angle of
30 to 45 degrees into the vein when the intravenous route is used
the nurse administers an analgesic medication to a patient with a stage 4 pressure ulcer who needs to have a dressing change in relation to administering the analgesic
30 to 60 minutes after administration
perception is the
3rd phase of nociceptive pain and it signifies conscious awareness of painful sensation in the patient
Nursing-sensitive patient outcome
A measurable patient, family, or community state, behavior, or perception largely influenced by and sensitive to nursing interventions
while assessing the muscles around the wrist joint of a patient the nurse finds full range of motion against gravity and some resistance which grade would the nurse document in the patients medical record
4
the nurse would count the pulse of a patient with an irregular heart rate for how many seconds
60
which size tape would the nurse use to stabilize a large dressing
7.5 cm which is 3 inches
which pressure injury is expected to heal through granulation and reepithelialization
stage 4
risk nursing diagnosis
Describes human responses to health conditions/life processes that may develop
which test would help assess a flexion deformity of the patients hip
thomas test
Gorden's 11 Functional Health Patterns
Health Perception Health Management Pattern Nutritional Metabolic Pattern Elimination Pattern Activity Exercise Pattern Sleep Rest Pattern Cognitive-Perceptual Pattern Self-Perception-Self-Concept Pattern Role-Relationship Pattern Sexuality-Reproductive Coping-Stress Tolerance Pattern Value-Belief Pattern
Nursing Evaluation
Involves measuring if goals in planning step were met: progress is evaluated; changes in nursing diagnoses, goals & care plan may result; NA has keep role as NA's observations are used for this step
which instruction regarding sublingual nitroglycerin would the nurse provide to the patient
dont swallow the med place the med under the tongue
supination is
Palm up
components of a med prescription
dose frequency of the med route generic name
which role does vitamin a play in wound healing
Promotes wound closure
no dressing is appropriate for an intact
stage 1 pressure injury
flacc is a
different nonverbal pain assessment tool that helps evaluate pain intensity of pain in younger child
pain that is felt at a
different site than the site of orgin is referred pain
a composite file dressing can be used for a clean
stage 2 pressure injury
while administering a med if a patient has
difficulty swallowing a med the nurse should notify the health care provider
lotion
Semiliquid suspension that usually protects, cools, or cleanses skin
when using the verbal descriptor scale
THE NURSE WOULD ASK PATIENTS TO describe their feelings and the intensity of the pain that they are experiencing
which condition warrants the use of cold therapy
direct trauma
which technique would the nurse use to address lateral violence
directly ask for the abuse to stop
which term would the nurse document to describe individual lesions that remain separate from each other
discrete
a calcium alginate dressing is appropriate for a clean
stage 3 or 4 pressure injury
what regulatory agency is responsible for rigorous testing of medications before making them available to the public
US FDA
organic mental health disorders
disorders of decreased mental function resulting from a medical or physical disease
herpes zoster, trigeminal neuralgia and distal polyneuropathy are
disorders that cause neuropathic pain because they cause a primary lesion called a neuroma and damage the nervous system
discrete describes
distinct individual lesions that remain separate from each other
nonblanchable erythema indicates
damage to bvs and tissue
seborrheic keratosis looks
dark greasy and stuck on
which assessment finding would likely be the cause of a pulse oximeter not providing a reading when the nurse attempts to determine the patients o2 saturation
dark nail polish
the removal of devitalized tissue from a wound describes which process
debridement
dose and frequency of a med
decided based on the patients weight and amount of med required to obtain the therapeutic effect
spontaneous movements are
decreased in a patient who is lethargic
which statement describes the role of state nurse practice acts in nursing
defining the scope of nurses professional functions
the first sound heard as the blood pressure cuff begins to
deflate is the first korotkoff sound which indicates systolic bp
which action by the nurse during a blood pressure assessment would lead to a falsely high diastolic reading
deflating blood pressure cuff to slowly
the nurse askes the patient with lower back pain how does the pain limit your daily activities to determine which aspect of the patients pain experience
degree of impairment
agression is a characteristic of
delirium
which mental health disorder is classified as an organic disorder
delirium alcohol intoxication dementia
which mental health disorder is associated with agnosia
dementia
lack of exercise causes
demineralization of bones leading to osteoporosis
route of a med
depends on the types of med and condition of patient
intradermal injections
deposit meds into the dermis
subcutaneous injections
deposit the meds just below the dermis of the skin
irritability, apathy and extreme sadness are emotional states common in
depression
the nurse would use the patient health questionnaire 9 to screen a patient for which condition
depression
which mental health disorder is observed in children
depression autism adhd
a problem focused diagnosis
describes a clinical judgment concerning an undesirable human response to a health condition/life process that exists in an individual, family, or community.
