Exam 2 Basics Nursing (Charity)

Front 1

Body Temperature

Back 1

The heat of the body determined by the balance of heat produced and heat lost. Stated in degrees Fahrenheit or Celsius

Front 2

Core Temperature

Back 2

Reflects temperature of core body tissues (muscles, viscera). Tympanic and rectal temps are examples of this temperature. More accurate

Front 3

Surface Temperature

Back 3

Temperature varies according to site used (lower than core). Oral and axillary temps are examples of this temperature. Can be affected by the sucutaneous fat.

Front 4

Hypothermia

Back 4

Subnormal temperature <96.8 or 36C

Front 5

Fever

Back 5

Pyrexia. Temperature >100.4 F or 38 C

Front 6

Radiation

Back 6

Sitting in a col room (diffusion of heat by electromagnetic waves) No direct contact

Front 7

Conduction

Back 7

Taking a cool bath (transfer through direct contact)

Front 8

Convection

Back 8

Using an electric fan to cool off (through air currents)

Front 9

Evaporation

Back 9

Sweating and respiration (conversion of liquid to vapor)

Front 10

Chill phase

Back 10

(heat is conserved) setpoint rises, client experiences chill and shivering because the body is trying to conserve heat.

Front 11

Plateau phase

Back 11

Chills subside; client experiences a warm and dry feeling because the new temperature setpoint is reached.

Front 12

Fever break

Back 12

(heat is lost) vasodilation occurs; client experiences sweating (diaphoresis) because the setpoint decreases, and the body is attempting to lose heat or return to its normal setpoint. Fever breaks

Front 13

Respirations

Back 13

Act of breathing for 1 minute; cycle of inspiration and expiration counts as 1 breath.

Front 14

Physical examination

Back 14

A systematic, orderly process by which the nurse collects objective data about the client's body, mindand spirit. It is a critical investigation and evaluation of client's present status

Front 15

Validation

Back 15

Comparing data with another source

Front 16

Cephalocaudal

Back 16

Head-to-toe approach

Front 17

Inspection

Back 17

Visual examination; to observe, to look, to smell. the nurse observes shape, size, color, position, movement, symmetry, equality, congruence.

Front 18

Palpation

Back 18

Using the sense of touch; to feel, to stroke the surface of an area to detect its characteristics such as temperature, vibration, turgor, texture, masses, moisture, distention, presence of pain.

Front 19

Diaphram of stethoscope

Back 19

Used to hear high-pitched sounds (e.g bowel sounds) are heard best with this part. Most commonly used.

Front 20

Bell of stethoscope

Back 20

Used to hear low-pitched sounds (e.g heart sounds) are heard best with this part.

Front 21

Hemoptysis

Back 21

bloody sputum

Front 22

Dysphasia

Back 22

Difficulty with speech

Front 23

Edema

Back 23

The abnormal presence of fluid in the body

Front 24

Alopecia

Back 24

Loss of hair or absence of hair

Front 25

Ptosis

Back 25

Drooping of the eye lid

Front 26

Myopia

Back 26

Nearsightedness

Front 27

Hyperopia

Back 27

Farsightedness

Front 28

Presbyopia

Back 28

Difficulty reading small print

Front 29

Describe factors that affect the vital sign temperature and accurate measurement of them.

Back 29

Oral - If the temp is taken too soon after a person has had food, drink, gum or smoked. Age, diurnal variations, exercise, hormones, stress, environment

Front 30

Describe factors that affect the vital sign Pulse (P) or the Heart Rate (H/R) and the accurate measurement of them.

Back 30

Age - in newborn (faster pulse); Sex - slightly lower in males, activity - can increase pulse; fever - can increase pulse; medications - can either increase or decrease; hemorrhage - increases pulse initially; stress - increases pulse; position changes - can increase or decrease; vagal stimulation - decreases pulse; pain - increases pulse; anxiety/fear - increases pulse

Front 31

Describe factors that affect the vital sign Respiration (R) and the accurate measurement of them.

Back 31

Exercise - increases; acute pain - may alter rate and rhythm increase or decreases; anxiety - increases rate and depth; smoking - increases rate at rest; body position - straight tall is best and can either increase or decrease depending on the position; neurological injury - decreases rate and changes rhythm; hemoglobin function - increases rate and depth

Front 32

Identify the normal adult ranges for each vital sign

Back 32

Temp: Oral - 97.6F to 99.6F or 36.5C to 37.5C. Rectal - 98.6F to 100.6F or 37C to 38C. Axillary - 96.6F to 98.6F or 36C to 37C. Tympanic - 0.5F higher than oral. Pulse - 60-100 beats per minute. Respirations - 12-20 Breaths per minute. Blood pressure - 90/60 to 119/79

Front 33

Describe pulse sites commonly used to assess the pulse

Back 33

Peripheral - Carotid (most accurate), Radial (most common), Brachial, Femoral, Popliteal, Pedal pulses (Dorsalis pedis and Posterior tibial. Central site - Apical pulse (most accurate pulse of all of the pulse sites.

Front 34

Discuss the components and physiology of blood pressure

Back 34

Systolic B/P - higher value, as the left ventricle ejects blood.
Diastolic B/P - lower value, when the heart relaxes.