Firelands School Of Nursing Foundations Test 2

Front 1

Infection

Back 1

Invasion of a susceptible host by microorganisms (pathogens), resulting in disease

Front 2

Asymptomatic

Back 2

without symptoms of infection

Front 3

Symptomatic

Back 3

with symptoms of infection

Front 4

Contagious

Back 4

Infectious disease transmitted directly from one person to another

Front 5

Virulence

Back 5

ability to produce disease

Front 6

Reservoir/ Host

Back 6

Humans, animals, insects, inanimate objects

Front 7

Portal of Entry

Back 7

Skin, mucous membranes, respiratory tract, gastrointestinal, reproductive system, blood

Front 8

Modes of Transportation

Back 8

Direct/ Indirect/ Droplet/ Airborne

Front 9

Direct

Back 9

hand to hand

Front 10

Indirect

Back 10

Objects

Front 11

Droplet

Back 11

coughing

Front 12

Airborne

Back 12

coughing

Front 13

Hand Hygiene

Back 13

Primary Prevention

Front 14

Localized Infection

Back 14

one area; treat with antibotics and wound care

Front 15

Systemic

Back 15

Whole system

Front 16

Sepsis infection

Back 16

in the bloodstream

Front 17

Normal Flora

Back 17

microorganisms that reside in the body

Front 18

Body System defenses

Back 18

organs specialized defense mechanism

Front 19

Inflammation

Back 19

Cellular response to injury or infection.

Signs: swelling, redness, heat, pain, or tenderness

Front 20

Immune response

Back 20

Produce antibodies to neutralize, destroy, or eliminate antigens

Front 21

Antibodies

Back 21

Bodies defense

Front 22

Antigens

Back 22

Infection

Front 23

HAI

Back 23

Healthcare

Acquired

Infection

Front 24

Exogenous

Back 24

microorganism outside the individual

Front 25

Endogenous

Back 25

Patient's flora becomes altered and an overgrowth results

Front 26

Asepsis

Back 26

technique to keep patients as free from exposure to infectious-causing pathogens as possible

Front 27

Medical Asepsis

Back 27

Clean technique: procedure used to reduce the number & prevent the spread of microorganisms