neologism
describes the use of words that are invented by the patient and that hold no actual meaning except to the patient
Denver II screening test
detects devolpmental delays in infants and preschoolers
while administering an oral med to a patient with dysphagia which health care professional should the nirse collaborate with to determine the best techniques for med administration
dietitian speech therapist occupational therapist
conditions that limit blood flow or blood perfusion inhibt the
distribution of a med
anxiety and schizophrenia are classified as
psychiatric mental health disorders
Hypochondriasis
psychological condition in which the patient excessively worries about his or her own health
growth and development status is related to
psychophysiological context
adults, adolescents and preschoolers require
pulling the auricle upwards and outwards
if the nurse finds the nail base of a patient to be soft spongy and at an angle of 180 degrees for which additional condition would the nurse monitor
pulmonary disease
a patients wound drainage appears thick and yellow whic type of drainage is this considered
purulent
which action would the nurse take while removing a dressing on an older adult patient
push the skin away from the adhesive
which joint would facilitate pronation and supination movements of the hand and the forearm
radioulnar
keratoses are
raised thickened areas of pigmentation that look crusted scaly and warty
inhalational routes provide
rapid relief for local respiratory problems
which speech disorder causes a patient to have difficulty understanding language
receptive aphasia
which route of the administration is suitable for administering a suppository
rectal
where would the nurse place a rectal suppository in an adult
rectal wall 10 cm into the rectum
erythrocytes are
red nlood cells
actinic keratoses are
red tan scaly plaques that increase over the years to become raised and roughened
a splinter hemorrhage is associated with the presence of
reddish brown linear steaks on the fingers and toenails
which assessment finding would related to erythema in a dark skinned patient diagnosed with polycthemia
reddish lips
which physiologic change affecting the metabolism of meds would the nurse be aware of in geriatric patients
reduced liver function reduced absorptive capacity
Phase 1 of Korotkoff sounds
refer to the systolic pressure there are soft and clear tapping sounds with increasing intensity
achilles tenosynovitis
refers to the inflammation of the tendon sheath near the ankle
agnosia
refers to the loss of the ability to recognize objects, persons, sounds or smells
peak concentration
refers to the time taken to attain the highest effective concentration and doesnt provide info related to the onset of action
which condition would a nurse suspect in a patient with a broken leg who reports swelling, stiffness and burning pain in the leg who has noticeably brittle nails and pale dry shiny skin
reflexive sympathetic dystrophy
functions of the skin include
regulates boy temp prevents invasion of microorganisms assists in the prodcution of vitamin d
which cognitive function is the nurse assessing during a mental status assessment when the nurse asks about the patients first job
remote memory
which sense would the nurse use during a routine physical exam
sight smell touch hearing
pharyngeal edema (constriction of bronchiolar muscles) and severe wheezing are
signs of an anaphylactic reaction and is life threatening
which dressing would be inappropriate for a patient with a clean stage 2 pressure injry
silver
sanitization is
simply cleaning the wound
while interviewing the patinet the nurse should not
sit straight in the chair because it affects awareness attention and immediacy
grade 1 muscle strength indicates
slight contraction
