Block #1 / Exam #2

Front 1

What is the purpose of OSHA?

Back 1

-designed to protect the employee from exposure

Front 2

What is the purpose of the CDC?

Back 2

-protect the patients and employees from infection transmission

Front 3

What is an infection?

Back 3

-entry and multiplication of infectious agent or pathogen in host tissue
-causes cell injury

Front 4

Colonization:

Back 4

-pathogen is present, but does not cause cell injury

Front 5

Symptomatic Infection:

Back 5

-pathogens multiply and cause clinical s/sx

Front 6

What is the chain of infection?

Back 6

-infections agent
-reservoir
-portal of exit
-mode of transmission
-portal of entry
-host

Front 7

Incubation Period:

Back 7

-the time entrance of the pathogen and the appearance of the first symptoms

Front 8

Prodromal Stage:

Back 8

-from general to specific symptoms

Front 9

Illness Stage:

Back 9

-symptoms of the specific disease

Front 10

Convalescence:

Back 10

-acute symptoms are gone and the recovery phase begins

Front 11

Means of infection transmission?

Back 11

-Contact
-Droplets
-Airborne
-Common Vehicle
-vector

Front 12

Contact:

Back 12

-direct or indirect

Front 13

Droplets:

Back 13

-sneezing or suctioning

Front 14

Airborne:

Back 14

-dust
-droplets remain suspended in the air

Front 15

Common Vehicle

Back 15

-equipment
-food
-water

Front 16

Vector:

Back 16

-mosquito
-rat

Front 17

Iatrogenic:

Back 17

-result from procedure
-example: catheter or IV

Front 18

Endogenous:

Back 18

-normal flora become altered & overgrowth occurs
-example: yeast infection from taking meds

Front 19

Exogenous:

Back 19

-organism present outside of clients normal flora

Front 20

Risk factors that make a pt more susceptible to infection:

Back 20

-malnutrition
-immuno suppression drugs
-chronic disease
-deficient knowledge regarding infection control
-invasive procedure
-impaired primary/secondary defense mechanisms

Front 21

Measurable criteria pt does not have an infection?

Back 21

-vital signs stay with normal range
-pt remains afrebile (w/out fever)
-wound decreasing in size
-lungs clear, sputum white or clear
-urine clear, no pain or burning w/voiding

Front 22

Asepsis:

Back 22

-is the absence of pathogenic (disease producing) microorganisms

Front 23

Aseptic technique:

Back 23

-procedures that assist in reducing the risk for infection or infection transmission

Front 24

Sterility:

Back 24

-maintain sterility of anything that’s going to enter client’s body (except thru GI tract)

Front 25

Which blood borne pathogens can be found in blood or body fluid?

Back 25

-HIV
-AIDS
-Hep C

Front 26

Cohort:

Back 26

-Someone with the same infection

Front 27

Reduce reservoirs of infection by:

Back 27

-bathing
-change of dressings
-moisture resistant bags
-needles or sharps features and containers
-keep table surfaces dry and clean

Front 28

Excessive smoking:

Back 28

-increased risk of liver disease, MVA

Front 29

Smoking:

Back 29

-increased risk of CV, pulmonary disease

Front 30

Excessive stress:

Back 30

-increased risk of accident, illness

Front 31

Sexual practices:

Back 31

-risk of HIV
-Hepatitis
-STD’s
-undesired pregnancy

Front 32

MSDS:

Back 32

-material safety data sheet

Front 33

Musculoskeletal changes:

Back 33

-impair mobility

Front 34

Nervous system changes:

Back 34

-slows reflexes
-reaction time

Front 35

Sensory changes:

Back 35

-decreased vision
-touch

Front 36

Genitourinary changes:

Back 36

-nocturia
-incontinence

Front 37

Environmental Risks:

Back 37

-equipment or furniture inhibits ambulation
-call light, personal supplies out of reach
-equipment malfunction
-chemicals spills

Front 38

Home Hazards:

Back 38

-throw rugs
-electrical equipment
-obstructed pathways
-lighting
-need for safety equipment in bathroom
-smoke detectors

Front 39

What factors increase the risk of patient falls?

Back 39

-hx of falls
-meds se
-need to use the restroom
-slow call light response
-disoriented or confused
-use assistive device
-age >65 forget how to walk
-chronic diseases leading to weakness and dizziness
-unsteady gait, hemi paresis
-osteoporosis
-uncooperative pt gets up without asking for help

Front 40

How can you reduce the risk of patient falls?

Back 40

-bed alarms
-toilet schedule every 2 hours
-beside commode and urinal within reach
-call light, beside table within reach
-non-skid reach
-educate on use of call light, special call light
-sitter
-vail bed or posey

Front 41

How often should you assess a pt in restraints?

