Fundamentals Test 2

Front 1

what is it called when the hypothalmus controls body temp by attempting to maintain a "set point". When the hypothalamus senses an increase in body temp, it sends impulses out to reduce body temp by sweating and vasodialation, if body temp is too low, it causes muscle shivering and vasoconstiction.

Back 1

neural and vascular control

Front 2

heat is a byproduct of metabolism. increased metabolism=increase heat

Back 2

heat production

Front 3

? and production occur at the same time.

Back 3

heat loss

Front 4

the transfer of heat between two objects w/o physical contact

Back 4

radiation

Front 5

transfer of heat from one object to another through direct contact

Back 5

conduction

Front 6

transfer of heat away by air movement

Back 6

convection

Front 7

transfer of heat energy when a liquid is changed to a gas (sweating=diaphoresis)

Back 7

evaporation

Front 8

when environment temp falls, the person does things to get warm, like adding clothes or standing by a fire

Back 8

behavior control

Front 9

fever, hyperthermia, hypothermia

Back 9

temperature alterations

Front 10

? ? are assessed whenever a patient enters any health care agency

Back 10

vital signs

Front 11

temperature of 96.8-100.4
pulse 60-100
respirations 12-16

Back 11

normal readings

Front 12

blood pressure of 140/90 or greater is

Back 12

hypertension

Front 13

? ? is present when systolic blood pressure falls to 90 or below

Back 13

hypotension

Front 14

where are the pulse sites?

Back 14

temporal, carotid, apical, brachial, radial, ulnar, femoral, popliteal, posterior tibial, dorsalis pedis

Front 15

what pulse is over the temporal bone of head, above and lateral to the eye

Back 15

temporal

Front 16

what pulse is along medial edge of sternocleidomastoid muscle in the neck

Back 16

carotid

Front 17

what pulse is on the fourth to fifth intercostal space at left midclavicular line

Back 17

apical

Front 18

what pulse is in the groove between the biceps and triceps muscles at antecubital fossa

Back 18

brachial

Front 19

what pulse is on the radial or thumb side of the forearm at the wrist

Back 19

radial

Front 20

what pulse is on the ulnar side of forearm at wrist

Back 20

unlar

Front 21

what pulse is below inguinal ligament, midway between symphysis pubis and anterior superior iliac spine

Back 21

femoral

Front 22

what pulse is behind the knee in popliteal fossa

Back 22

popliteal

Front 23

what pulse is on the inner side of ankle, below medial mallelous

Back 23

posterior tibial

Front 24

along top of foot, between extension tendons of great and first toe

Back 24

dorsalis pedis

Front 25

situation in which the body temp. exceeds the set point

Back 25

hyperthermia

Front 26

an elevated body temp. related to the body's inability to promote heat loss or reduce heat production

Back 26

hyperthermia

Front 27

a hereditary condition of uncontrolled heat production. occurs when pts. with this condition receive certain anesthetic drugs

Back 27

malignant hyperthermia

Front 28

abnormal lowering of body temp., below 95 degrees F, usually caused by prolonged exposure to cold, can be intentional or accitdental

Back 28

hypothermia

Front 29

during prolonged neurological or cardiac surgery, surgeons use intentional ? to reduce the body's needs for oxygenated blood

Back 29

hypothermia

Front 30

accidental ? develops gradually and may go unnoticed for several hours

Back 30

hypothermia

Front 31

these sypmtoms...uncontrolled shivering, loss of memory, depression, and poor judgement indicate what

Back 31

hypothermia

Front 32

as the body temp falls below 93.2 F the heart, respiratory rates, and blood pressure falls when the person is in

Back 32

hypothermia

Front 33

what is the technique for auscultation of the lungs

Back 33

inspect, palpate spinous process for chest rise, tactile fremitis, and chest excursion, percuss for cva tenderness, auscultate for breath sound

Front 34

palpate ? of ? ? (?) locate the fifth intercostals space just to the left of the sternum and move your fingers laterally to the left midclavicular line

Back 34

point of maximal impulse (PMI)

Front 35

what pulse is felt 1-2 cm in diameter at the apex of the heart?

Back 35

apical

Front 36

? heart for normal heart sounds, extra heart sounds, and murmers, rate and rhythm

Back 36

auscultation

Front 37

what type of heart sounds produces a blowing or humming sounds

Back 37

murmers

Front 38

what are the five spots to listen to the heart sounds

Back 38

aortic, pulmonic, erbs, tricuspid, and mitra

Front 39

inspect and watch for shortness of breath which may indicate ? disease

Back 39

heart

Front 40

when looking the abdomen you must ?

