Nursing 110 Test Two

Front 1

Where are the five levels of hierachy by Maslow?

Back 1

PHYSIOLOGICAL - (physical)
SAFETY AND SECURITY
LOVE AND BELONGING
SELF ESTEEM

Front 2

Wellness

Back 2

Dynamic state of health in which one progresses toward a higher level of functioning, optimum balance

Front 3

Illness

Back 3

Abnormal process in which a
any aspect of ones functioning is diminished or impaired as compared with ones previous condition

Front 4

Health Promotion

Back 4

Act positively in regards to health, encompasses the community, lifestyle and behavioral changes.

Front 5

Acute Illness

Back 5

short term, severe (<3 months)

Front 6

Chronic Illness

Back 6

limitations in functions, relapses (>3 months)

Front 7

Maslows Heirarchy of Human Needs:

Back 7

There are five of them

Front 8

Self-Actualization

Back 8

achieving life’s full potential, fulfillment

Front 9

Self Esteem

Back 9

feeling good about oneself, appreciated, recognized

Front 10

Love and Belonging

Back 10

love, acceptance, comfort from others

Front 11

Safety and Security

Back 11

getting rid of threats to the body or life

Front 12

Physiologic

Back 12

HIGHEST PRIORITY, essential for survival, OXYGEN, FLUIDS, FOOD, TEMPERATURE, ELIMINATION, SHELTER, REST

Front 13

Older Adult (65+)

Back 13

Erikson’s stage: Ego Integrity vs Despair

Front 14

Psychosocial

Back 14

Moral/Spiritual, Cognitive, Health Promotion

Front 15

Older Adult (65+)

Back 15

-Diminished taste
-hearing/visual changes
-decreased lung expansion, loss of lung elasticity
-high risk for irregular heart rhythms
-diminised baroreceptor response (rise slowly)
-decreased motility –adequate fiber/fluids
-delayed emptying, diminished gag reflex
-frequency/urgency urinating
-bone issues,ROM, joint mobility, muscle mass and strenth
-shorter sleeping periods, slower reaction times
-potential memory and cognitive functioning

Front 16

Family

Back 16

A network of individuals who influence each other and/or
A set of relationships that the patient identifies as a family

Front 17

Nuclear Family

Back 17

mother, father, children

Front 18

Extended Family

Back 18

grandparents, aunts, and uncles

Front 19

Single – Parent

Back 19

Child care main issue

Front 20

Blended

Back 20

Kids from previous marriages

Front 21

Alternate Patterns

Back 21

Gay families, living with aunt/grandparent

Front 22

Nursing Diagnosis

Back 22

Altered family process, fear, ineffective family coping

Front 23

Nursing Goal

Back 23

Help the individual and family attain and maintain their maximum level of health

Front 24

Sensory-Motor Altered Innervation

Back 24

Can’t feel bladder fullness

Front 25

Enuresis

Back 25

Wets the bed

Front 26

Turbidity

Back 26

Cloudy Urine

Front 27

Specific Gravity

Back 27

1.01 – 1.03 normal (degree of concentration of a substance)

Front 28

Flank Pain

Back 28

kidney infection, stones

Front 29

Laxative

Back 29

agent used to evacuate stool

Front 30

Melena

Back 30

bloody/tarry stool

Front 31

Peristalsis

Back 31

rhythmic contraction of the GI tract

Front 32

Steatorrhea

Back 32

frothy fowl smelling stool

Front 33

Cathartic

Back 33

laxative to evacuate bowel

Front 34

Constipation

Back 34

hard stool

Front 35

Defecation

Back 35

expulsion of feces

Front 36

Diarrhea

Back 36

liquid feces

Front 37

Fecal Impaction

Back 37

Seepage of fluid

Front 38

Flatus

Back 38

Gas

Front 39

Hemorroids

Back 39

inflamed distended veins (internal or external)

Front 40

Dysuria

Back 40

difficult or painful urination

Front 41

Hematuria

Back 41

bloody urine

Front 42

Nocturia

Back 42

Night Urine (frequently)

Front 43

Oliguria

Back 43

not a lot of urine

Front 44

Polyuria

Back 44

excessive urination

Front 45

Frequency

Back 45

How often - small amounts often

Front 46

Urgency

Back 46

sensation, a sudden uncontrollable urge

Front 47

What is the normal urinary output?

Back 47

should be 30mL/hr or 1mL/Kg/hr
Divide weight by 2.2 to find out Kg/hr
Nursing Diagnoses – bowel incontinence, constipation, diarrhea SPECIFY
Nursing Diagnoses: Urinary retention (r/t surgery)
Goal: Pt. will have 30 mL/ hr of output
Intention: Encourage toileting, assess the bladder

Front 48

Nutrition?