which characteristic would be present in stage 3 pressure injury
slough may be present but doesnt obscure the depth of tissue loss
onychomycosis is a
slow persistent fungal infection that causes changes in color
volume controlled infusions administer meds in
small amounts such as 100ml
tuberculin syringe
small diameter syringe that is useful for preparing small precise doses of meds for subcutaneous injection in infants and newborns
senile lentigines, liver spots are
small flat brown macules that appear on the foremarm and dorsa of the hands as seen on older adults
which term describes the type of communication involved when the nurse teaches individuals about healthy meal planning
small group
herpes zoster causes
small grouped vesicles that emerge along the route of cutaneous sensory nerve pathways then form pustules then crusts and are unilateral
which patient assessment would the nurse report as a normal skin finding
smooth firm skin
customs and expectations are
sociocultural elements that affect and interaction
dull percussion note
soft high muffled thud short
a caplet is a
solid dosage form of med whic is available in coated form and meant to be swallowed whole
which info will the nurse elicit to help arrive at the probable cause when a patient is reporting severe abdominal pain in the right iliac region
some questions about the digestive system
moisture or fricition injury to superficial layers causes
soreness upon touch
Phase III and II Korotkoff sounds
sounds are knocking and swooshing sounds and also indicate diastolic pressure
which part of a pressurized metered dose inhaler or device is used to improve drug absorption in a patients airway
spacer
when developing client goals it is important to use the smart acronym which stands for
specific measurable attainable realistic times
clanging
speech disorder in which the patient chooses words that sound similar but dint carry a logical connection and that usually rhymes or puns
breakthrough pain
spikes btwn long acting pain meds
to assess posture the nurse should ask the patient to
stand still and observe the normal plumb line through the anterior ear, shoulder, hip and patella and ankle
us pharmacopeia and the national formulary sets
standards for medication strength, quality, purity , packaging, safety and dose form
which type of prescription order would the nurse carry out until the health care provider cancels the order
standing order
which criterion would the nurse observe while performing a body structure assessment of a patient
stature symmetry contour
which action would the nurse take if infiltration is noted at the iv site of a patient receiving iv therapy
stopping the iv infusion
which guideline would the nurse follow for the safe use of narcotices
store narcotics in locked containers frequently count narcotics especially during shift change document and record patient details
the process of extension involves
straightening a limb at a joint
a topper dressing helps prevent
strike through of the wound drainage
phobia
string irrational fear of an object or situation
one should maintian a 45 or 90 degree angle to administer meds through the
subcuatenous route
for low molecular weight heparin
subcutaneous injection is preferred
quality refers to the
subjective difference caused by the distinctive overtones of a sound
film dressings are used for
superficial ulcers
an abrasion is a
superficial wound with less bleeding it is considered a partial thickness wound because it doesnt involve deep layers of the dermis
which position would the nurse instruct a frail older adult patient to assume for the exam process
supine
which position would the nurse instruct the patient with overwhelming fatigue to assume during the assessment
supine
Which adjuvant treatment is only considered for patients diagnosed with an unstageable pressure injury?