Back 40

inspect for symmetry and contour, auscultate bowel sounds in all four quadrants, percussion or major organ locations, and palpation in all four quadrants for masses, organomegaly

Front 41

what are the four basic parts of the baseline assessment?

Back 41

inspection, palpation, percussion, and auscultation

Front 42

what number do you give a absent, not palpable pulse

Back 42

0

Front 43

what number do you give a pulse that is diminished, barely palpable

Back 43

1+

Front 44

what number do you give a pulse that is easily palpable, normal

Back 44

2+

Front 45

what number do you give a pulse that is full, increased

Back 45

3+

Front 46

what number do you give a bounding pulse, one that can't be obliterated

Back 46

4+

Front 47

what is A & O x 3 stand for

Back 47

alear and orientated to person, place, time

Front 48

objective measurement of consciousness on a numerical scale

Back 48

Glasgow coma scale GCS

Front 49

a muscle has increased tone

Back 49

hypertonicity

Front 50

a muscle has little tone

Back 50

hypotonicity

Front 51

hunchback, or exaggeration of the posterior curvature of the thoracic spine

Back 51

kyphosis

Front 52

swayback, or increased lumbar curvature

Back 52

lordosis

Front 53

lateral spinal curvature

Back 53

scoliosis

Front 54

if they are distended when patient is sitting at a 45 degree angle, it can indicate right sided heart failure

Back 54

jugular vein distention

Front 55

start with angle of louis, second intercostal space on the right is the ?

Back 55

aortic area

Front 56

the left second intercostal space is the ?

Back 56

pulmonic area

Front 57

the left third intercostal space it the second ?

Back 57

pulmonic area (Erbs)

Front 58

the left fourth intercostal space is the ?

Back 58

tricuspid area

Front 59

the fifth intercostal space just to the left of the sternum and lateral to the left midclavicular line

Back 59

mitral area or OMI

Front 60

basic medical techniques that break the chain of infection, procedures used to reduce the number of micro-organisms and prevent their spread

Back 60

medical asepsis

Front 61

the invasion of a susceptible host by pathogens or microorganisms, resulting in disease

Back 61

infections

Front 62

an infectious disease transmitted directly from one person to another

Back 62

communicable disease

Front 63

comes from microorganisms outside the individual, salmonella, clostridum, tetani, and aspergiius

Back 63

exogenous infection

Front 64

occurs when part of the patients flora becomes altered and an overgrowth results, staphylococci, enterococci, yeasts and streptococci, when patient receives broad spectrum antibiotics. when sufficient numbers of microorganisms normally found in one body cavity or lining move to another body site

Back 64

endogenous infections

Front 65

infections that affect the body as a whole

Back 65

systemic infections

Front 66

improper insertion of catheter, open or disconnected drainage system; improper specimen collection technique, obstruction of drainage, reflux of urine into bladder, contaminated catheter or equipment improper hygiene technique

Back 66

urinary tract infections

Front 67

improper aseptic technique during pin care or dressing care

Back 67

bone and joint infection

Front 68

improper aseptic technique during dressing changes or following cardiac surgery

Back 68

cardiovascular system infection

Front 69

improper aseptic technique during dressing changes or during monitoring of intracranial monitoring device

Back 69

central nervous system infection

Front 70

contaminated food or water, overuse of anitbiotics

Back 70

GI system infection

Front 71

normal 5,000-11,000/mm, is increased in acute infection, decreased in certain viral or overwhelming infections

Back 71

WBC count

Front 72

normal, up to 15 mm/hr for men and 20 mm/hr for women, elevated in presence of inflammatory process

Back 72

erythrocyte

Front 73

normal 60-90 mg/110ml, decreased in chronic infection, cultures of blood, normally sterile, without microorganisms growth, presence of microorganism growth may indicate infection, same with cultures of wound

Back 73

iron wounds

Front 74

normal, nitrate and leukocyte negative, WBC 0-11/mm3 esterases

Back 74

urinalysis

Front 75

factors for infections ? have a immature immune system

Back 75

infants

Front 76

factors for infections ? acquire more immunity but are susceptible to mumps and measles

Back 76

children

Front 77

factors for infections ? and ? ? ? have refined body system defenses and immunity

Back 77

young and middle age adults

Front 78

factors for infections ? ? immune response decline, and the sturcture and function of major organs