Front 28

Surgical Asepsis

Back 28

Sterile technique: procedure to eliminate all microorganisms from an area

Front 29

Granulation Tissue

Back 29

Beginning formation of a scar

Front 30

MDROs

Back 30

MultiDrug- Resistant Organisms

Front 31

MRSA

Back 31

Methicillin-Resistant Staphylococcus Aureus

Front 32

VRE

Back 32

Vancomycin-Resistant Enterococcus

Front 33

C-Diff

Back 33

Clostridium Difficile

Front 34

Specimin Collection

Back 34

1. Use Sterile Equipment

2. Collect fresh material

3. Seal Containers tightly

4. Properly label specimens( Time, Date, Type, & Initial)

5. Place in labeled leak-proof biohazard bags for transport

Front 35

Biohazardous Waste

Back 35

1. Cultures

2. Pathological waste

3. Blood & Blood Products

4. Sharps

5. Selected Isolation Materials

Front 36

Vital Signs

Back 36

Temperature

Respirations

Oxygen Saturation

Blood Pressure

Pulse

Pain

Front 37

Guidelines for when to do VS

Back 37

1.Entering Healthcare Facility

2.Change in condition

3. Before/After- Medication

4. Before/During/After- Blood Transfusion & Surgical Procedures

Front 38

Guidelines for VS assessment

Back 38

1. Must be measured correctly

2. Equipment should be working and appropriate size for patient

3.Must be understood & interpreted

4. Must be communicated- Verbally & Documented

Front 39

Pyrexia

Back 39

Defense Mechanism from an infection

Front 40

Afebrile

Back 40

No fever

Front 41

Febrile

Back 41

Fever

Front 42

Body Temperature

Back 42

Heat Production-Heat loss

Front 43

Normal Temp. range

Back 43

36 - 38 degrees C

96.8 - 100.4 degrees F

Front 44

Body Temp Regulations

Back 44

1. Neural & Vascular control

2. Heat production

3. Heat loss (diaphoresis=sweating)

4. Skin

5. Behavioral control

6. Age- elderly less temp. control

Front 45

Diaphoresis

Back 45

Sweating

Front 46

Antipyretic

Back 46

Fever reducer

Front 47

Hyperthermia

Back 47

High body temp.; overload on body temperature release mechanism

ie. Out in sun to long

Front 48

Hypothermia

Back 48

Low body temp.; heat loss resulting from prolonged exposure to cold

ie. In cold water

Front 49

Exact temperature area

Back 49

1. Core~Internal (temperature of deep structures of the body)

2. Surface~ External

Front 50

Core Temperature

Back 50

1. Pulmonary Artery

2. Esophagus

3. Bladder

Front 51

Surface Temperature

Back 51

1. Oral

2. Auxillary

3. Rectal

4. Tympanic

5. Temporal Artery

Front 52

Bradycardia

Back 52

Low BP <60

Front 53

Tachycardia

Back 53

High BP >100

Front 54

Hypoxia

Back 54

Lack of Oxygen in Blood

Front 55

Pulse Deficit

Back 55

Difference between radial and apical rate

Front 56

Dysrhythmia

Back 56

Irregular beat, pauses in between beats

Front 57

Blood Pressure

Back 57

force exerted on the walls of an artery created by the pulsing blood under pressure from the heart

Front 58

Systolic

Back 58

(High Pressure)(Top Number)

Ventricular contraction that forces blood into the aorta- resistance of aorta as blood pumps out of left ventricle

Front 59

Diastolic

Back 59

(Low Pressure)(Bottom Number)

Minimal pressure exerted against the arterial wall, ventricles are relaxing. Also indicates volume of blood in heart.

Front 60

Pulse Pressure

Back 60

Difference between systolic and diastolic pressure

Front 61

Hypotension

Back 61

Low blood pressure

<90/60

Front 62

Hypertension

Back 62

High Blood Pressure

>140/90

Front 63

Orthostatic Blood Pressure

Back 63

Postural Hypotension

Drop of SBP 20mmHG w/in 3 minutes

Drop of DBP of 10 mmHG w/in 3 minutes

Increase HR>20 bpm of standing/sitting

Front 64

Factors of BP

Back 64

Age, Race, Weight, Gender, Ethnicity, Sympathetic Stimulation, Daily VAriation, Medication and Treatment, Activity, Diet, Smoking

Front 65

Respiration

Back 65

Mechanism the body uses to exchange gases among the atmosphere, blood, and cells

Front 66

Diffusion

Back 66

movement of gas out of the alveoli

Front 67

Perfusion

Back 67

transport of gas

Front 68

Ventilation

Back 68

movement of air into and out of the lungs

Front 69

Eupnia

Back 69

Normal adult breathing

Front 70

Factors of Respiration

Back 70

Exercise, Acute Pain, Anxiety, Smoking, Body Position, Medications, Neurological Injury, Hemoglobin Function, Chest wall movement

Front 71

Bradypnea

Back 71

breaths < 12

Front 72

Tachypnea

Back 72

breaths > 20

Front 73

Apnea

Back 73

No breath

Front 74

Variations in Respiratory

Back 74

1. Fever 2. Pain & Anxiety

3. Diseases to chest wall or muscles/ lungs

4. Constrictive Chest/Abdominal dressing

5. Abdominal Incision 6. Gastric Distention

7. Chest Tube 8. Injury to Chest Wall

9. Respiratory Infection 10. Brain Injury

Front 75

Pulse Oximeter

Back 75

Capillary Measurement;

Hemoglobin saturation in the oxygen

Front 76

SpO2

Back 76

abbreviation for Pulse Oximeter

Front 77

Factors of Pulse Oximeter

Back 77

1. Hypotension 2. Hypothermia

3. Hypoperfusion (Peripheral Vascular Disease)

4. Nail Polish (Acrylic nails w/ polish)

5. Anemia (low hemoglobin)

6. Cyanosis to nail beds

7.Restlessness, confusion

8. Medications (Bronchodilators)

Front 78

Purpose of Physical Exam

Back 78

1. Gather baseline data

2. Supplement, confirm, or refute data

3.Confirm & identify nursing daignoses

4. Make clinical judgments

5. Evaluate the outcomes of care

Front 79

Subjective Data

Back 79

Insight from Patient themself;

What they tell you.

Front 80

Objective Data

Back 80

Measurement of information;

What we can see.

Front 81

Cultural Sensitivity

Back 81

Cultural differences influence a patient's behavior.

