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31 Cards in this Set
- Front
- Back
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When documenting assessment data for a patient experiencing a loss of muscle power, it is acceptable to state, "Patient is experiencing muscle fatigue."
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false
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When taking a blood pressure on an average-sized patient, the nurse chooses a cuff that is 10 cm wide. The blood pressure reading can be expected to be __________.
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high
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A nurse documents periods of deep breathing followed by periods of apnea. The appropriate term for this type of breathing is
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Cheyne-Stokes
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To hear Korotkoff sounds best, the nurse should use the __________ part of the stethoscope.
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bell
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A patient with hypoglycemia, postictal state, or a subdural hematoma may have an odor of alcohol.
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true
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The nurse is having difficulty auscultating Korotkoff sounds. The nurse should (Select all that apply.)
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consider shock, be certain there is full skin contact with the bell, reposition the stethoscope
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general survey
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general appearance, apparent state of health, demeanor, facial affect or expression, grooming, posture, and gait
also height and weight at the end |
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contributing to general survey
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socioeconomic status, nutrition, genetic composition, degree of fitness, mood state, early illnesses, gender, geographic location, and age cohort
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weakness
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loss of muscle power
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blood pressure cuff
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width of bladder=40% of limb selected
length of bladder should be 80% of upper arm circumference |
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False high readings
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cuff too small
cuff too loose or uneven arm below heart level arm not supported inflating or deflating cuff too slowly(high diastolic) |
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False high readings
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cuff too small
cuff too loose or uneven arm below heart level arm not supported inflating or deflating cuff too slowly(high diastolic) |
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False low readings
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cuff too large
repeating assessments too quickly inaccurate level of inflation pressing stethoscope too tightly against pulse |
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False low readings
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cuff too large
repeating assessments too quickly inaccurate level of inflation pressing stethoscope too tightly against pulse |
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Classification
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normal: 120/80
prehtn: 120-139/80-89 htn 1: 140-159/90-99 htn 2: >160/>100 |
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Classification
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normal: 120/80
prehtn: 120-139/80-89 htn 1: 140-159/90-99 htn 2: >160/>100 |
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nociceptive or somatic pain
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related to tissue damage
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nociceptive or somatic pain
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related to tissue damage
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neuropathic pain
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from direct injury to the peripheral or central nervous system
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neuropathic pain
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from direct injury to the peripheral or central nervous system
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psychogenic pain
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psych conditions affecting pain views
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psychogenic pain
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psych conditions affecting pain views
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idiopathic pain
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pain without an identifiable etiology
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idiopathic pain
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pain without an identifiable etiology
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Health disparities
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lowers use of analgesics in ER for african american and hispanic
use of analgesics for cancer, postoperative, and low back pain |
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Health disparities
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lowers use of analgesics in ER for african american and hispanic
use of analgesics for cancer, postoperative, and low back pain |
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COLDSPAA
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Character
Onset Location Duration Severity Pattern Associated factors Affects |
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Fever
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malaise, headache, night sweats, pain in muscles and joints
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COLDSPAA
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Character
Onset Location Duration Severity Pattern Associated factors Affects |
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Fever
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malaise, headache, night sweats, pain in muscles and joints
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Temps
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Oral: 37 degrees C
Rectal are higher than oral by 0.4-0.5 degrees C Axillary are lower than oral by 1 degree(less accurate) |