Back 78

older adults

Front 79

congenital and genetic chromosomal disorders can have an effect on humoral or cellular immunity. diabetes are more at risk for infections and delayed wound healing

Back 79

heredity

Front 80

culture or religious beliefs interfere with seeking treatment or use of methods to prevent infection

Back 80

cultural practices

Front 81

a reduction in protein, carbs, and fats as a result of illness inadequate diet, or debility increases a pts susceptibility to infection and delays wound repair

Back 81

nutritional status

Front 82

increased ? elevates cortisone levels, causing decreased resistance to infection, continuois ? exhausts energy stores

Back 82

stress

Front 83

inadequate ? and ? increases stress and decreases body functions

Back 83

rest and exercise

Front 84

primary and secondary defense are altered

Back 84

inadequate defenses

Front 85

chain of infection includes

Back 85

pathogen, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host

Front 86

the most important and most basic technique in preventing and controlling transmission of infection is hand hygiene

Back 86

nurses role in infection control

Front 87

infection caused by the presence of a ? in the body, requires living hosts to multiply, invades normal cells and takes over, causes severe illnesses such as AIDS, smallpox, and hemorhagic fevers, antibiotics do not work for this infection

Back 87

viral infection

Front 88

single celled "living" microorganisms that reproduce by dividing, some examples of this are step throat and tuberculosis, growth of disease causing bacteria can be halted by the use of antibiotics

Back 88

bacterial infection

Front 89

largest body organ, 16% total body weight

Back 89

skin

Front 90

outermost layer that covers the dermis, produce melanin that helps dertermine the color of the skin

Back 90

epidermis

Front 91

below epidermis, strong connective tissue that contains nerve endingd, sweat glands, hair roots

Back 91

dermis

Front 92

lies beneath the dermis

Back 92

sub-q or subcutaneous

Front 93

care given during the daily bath or if the pt is incontinent, important to always wipe from front to back to prevent UTI's, if male is uncircumcised make sure to retract the foreskin to clean the area, make sure to change location on the washcloth with each wipe

Back 93

peri-care

Front 94

make sure you line the sink with towels when washing ?

Back 94

dentures

Front 95

infestation of humans by lice

Back 95

pediculosis

Front 96

pediculosis capitis

Back 96

head lice

Front 97

pediculosis corporis

Back 97

body olice

Front 98

pediculosis publis

Back 98

crabs or pubic lice

Front 99

lice is transmitted by

Back 99

contact with contaminated articles

Front 100

s/s of ? are severe itching in affected area

Back 100

lice

Front 101

important to change position of a ? pt every two hours

Back 101

unconscious

Front 102

make sure to continue to talk and explain all procedures to pts, give oral care every two hours, perform passive ROM, monitor I and Os, and maitain good hydration and nurtition are all important when taking care of a ? pt

Back 102

unconscious

Front 103

use special combs to comb hair with a fine-toothed comb, use this with RID and NIX shampoo, may need to retreat 1 week to 10 days later for newly hatched ?

Back 103

lice

Front 104

controls inflammation by suppressing or preventing many of the components of the infammatory process at the injured site, used to control arthritic flare-ups, do not stop suddenly, need to taper off over a period of 5-10 days

Back 104

corticosteriod

Front 105

right size bp cuff is ?% of the circumference or ?% wider than the diameter, of the midpoint of the limb that you used to measure the BP

Back 105

40
20

Front 106

If you use a cuff that is too big or too small you might end up getting a ? reading

Back 106

false

Front 107

this position allows the nurse to assess the head, neck, back, posterior thorax and lungs, anterior thorax and lungs, breasts, axillae, heart, vital signs, and upper extremities

Back 107

SITTING

Front 108

this position allows the nurse to assess head, neck, anterior thorax and lungs, breasts, axillae, heart, abdomen, extremities, pulses

Back 108

supine

Front 109

this position allows nurse to assess head, neck, anterior thorax and lungs, breasts, axillae, heart, abdomen