Front 82

Assessment Techniques

Back 82

1. Inspection (observation)

2. Palpation ( hands to feel)

3. Percussion ( hands to tap & listen)

4. Auscutation (use of stethoscope)

5. Olfaction (smelling)

Front 83

Inspection

Back 83

Inspect for size, shape, color, symmetry, position, & abnormalities

Front 84

Palpation

Back 84

Using the hands, press about 1/2 in. w/ light intermittent pressure.

Skin: Temperature, moisture, texture, turgor, tenderness, or thickness

Abdomen: Tenderness, distention, or masses

Front 85

Percussion

Back 85

Tapping the body w/ fingertips to produce a vibration.

Tap to determine location, size, & density of structures.

Abnormal sounds can be mass, air, or fluid.

Front 86

Auscultation

Back 86

Use stethoscope to listen to sounds produced by the body.

Assess sounds heard in heart, lungs, or gastrointestinal systems

Front 87

Olfaction

Back 87

Identify nature & source with nose.

Determine: Wounds, Urine, Stool, Body Odor.

Front 88

Supine

Back 88

Lay flat on back

Front 89

Prone

Back 89

Lay on abdomen

Front 90

Lateral

Back 90

Lay on side

Front 91

Sims

Back 91

Side laying position w/ knee bent up.

Front 92

General Survey

Back 92

Begins w/ first meet a patient.

Provides basic information; Characteristics of illness, Hygiene, Skin condition, Body image, Emotional state, Development status

Front 93

Skin Assessment

Back 93

Color, moisture, temperature, lesions, texture, turgor, vascularity, petechiae, or edema

Front 94

Jaundice

Back 94

Yellowing of skin and eyes

Front 95

Erythemia

Back 95

Reddening of skin

Front 96

Pallor

Back 96

Pale complexion

Front 97

Cyanosis

Back 97

Blue tinge to skin or nails

Front 98

Petechia

Back 98

Capillaries break under skin and cause red pin points on skin.

Front 99

Skin Turgor

Back 99

Elasticity of skin

Front 100

Edema

Back 100

Fluid escaping from vascular system to skin causing swelling in the limb.

Front 101

Pressure Ulcer

Back 101

(Bed sore) Skin breakdown on bony prominences of the body where they lose blood circulation to the area and cause a wound.

Front 102

Nail Assessment

Back 102

1. Palpate for Capillary refill

2. Inspect for deformities

Front 103

Head & Neck Assessment

Back 103

Headache, dizziness, seizures, poor vision, loss of consciousness.

Size, shape contour of head & skull.

Facial symmetry

Front 104

Eye Assessment

Back 104

Pupils- Size

Conjuctive & Sclera- Color

Front 105

Conjuctivitis

Back 105

Pink-eye

Infection in the Conjuctive of the eye

Front 106

PERRLA

Back 106

Pupils Equal, Round, Reactive to LIght and Accommodation

Front 107

Cataracts

Back 107

Glazed over opaque look on the eye

Front 108

Ear Assesssment

Back 108

Hearing ability

Drainage

Trauma to Head/Ears

Front 109

Mouth/Pharynx Assessment

Back 109

Overall health

Oral Hygiene

Oral Trauma

Airway Trauma

Front 110

Thorax & Lung Assessment

Back 110

Siiting upright Auscultate for 1 full ventilation through the mouth.

Palpate for deformities.

Inspect for abnormalities.

Front 111

Ventilation

Back 111

Full round of Expiratory and Inspiratory.

Front 112

Inspiratory

Back 112

To breath in

Front 113

Expiratory

Back 113

To breath out

Front 114

Orthopnea

Back 114

Difficulty breathing laying flat

Front 115

Dyspnea

Back 115

Shortness of Breath with activity or rest

Front 116

Kyphosis

Back 116

Increased thoraxic curvature

Has a slumped shoulders and a hump back appearance.

Front 117

Lordosis

Back 117

Increased lumbar curvature

Front 118

Scoliosis

Back 118

S-Shaped Vertabrae curvature in back

Front 119

Barrel Chest

Back 119

Expanded sternum & rib cage

Front 120

Crepitus

Back 120

Air under skin. Subcutaneous Emphysema.

Will have a bubble wrap feeling.