Back 48

Digestion, Absorption, Metabolism, Elimination

Front 49

*Intake of fats should be?

Back 49

<30% of total calories

Front 50

Sugar

Back 50

4kg/gm (empty calories, tooth decay

Front 51

Non saturated fats?

Back 51

*Non-saturated fats are solidified overnight, fats remain liquid

Front 52

Salt

Back 52

daily should not exceed 6gms (1 teaspoon), can increase BP

Front 53

Older adults - nutrition

Back 53

Older adults have a decreased glucose tolerance, gastric secretions, and caloric needs… NEEDS PROTEIN

Front 54

Signs of poor nutrition

Back 54

ht/wt, skin dry, rashes, hair, nails, LAB DATA

Front 55

CBC

Back 55

detect anemia

Front 56

Albumin

Back 56

protein (3.5-5) *Less than 2 = malnourished

Front 57

Transferrin

Back 57

protein carries iron from intestines (TIBC)

Front 58

Triglycerides

Back 58

fats (cholesterol level)

Front 59

Glucose

Back 59

70-100

Front 60

Nitrogen

Back 60

24 hour urnine specimen

Front 61

creatinine

Back 61

Detects renal failure

Front 62

Nusing Diagnosis

Back 62

altered nutrition r/t more/less than body requirements, feeding self care deficit r/t decreased strength and fatigue

Front 63

Goal

Back 63

Maintain or restore optimum nutritional status, decrease or regain weight

Front 64

Interventions

Back 64

Interventions: I&O q shift, monitor CBC, encourage diet intake

Front 65

Soft Diet

Back 65

mashed potatoes, applesauce

Front 66

Puree Diet

Back 66

Pureed food

Front 67

Clear Liquid Diet

Back 67

only clear – tea, water, coffee without milk

Front 68

Full Liquid Diet

Back 68

milk, juices, non-transparent liquids ok

Front 69

Vitamin B1
(thiamin)

Back 69

Helps body digest carbohydrates - needed for normal functioning of nervous system

Front 70

Found in:

Back 70

Enriched or whole grain cereals, pastas, peas, nuts, beans, meats

Front 71

Vitamin B2
(riboflavin)

Back 71

Helps the body to release energy to cells: promotes healthy skin

Front 72

Found in:

Back 72

Liver, milk, yogurt, cottage cheese, eggs and leafy vegetables.

Front 73

Vitamin B3
(niancin)

Back 73

Promotes healthy skin, nerves, and digestion - helps the body use carbohydrates

Front 74

Found in:

Back 74

Liver, peanuts, chicken, salmon and tuna

Front 75

Vitamin B6
(pyridoxine)

Back 75

Helps form red blood cells; helps body use protein, fat, and carbohydrate

Front 76

Found in:

Back 76

Liver, meat, poultry, peanuts

Front 77

Vitamin B12
(cobalamin)

Back 77

Maintains nervous system, needed to form red blood cells

Front 78

Found in

Back 78

Liver, meat, eggs, shellfish

Front 79

Vitamin C

Back 79

Speeds healing of wounds and bones, increases resistance to infection; needed to form collagen

Front 80

found in

Back 80

Citrus fruits, melons, stawberries, green pepper, broccoli, brussels sprouts, turnip greens

Front 81

Zinc

Back 81

Needed to produce some enzymes and insulin

Front 82

Found in

Back 82

Red meat, shellfish (oysters), eggs

Front 83

Macule

Back 83

Flat, nonpalpable change in skin color smaller than 1 cm (freckle, petechia) AIDS - HIV

Front 84

Papule

Back 84

palpable, circumscribed, solid elevation in skin, smaller than 0.5 cm (birthmark)

Front 85

Nodule

Back 85

Elevated solid mass, deeper and firmer than papule 0.2 to 0.5 cm (wart)

Front 86

Tumor

Back 86

solid mass that may extend deep through the subcutaneous tissue, larger than 1 to 2 cm

Front 87

Wheal

Back 87

irregular shaped, elevated area or superficial localized edema (hive, mosquito bite)

Front 88

Vesicle

Back 88

circumsized elevation of skin filled with serous fluid (herpes, chickenpox)

Front 89

Pustule

Back 89

elevation of skin vesicle but filled with pus ( acne)

Front 90

Ulcer

Back 90

deep loss of skin surface that may extend to dermis and frequently bleeds and scars (ulcer)

Front 91

Atrophy

Back 91

thinning of skin with loss of normal skin furrow with skin appearing shiny and translucent - PPD tightness of skin.