Back 109

dorsal recumbent

Front 110

this position allows nurse to assess female genitalia and genital tract

Back 110

lithotomy

Front 111

this position allows nurse to assess rectum and vagina

Back 111

sims

Front 112

this position allows nurse to assess musculoskeletal system

Back 112

prone

Front 113

this position allows nurse to assess heart

Back 113

lateral recumbent

Front 114

this position allows nurse to assess rectum

Back 114

knee-chest

Front 115

flat, no palpable change in skin color, smaller than 1 cm

Back 115

macule

Front 116

palpable, circumscribed, solid elevation in skin, smaller than 1 cm

Back 116

papule

Front 117

elevated solid mass, deeper and firmer than papule, 1-2 cm

Back 117

nodule

Front 118

solid mass that extedns deep through SQ tissue, larger than 1-2 cm

Back 118

tumor

Front 119

irregularly shaped, elevated area or superficial localized edema, varies in size

Back 119

wheal

Front 120

circumscribed elevation of skin filled with serious fluid, smaller than 1 cm

Back 120

vesicle

Front 121

circumscribed elevation of skin similar to vesicle but filled with pus, varies in size

Back 121

pustule

Front 122

deep loss of skin surface that sometimes extended to dermis and frequently bleeds and scars, varies in size

Back 122

ulcer

Front 123

thinning of skin with loss of normal skin furrow with skin appearing shiny and translucent varies in size

Back 123

atrophy

Front 124

when a physician or nurse is examining a pts eyes he is checking for?

Back 124

PERRLA

Front 125

what does PERRLA stand for

Back 125

pupils equal, round, reactive to light and accommodation

Front 126

nails are what type of tissue

Back 126

epithelial tissue

Front 127

a ? nail is transparent, smooth, and convex, with a pink nail bed and translucent white tip

Back 127

healthy

Front 128

what causes changes in the shape, thickness, and curvature of the nail

Back 128

diseasE

Front 129

never soak or apply lotions or cream in between the toes of ? feet or hands becuase of the risk of infection due to the extra moisture

Back 129

diabetics

Front 130

coarse rales, loud, low-pitched, bubbling and gurgling sounds heard in early inspirations and may be present in expiration

Back 130

crackles

Front 131

high-pitched, musical squeaking sounds, predominant in expiration

Back 131

wheezes-1

Front 132

low-pitched, monophonic single note, musical snoring, moaning sounds

Back 132

wheezes-2

Front 133

high-pitched, monophonic, aspiratory, crowing sound, louder in the neck than over the chest

Back 133

stridor

Front 134

a very superficial sound that is coarse and low pitched; two pieces or leather rubbed together; sounds just like crackles, but close to ear

Back 134

pleural friction rub

Front 135

accumulation of an excessive amount of vatery fluid in cells, tissues or serous cavities,

Back 135

edema

Front 136

measured +1, +2, +3, +4 around feet and ankles could be a sign of venous insufficiency or right sided heart failure

Back 136

edema

Front 137

meds that reduce fevers such as acetaminophen, salicylates, ibuprofen, indomethacin, ketorolac

Back 137

antipyretic meds

Front 138

change position every two hours to increase blood circulation, dress affected side first, when undressing undress affected extremity last, be aware of pain, heat, or cold, also risk for skin impairarity

Back 138

caring for a paralyzed pt

Front 139

freckles, skin tags, senile keratosis, cherry angiomas, atrophic warts are ? skin lesions

Back 139

normal

Front 140

? which occurs as initial spontaneous manifestations of a pathoilogical process

Back 140

primary

Front 141

? results from later fromation of trauma to a primary lesion (like a pressure ulcer)

Back 141

secondary skin lesion

Front 142

? self-exam, look for swelling or lumps in the skin of the scrotum while looking in te mirror

Back 142

testicular

Front 143

when giving a ? ?-? use both hands, placing the index and middle fingers under the testicles and the thumb on top

Back 143

testicular self-exam

Front 144

gently roll the testicle, feeling for lumps, thickening, or a chnage in consistency, find the epididymis, feel for small, pea-size lumps on the front and side of the testicle is all things you look for when performing a

Back 144

testicular self-exam

Front 145

biceps, triceps, brachioradialis, patellar, achiles, plantar/babinski, and clonus

Back 145

reflex areas

Front 146

reflex responses- very brisk, hyperactive with clonus, indicative of disease

Back 146

4+

Front 147

reflex response- brisker than average, may indicate disease

Back 147

3+

Front 148

reflex response- average, normal

Back 148

2+

Front 149

reflex responses- diminished, low normal

Back 149

1+

Front 150

reflex responses- no response

Back 150

0

Front 151

what temp should the basin of water be when giving a bed bath

Back 151

110-115 F

Front 152

during a complete bed bath the bed rail should be raised T or F

Back 152

T

Front 153

a complete bed bath is given to a pt who is ? and is unable to bathe himself

Back 153

bedridden