surgical consultation for debrdiement
which communication technique is nontherapeutic
sympathizing
needles of the enteral syringes do not attach to the
syringes and cant be inserted into any type of intravenous line
the working phase involves
taking actions to meet the goals set for the patient
fMRI determines
the structural and neurochemical changes caused in the brain by nociception
peak is
the time it takes for a med to reach its hightst effective concetration
the question are you ever awakened by pain indicates
the timing criterion because the nurse is assessing the time of pain
which statement is true regarding irrigation equipment used for cleaning wounds
the volume of the irrigant should be higher than the volume of the wound
precut gauze is used when
the wound drains
the nurse assesses a patients abdominal wound and finds that the wound is in the proliferative phase of healing which change in the wound might have led the nurse to this conculsion
the wound is filled with granulation tissue the wound contracts to reduce the area that requires healing there is reepithelialization of the wound surface
if a patient experiences lower back pain for more than 6 months
then it indicates chronic pain
summarizing is a
therapeutic communication technique that involves a concise review of key aspects of an infection
focusing is a
therapeutic communication technique that involves centering a convo on key elements or concepts of a message
clarifying is a
therapeutic communication technique to check whether one understands a message accurately by restating an unclear or ambiguous message to clarify the senders meaning
focusing, clarifying and summarizing are
therapeutic techniques
the human body maintains
thermostatic equilibrium by a feedback mechanism regulated in the hypothalamus of the brain
which info would the nurse include in patient teaching regarding the lesions of seborrheic keratosis
they dont become cancerous
which statment is true regarding hydrogel dressings
they enhance autolytic debridement
creativity and perseverance are attitudes conducive to communication because
they motivate the nurse to identify innovative sloutions
purulent drainage is
thick and yellow
crusts are the
thick dried exudates left after the bursting of vesicles or pustules
when a child diagnosed with impetigo presents with vesicles having an erythematous base for which additional assessment finding would the nurse monitor
thick honey colored crusts
on the palm and soles skin is
thicker because of work and weight bearing
the epidermis is
thin but tough and ts cells are bound tightly together into sheets that formed a rugged protective barrier
subjective data
things a person tells you about that you cannot observe through your senses; symptoms
which factor increases the risk of injury when applying heat therapy to a wound for a pediatric patient
thinner layers of skin
while caring for a patient who orally takes herbal and nutritional supplements a rn teaches a nursing student about the interactions of a newly prescribed oral med with the nutritional and herbal supplements the patient is already administering how does this knowledge help the nursing student provide effective care for this patient
this knowledge helps determine the best time for the med administration
which factor would the nurse consider when using the method of confrontation as a therapeutic means of communication with the patient
this should be done gently and after establishing trust this method improves patient self awareness in a therapeutic way using this technique helps the patient become aware of inconsistent feelings
which term would be used to describe the pain for a patient with a gastric ulcer who reports dull, deep , squeezing pain in the stomach
visceral
pain associated with appendicitis and cholecystitis is
visceral pain
which pain assessment tool is being used when the nurse askes the patient to make a mark along a 10 cm horizontal line from no pain to worst pain imaginable
visual analogue scale
when a patient is devoid of melanin pigment in patchy areas of the skin on the face, neck, feet and body folds which condition would the nurse document
vitiligo
medwatch is
voluntary program that enables health care personnel to report any adverse effects of meds
which appearance would be typical of a patient with organic brain syndrome
wears a raincoat on a hot sunny day with out a cloud in the sky
because of damage to capillaries plasma may leak giving the wound a
weepy appearance
Pharmacokinetics
what the body does to the drug
the nurse would ask a patient which question to test for recent memory
what time did you get up today
a patient experiencing a cardiopulmonary event may present with
wheezing diaphoresis sob
transpersonal communication is
when a patient is communicating through prayer meditation or other means witha higher power or deceased loved one
observation occurs
when the nurse is in contact with the client or support person
calcium alginate dressings are used
when the pressure injury is producing significant exudate
when would the nurse administer a medication scheduled on call for surgery
when the surgical staff is coming to get the patient
grade 4 muscle strength is
when there is full range of motion against gravity and some resistance
which question would the nurse ask to determine possible anorexia nervosa in a femal adolescent patient who presents with marked weight loss and reports exercising 2 hours every day
when was your last menstrual period
The nurse asks another nurse how to collect a laboratory specimen and is told, "Why don't you figure it out?" Which would be the best response?
when you brush me off like that it takes me even longer to do my job
the nurse has to inquire about the pain that the patient is experiencing asking
where exactly the pain is gives the location of pain if the patient has turned or moved helps the nurse to establish mobility status as well as severity of pain rate the pain on a scale of 0-10 helps asses the severity of the pain
tendons are
white glistening fibrous bands of tissue that connect muscles to bones
which assessment finding would the nurse expect in an infant diagnosed with milia
white papules on the cheeks forehead nose and chin