Front 92

Oxygenation

Back 92

Effects: Physiological, Developmental, Behavioral, and Environmental factors

Front 93

Transport of gases

Back 93

ventilation, perfusion, diffusion, oxygen carrying capacity

Front 94

Regulate Respirations

Back 94

CNS control of rate, rhythm, and depth

Front 95

History for Respirations

Back 95

cough and color of sputum, fatigue, risk factors

Front 96

Inspection (Respiration)

Back 96

skin color, general appearance, LOC

Front 97

Palpation

Back 97

chest excursion, tenderness, abnormal masses

Front 98

Percussion

Back 98

normal not is resonant *** check this one doesnt sound right***

Front 99

Auscultation

Back 99

instruct pt to breathe through the mouth more deeply than usual

Front 100

Hypoxia

Back 100

low oxygen, inadequate cellular oxygen

Front 101

Hypoexmia

Back 101

low blood oxygen

Front 102

Cyanosis

Back 102

discoloration (blue) mucous membranes

Front 103

Orthopnea

Back 103

difficulty breathing, laying down flat

Front 104

Dyspnea

Back 104

difficulty breathing

Front 105

ABG

Back 105

arterial blood gases

Front 106

Pain

Back 106

Pain is whatever a person says it is “subjective”

Front 107

(Pain and Comfort)
Thermal

Back 107

heat

Front 108

(Pain and Comfort)
Mechanical

Back 108

muscle spasms

Front 109

Pain and Comfort)
Chemical

Back 109

imbalance

Front 110

(Pain and Comfort)
Somatic

Back 110

cutaneous and deep tissue well defined and localized

Front 111

(Pain and Comfort)
Visceral

Back 111

body organs diffuse, referred

Front 112

Psychosocial Assessment
Affect

Back 112

external expression of emotion (how the person looks or acts) appropriate/inappropriate/flat/blunted/at east with self

Front 113

Psychosocial Assessment
Orientation

Back 113

to person, place, time and event

Front 114

Psychosocial Assessment
Self-Concept

Back 114

how you see everything compared to yourself (+ or -)

Front 115

Psychosocial Assessment
Body Image

Back 115

any change in appearance can cause stress

Front 116

Psychosocial Assessment
Self-Esteem

Back 116

illness, surgery, injury that can interrupt or change life patterns

Front 117

Sexual Health

Back 117

Integration of the somatic, emotional, intellectual, and social aspects of sexual being, in ways that are positively enriching and that enhance personality, communication, and love

Front 118

Sexual Health
Childhood

Back 118

private vs public behavior

Front 119

Sexual Health
Adolescence

Back 119

puberty, sexual activity, identity

Front 120

Sexual Health
Young and Middle Adults

Back 120

sexual activity becomes a basic need, desire can be channeled into other forms of intimacy

Front 121

Sexual Health
Older Adults

Back 121

satisfaction with aging can be understood through an active sex life, illness may require change

Front 122

Physical Assessment

Back 122

Environment – provide privacy, lighting, comfort’ be professional and use appropriate language, encourage relaxation

Front 123

Physical Assessment
Inspection

Back 123

size, color, shape, symmetry, position

Front 124

Physical Assessment
Palpation

Back 124

texture, temperature, consistency, tenderness, moisture

Front 125

Physical Assessment
Percussion

Back 125

location, suze, density (tap one finger against the other)
Bone/Muscle = flat
Cardiac = dull
Stomach = drum
Lung = resonance (air filled)
Liver = dull

Front 126

Physical Assessment
Auscultation

Back 126

frequency, loudness, quality, duration

Front 127

Physical Assessment
Olfaction

Back 127

smell for alcohol, halitosis, body odor, foul/infection

Front 128

Physical Assessment
Respitory

Back 128

pattern, color, ease of respirations, breath sounds (crackles, rhonchi

Front 129

Physical Assessment
Musculoskeletal

Back 129

– size, symmetry, muscle tone, ROM, gait, coordination

Front 130

Physical Assessment
Musculoskeletal

Back 130

size, symmetry, muscle tone, ROM, gait, coordination

Front 131

Physical Assessment
Cardiovascular

Back 131

– heart, peripheral circulation, apical pulse

Front 132

Physical Assessment
Renal

Back 132

amount, color, clarity, continence/incontinence, distention, flank pain

Front 133

Physical Assessment
Neurological

Back 133

mental status, LOC, mood, orientation

Front 134

Physical Assessment
Integumentary –

Back 134

color, lesions, scars, bruises, edema, turgor, hair, nails

Front 135

Physical Assessment
Positioning
Sims
Knee chest
Lithotomy

Back 135

depending on type of procedure/comfort level of patient

Lithotomy – position for pap smear
Sims – L lateral position for enema
Knee-Chest – different enema position

Front 136

Physical Assessment
Supine

Back 136

– flat

Front 137

Physical Assessment
Prone

Back 137

on stomach

Front 138

Physical Assessment
Recumbent

Back 138

– legs bent but laying down