Front 121

Auscultate

Back 121

To listen with a stethoscope

Front 122

Normal Breath Sounds

Back 122

Vesicular

Bronchovesicular

Tracheal

Front 123

Vesicular

Back 123

Posterior Thorax;

Soft, breezy & low pitched.

Inspiration is longer than Exporation

Front 124

Bronchovesicular

Back 124

Posterior Thorax;

Medium Pitch

Heard between scapula

Front 125

Tracheal

Back 125

Anterior on Trachea;

Louder and Harsher

Front 126

Adventitious Breath Sounds

Back 126

Rhonchi

Crackles

Wheezes

Pleural Friction Rub

Front 127

Rhonchi

Back 127

Loud, Snoring; Gurgling; Large Airways( Bronchi)

Can clear with coughing

Front 128

Crackles

Back 128

Soft, Wet; in Alveoli

Front 129

Wheezes

Back 129

Musical sounding;

Caused by narrowing of airway

Front 130

Pleural Friction Rub

Back 130

Sounds like crackling leather;

Heard on inspiration;

Inflammation of Pleural space & lining

Front 131

Heart Assessment

Back 131

Aortic, Pulmonic, 2nd Pulmonic, Tricuspid, Mitral

Front 132

Aortic

Back 132

2nd intercostal space Right of the Sternum

Front 133

Pulmonic

Back 133

2nd intercostal space Left of the Sternum

Front 134

2nd Pulmonic

Back 134

3rd intercostal space Left of the Sternum

Front 135

Tricuspid

Back 135

4th intercostal space Left of the Sternum

Front 136

Mitral (Apical Pulse)

Back 136

5thg intercostal space Left of the Sternum Midclavicular Line

Front 137

Factors Influencing Heart

Back 137

Smoking, alcohol intake, caffiene, use of drugs, exercise habits, fat intake, & sodium intake.

Front 138

Cardiac Medications

Back 138

Beta-Blockes, ACE Inhibitors, Diuretics, antidysrhymics

Front 139

Bet-Blockers

Back 139

Block beta cells;

Regulate heart rate

Lower HR

Front 140

ACE Inhibitor

Back 140

Blocks angiotensin out of Kidneys & causes Vaso-Constriction

Front 141

Diuretics

Back 141

Releases extra fluid from body

Front 142

Antidysrhymics

Back 142

Regulate the heart rate

Front 143

Cardiac Assessment

Back 143

Family History

Chest pain, pressure, tightness, stress, fatigue

History of HTN, High Cholesterol, diabetes, stroke, heart disease, valvedisease/ replacement, blood clotting disorders.

Front 144

Pulses

Back 144

Radial

Brachial

Dorsalis Pedis

Posterior Tibial

Front 145

Radial Pulse

Back 145

In the wrist, thumb side

Front 146

Brachial Pulse

Back 146

In the anticubital space

Front 147

Dorsalis Pedis Pulse

Back 147

Top of the foot between the big toe and the next

Front 148

Posterior Tibial

Back 148

On the inner ankle big toe side

Front 149

Carotid Pulse

Back 149

Side of the neck towards the front. Check one at a time. Normally during CPR.

Front 150

Ulner Pulse

Back 150

In the wrist, pinky side

Front 151

Femoral Pulse

Back 151

Groin area, in the bend

Front 152

Popliteal Pulse

Back 152

Behind the knee, center to medial are

Front 153

Musculoskeletal Assessment

Back 153

Range of joint motion

Muscle strength

Gait & posture

Front 154

Flexion

Back 154

Movement decreasing angle between 2 adjoining bones; bending of limb

Front 155

Extension

Back 155

Movement increasing angle between 2 adjoining bones

Front 156

Hyperextension

Back 156

Movement of body part beyond it normal resting extended position

Front 157

Pronation

Back 157

Movement of body part so front or ventral surface faces down

Front 158

Supination

Back 158

Movement of body part so front or ventral surface faces upward

Front 159

Abduction

Back 159

Movement of extremity away from midline of body

Front 160

Adduction

Back 160

Movement of extremity toward midline of body

Front 161

Internal rotation

Back 161

Rotation of joint inward

Front 162

External rotation

Back 162

Rotation of joint outward

Front 163

Eversion

Back 163

Turning of body part away from midline

Front 164

Inversion

Back 164

Rotation of body part toward midline

Front 165

Dorsiflexion

(Dorsal Flexion)

Back 165

Flexion of toes and foot upward

(Pull toes toward nose)

Front 166

Plantar Flexion

Back 166

Bending of toes and foot downward

(Push toes against hand)

Front 167

Neurologic Assessment

Back 167

History

-level of consciousness

-language

-intellectual function

-cranial nerve function

-sensory nerve function

-motor function

-reflexes

Front 168

GCS

Back 168

Glasgow Coma Scale

-shows if patient is deteriating or improving

Front 169

Critical Thinking

Back 169

Clinincal Judgment

-Hallmark of what we do as a nurse.