Back 41

-every 15 mins

Front 42

Status epilepticus:

Back 42

-Seizures lasting >15 min. or repeated seizures in a 30 min. period

Front 43

What do you do when you have a status epilepticus?

Back 43

-insert airway when jaw is relaxed
-have O2, suction, and IV equipment available
-administer meds as directed by MD

Front 44

How can you reduce the risk of aspiration if a pt vomits?

Back 44

-turn them on their side

Front 45

Risk management:

Back 45

-root cause analysis to determine underlying causes

Front 46

Sentinel Events:

Back 46

-are occurrences that cause or have the potential to cause serious harm or death in a patient

Front 47

When can restraints be used?

Back 47

-ONLY as a last resort to immobilize pt or an extremity

Front 48

How long can restraints be used for?

Back 48

-remove every 2 hours to assess
-reassess every 24 hours

Front 49

How are Hepatitis A, B, C, and HIV transmitted?

Back 49

-blood

Front 50

Personal Protective Equipment:

Back 50

-exam gloves
-mask
-goggles
-face shields
-shoe covering
-leg coverings

Front 51

Health hx survey should be done before the physical exam. Why?

Back 51

-helps you focus on what you should be looking at during the physical.

Front 52

Who should you get health hx info from?

Back 52

-patient

Front 53

Cues:

Back 53

-information obtained through use of senses

Front 54

Inference:

Back 54

-are judgments or interpretations of cues

Front 55

How often is an assessment done?

Back 55

-initial assessment
-every shift
-hourly, weekly, monthly
-ongoing
-before and after a procedure or meds
-if pt has a health complaint

Front 56

How do you prepare a client for an assessment?

Back 56

-explain purpose
-establish a report

Front 57

Orientation/introductory phase:

Back 57

-explain purpose of interview
-ask non-threatening biographical information
-establishing nurse-client relationship

Front 58

Working Phase:

Back 58

-data regarding chief complaint and health hx collected for care plan development

Front 59

Termination phase:

Back 59

-give clue that interview is coming to an end
-summarize
-offer client opportunity to ask questions

Front 60

Subjective:

Back 60

-what pt/family tells you
-pt health hx

Front 61

Objective:

Back 61

-findings with physical assessment
-diagnostic test results

Front 62

What are the 4 assessment types?

Back 62

-complete
-episodic
-follow up
-urgent car/ER

Front 63

Complete:

Back 63

-admitted to the hospital

Front 64

Episodic:

Back 64

-doctors office

Front 65

Follow up:

Back 65

-after surgery

Front 66

Urgent care/ER:

Back 66

-ABC
-pain

Front 67

Complete Nursing Health History:

Back 67

-biographical info
-present illness or health concerns
-family history
-psychosocial history
-nutritional status
-client expectations
-past health history
-environmental history
-spiritual health
-functional status
-medication profile

Front 68

Biographical data:

Back 68

-age
-address
-occupation
-marital status
-health care insurance

Front 69

Client expectations:

Back 69

-find out what clients expect to happen to them while seeking treatments for their health

Front 70

Present illness or health concerns:

Back 70

-determine when the problem began
-how severe
-intensity
-quality
-what makes them worse
-what makes them better

Front 71

Family history:

Back 71

-blood relative health issues
-recent losses
-religious influences
-relationships

Front 72

Spiritual health:

Back 72

-religion
-religious habits

Front 73

Health history:

Back 73

-provides you with info regarding the clients past hx.

Front 74

Environmental hx:

Back 74

-home environment
-workplace environment
-exposure to pollutants

Front 75

Psychosocial hx:

Back 75

-support system
-spouse
-children
-friends
-family members
-coping mechanisms

Front 76

Review of systems:

Back 76

-a method for collecting data on body system

Front 77

Past Health history:

Back 77

-medical hx
-surgical hx
-medication (herbal and OTC)
-allergies
-injuries/accidents
-disabilities
-blood transfusions
-childhood illnesses
-immunizations

Front 78

Activates of Daily Living:

Back 78

-Physical self care

Front 79

Instrumental Activates of Daily living

Back 79

-things in which enable a person to function independently at home

Front 80

ABCT:

Back 80

-appearance
-behavior
-cognition
-thought processes

Front 81

Inspection:

Back 81

-looking at the client
-any data collect through smell is also considered to be a part of inspection

Front 82

Palpation:

Back 82

-use of hands to determine texture, size, shape consistency and location of certain body parts
-identify areas identified by pt as tender or painful

Front 83

Auscultation:

Back 83

-listen to the sounds of the body during a physical exam

Front 84

Different types of palpation:

Back 84

-pads of fingers (pulse)
-dorsum of hand (temp)
-bony part of palm at base of fingers (vibrations)

Front 85

Light Palpation:

Back 85

-1cm in depth
-gentle pressure to detect tenderness or pain

Front 86

Deep Palpation:

Back 86

-4cm in depth
-harder pressure is used to assess underlying organs

Front 87

Diaphragm of stethoscope:

Back 87

-to hear high pitch sounds

Front 88

Bell of Stethoscope:

Back 88

-to hear soft and low pitched sounds

Front 89

PERRLA:

Back 89

-pupils equal
-round
-reactive to light
-accommodation

Front 90

JVD:

Back 90

-jugular vein distension

Front 91

Clubbing:

Back 91

-in the fingers
-sx of chronic pulmonary disease

Front 92

Normal chest:

Back 92

-elliptical shape, ribs slope down
-1:2 ratio

Front 93

Barrel chest:

Back 93

-width & depth equal, ribs horizontal,
-normal with aging and infants
-1:1 ratio

Front 94

Symptoms of Hypoxia:

Back 94

-restlessness
-anxiety
-acute disease
-mental status change
-progresses to lethargy
-drowsiness

Front 95

Eupnea:

Back 95

-abnormal quiet respiration

Front 96

Bradypnea:

Back 96

-abnormally slow respiration

Front 97

Tachypnea-

Back 97

-rapid, shallow respirations

Front 98

Hyperventilation:

Back 98

-rapid, deep respirations
-caused by exertion, fear, anxiety, compensation for acidosis

Front 99

Apnea:

Back 99

-complete or intermittent cessation of breathing

Front 100

Cyanosis:

Back 100

-bluish discoloration of nail beds, oral mucosa, conjunctiva

Front 101

Angle of Louis:

Back 101

-boney ridge forming articulation of manubrium and body of sternum, Continues with 2nd rib.

Front 102

3 lobes:

Back 102

-right lung

Front 103

2 lobes:

Back 103

-left lung

Front 104

Vesicular:

Back 104

-rustling like wind in trees
-sound of air in bronchioles & alveoli
-primarily during inspiration

Front 105

Bronchial:

Back 105

-harsh, hollow sound
-normally heard over trachea & larynx
-abnormal if heard over lungs fields, associated with consolidation (pneumonia)

Front 106

Bronchovesicular:

Back 106

-upper sternum & between upper scapulae
-normal over large bronchi
-equal on inspiration & expiration
-moderate pitch, mix of bronchial & vesicular sounds
-abnormal over lungs fields, associated with consolidation

Front 107

Crackles:

Back 107

-formerly rales
-alveoli popping open
-like hair rubbing together
-fine, pitched crackling and popping noise
-not cleared by coughing
-early inspiratory crackles in COPD
-late inspiratory in restrictive disease (CHF, pneumonia)

Front 108

Wheezes:

Back 108

-due to narrow airways
-high pitched musical sound similar to squeak
-occurs in small airways

Front 109

Gurgles/Rhonchi:

Back 109

-low pitched, coarse, loud
-heard primarily during expirations
-coughing may clear

Front 110

Atelectasis:

Back 110

-collapsed shrunken section of alveoli due to airway obstruction by think exudates, foreign body, tumor

Front 111

Lobar Pneumonia:

Back 111

-infection in lung, alveoli fill with bacteria, debris, and fluid

Front 112

Bronchitis:

Back 112

-proliferation of mucous glands causing excessive mucous secretion & inflammation
-Harsh cough

Front 113

Emphysema:

Back 113

-destruction of pulmonary connective tissue & permanent enlargement of air sacs, trapped air

Front 114

Asthma:

Back 114

-reactive airway

Front 115

Pleural effusion:

Back 115

-collection of excess fluid in Intrapleural space (water, puss, blood)

Front 116

CHF:

Back 116

-Crackles at bases, sx fluid overload

Front 117

Aortic Area: (a pig eats ten melons)

Back 117

-2nd ICS, RTB

Front 118

Pulmonic Area: (a pig eats ten melons)

Back 118

-2nd ICS, LSB

Front 119

Erb’s point or second pulmonary: (a pig eats ten melons)

Back 119

-3rd ICS, LSB

Front 120

Tricuspid: (a pig eats ten melons)

Back 120

-5th ICS, LSB

Front 121

Mitral/ Apical Area: (a pig eats ten melons)

Back 121

-5th ICS, left midclavicular line or slightly medial

Front 122

S1:

Back 122

-lub
-first heart sound
-beginning of systole
-produced by closure in mitral & tricuspid valve
-heard best in mitral or apex are
-coincides with carotid artery

Front 123

S2:

Back 123

-dub
-second heart sound
-end of systole
-produced by closure of aortic and pulmonic valves
-heard best at base of heart (2nd ICS bilaterally)
-may be split-normal

Front 124

S3:

Back 124

-ventricular gallop
-apex or lower LSB
-early sign of heart failure

Front 125

S4:

Back 125

-atrial gallop
-heard at apex
-may occur normally after exercise
-may indicate CAD, cardiomyopathy, aortic stenosis, systemic hypertension

Front 126

Murmur:

Back 126

-blowing, swooshing sound that occurs with turbulent blood flow in heart or great vessels

Front 127

Heave:

Back 127

-also known as lift
-sustained forceful thrusting of ventricle during systole

Front 128

S/SX CHF, fluid overload:

Back 128

-dyspnea on exertion, orthopnea, fatigue
-crackles in lungs
-dependent pitting edema
-increased BP, bounding pulse initially
-Jugular vein distension
-skin pale, gray, or cyanotic/ cool & moist
-dilated pupils – sympathetic nervous system
-N & V
-ascites

Front 129

Order of assessing the abdominal:

Back 129

-I ate pecan pie
-inspection
-auscultation
-percussion
-palpation

Front 130

What area of the stomach do you start?

Back 130

-RLQ

Front 131

What do normal bowel sounds sound like?

Back 131

-high-pitched irregular gurgling 5-30x/min
-present in all 4 quadrants

Front 132

Abnormal bowel sounds:

Back 132

-hyperactive-loud, high-pitched, rushing, tinkling sound

Front 133

Hypoactive sounds:

Back 133

-after abdominal surgery
-peritonitis
-paralytic ileus
-late bowel obstruction
-med side effect

Front 134

Visceral Pain:

Back 134

-dull pain
-poorly localized

Front 135

Parietal Pain:

Back 135

-sharp
-localized
-increased with movement
-inflammation of peritoneum

Front 136

Somatic Pain:

Back 136

-bone and muscle tendons

Front 137

Referred Pain:

Back 137

-disorder in another site

Front 138

Blumberg’s Sign:

Back 138

-rebound tenderness
-use if pt c/o pain or tenderness
-deep palpation in area away from the tender spot
-let go quickly - + if pain occurs on release of pressure
-contralateral tenderness

Front 139

Murphy’s Sign:

Back 139

-palpate liver border
-have pt take deep breath
-feels sharp pain
-stop inspiration

Front 140

What are the 6 steps of the nursing process?

Back 140

-assessment
-diagnosis ADPIE
-planning
-implementation
-evaluation

Front 141

Anaphylaxis

Back 141

is a serious, potentially life-threatening allergic response that is marked by swelling, hives, lowered blood pressure, and dilated blood vessels. In severe cases, a person will go into shock. If anaphylactic shock isn't treated immediately, it can be fatal.

Front 142

Which pts are at a higher risk for anaphylaxis?

Back 142

People with a history of allergic reactions may be at greater risk for developing a severe reaction in the future.

Front 143

Adduction:

Back 143

is movement toward the body.

Front 144

Abduction:

Back 144

is movement away from the body.

Front 145

Resonance:

Back 145

is the low, hollow sound of normal lungs.

Front 146

Hyperresonance:

Back 146

can be heard over emphysematous lungs as a booming sound.

Front 147

Tympany:

Back 147

is the high-pitched, drumlike sound heard over a gastric air bubble.

Front 148

Dullness:

Back 148

is the soft, thudlike sound that is heard over dense organ tissue.

Front 149

A common abnormality encountered during inspection of the skin is pallor. Pallor is easily seen in the face, mucosa of the mouth, and nail beds. How would pallor appear in a brown-skinned client?

Back 149

18. A common abnormality encountered during inspection of the skin is pallor. Pallor is easily seen in the face, mucosa of the mouth, and nail beds. How would pallor appear in a brown-skinned client?
A) As shiny skin
B) As bluish skin
C) As yellowish skin
D) As ashen gray skin

Feedback: CORRECT
Pallor would appear as yellowish brown in brown-skinned people. Pallor would manifest as bluish skin in light-skinned people. Pallor would appear as ashen gray skin in black-skinned people. Shiny skin indicates edema.

Front 150

Using an otoscope, the nurse can inspect the tympanic membrane. A normal tympanic membrane appears

Back 150

A normal tympanic membrane is translucent, shiny, and pearly gray. Dark yellow and sticky describes normal moist cerumen (earwax) in front of the tympanic membrane. A white color indicates pus behind the membrane. A pink or red bulging membrane is an indication of inflammation.

Front 151

Kyphosis is:

Back 151

(hunchback) is an exaggeration of the posterior curvature of the thoracic spine and is common in older adults.

Front 152

Lordosis:

Back 152

(swayback) is increased lumbar curvature.

Front 153

Scoliosis:

Back 153

is lateral spinal curvature.

Front 154

Hypotonic muscle

Back 154

has little tone and feels flabby, usually because of atrophy of muscle mass.