Front 170

Interpretation

Back 170

Data collection

Front 171

Analysis

Back 171

Analyzing the data

Front 172

Inference

Back 172

Look at significance/ Make assumption

Front 173

Evaluation

Back 173

Look at the meaning

Front 174

Explanation

Back 174

Support your findings

Front 175

Self-regulation

Back 175

Self reflection or reflect on your experience

Front 176

Concept of Critical Thinking

Back 176

1. Truth seeking

2. Open-mindedness

3.Analytic approach

4. Systematic approach

5. Self-confidence

6.Inquisitiveness

7. Maturity

Front 177

Reflection

Back 177

Purposeful thinking back

Recalling a situation

Front 178

Language

Back 178

Use precisely and clearly

Front 179

Intuition

Back 179

Inner sensing (gut feeling)

Front 180

Critical Thinking Component-General

Back 180

Scietific

Problem Solving

Decision maker

Front 181

Critical Thinking Component- Specific

Back 181

Diagnostic reasoning & inference

Clinical decision making

Nursing process competency

Front 182

Critical Thinking Model

Back 182

Knowledge Base

Experience

Competence
Attitudes

Standards

Front 183

Attitudes of Critical Thinking

Back 183

Confidence Perserance

Independence Creativity

Fairness Curiosity

Responsibility Integrity

Risk taking Humilty

Discipline

Front 184

Reflective Journaling

Back 184

clarify concepts through reflection by thinking back or recalling situations

Front 185

Concept Mapping

Back 185

visual representation of patient problems & interventions that illustrate an interrealtionship

Front 186

Nursing Process

Back 186

Identifying, Diagnosing, and treating the Human Response to helath and illness

Front 187

Steps to Nursing Process

Back 187

1. Assess

2. Diagnose

3. Plan

4. Implement

5. Evaluate

(and repeat)

Front 188

Nursing Assessment

Back 188

Collection & verification of data

Analysis of data

Front 189

Database

Back 189

client's percieved needs, health problems & response to problems

Front 190

Sources of Data

Back 190

-Client

-Family & Significant Others

Health Care Team

-Medical Records

Front 191

Cues

Back 191

Information collected through your senses

Front 192

Inference

Back 192

Your interpretation of the Cue

Front 193

Nursing Health History

Back 193

Biographic Information Client Expextation

Present illness/ health concern Health Hx

Family Hx Environmental Hx

Psychosocial Hx Spiritual Hx

Review of Systems Documenting Findings

Diagnostics & Laboratory data

Front 194

Data Documentation

Back 194

Legal & Professional responsibility

Use proper terminology, abbreviations & correct spelling

Front 195

Nursing Diagnosis

Back 195

Clinincal judgment about the client in response to an actual/ potential health problem

(Our conclusion/ interpretation of our assessment rolled into a few words.)

Front 196

Medical diagnosis

Back 196

Identificatio of disease condition based on specific evaluation of s/s

Front 197

Collaborative problem

Back 197

an actual/ potential complication thastnurse monitor to detect a change in client status

Front 198

NANDA(-I)

Back 198

North

American

Nursing

Diagnosis

Association

(International)

Front 199

Diagnostic reasoning

Back 199

using assessment data to create a nursing diagnosis

Front 200

Defining characteristics

Back 200

Clinical criteria/asssessment findings

Help support the diagnosis

Front 201

Formulation of Nursing Diagnosis

Back 201

1. Actual Nursing Diagnosis (Highest Priority)

2. Risk Nursing Diagnosis

3. Wellness Nursing Diagnosis

Front 202

Actual Nursing Diagnosis

Back 202

Actual problem right now

Front 203

Risk Nursing Diagnosis

Back 203

Something that has the potential to happen in the future

Front 204

Wellness Nursing Diagnosis

Back 204

Readiness for enhancement