Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
61 Cards in this Set
- Front
- Back
|
What is the core temperature?
|
warmth in deeper sites within the body like the brain and heart
|
|
|
What is the body's shell temperature?
|
warmth at the skin surface
|
|
|
Which temperature the shell or core is more significant?
|
The core temperature is more significant because there is a much narrower range that it can fluctuate without negative outcomes.
|
|
|
What is the Core Body Temperature Range?
|
97.5˚ - 100.4˚ F
|
|
|
Where are the Assessment sites for temperature?
|
Ear- closest to core
Oral Rectal Axillary- best for infants |
|
|
What are some Signs and Symptoms of a high temperature or hyperthermia?
|
Pinkish, red (flushed) skin that is warm to the touch, Restlessness or excessive sleepiness, Irritability, Poor appetite, Glassy eyes & sensitivity to light, Increased perspiration, Headache, Above-normal pulse and respiratory rates, Disorientation and confusion (when the temperature is high)
Convulsions in infants and children (when the temperature is high) Fever blisters around the nose or lips in clients who harbor the herpes simplex virus |
|
|
How do you care for a client with fever < 102˚? 102˚-104˚? >104˚-105.8˚? >105.8˚?
|
<102˚ give 2500-3000 mL per day fluids and rest
102˚-104˚ give antipyretics 104˚-105.8˚ add phyisical cooling measures >105.8˚ or a temp that will not go down - more aggressive treatment is needed |
|
|
What phase of fever is it when the client has non specific symptoms before the temperature rises?
|
Prodromal Phase
|
|
|
What phase of fever is it when the client shows obvious mechanisms for increasing body temperature such as shivering develop?
|
Onset or Invasion Phase
|
|
|
What phase of fever is it when the client's fever is sustained?
|
Stationary Phase
|
|
|
What phase of fever is it when the client's temperature returns to normal?
|
Resolution or Defervescence Phase
|
|
|
What is the Normal Pulse Rate Range in an Adult?
|
60-100
|
|
|
What are some factors affecting Pulse Rates?
|
Age, circadian rhythm, Gender, Body Build, Exercise and Activity, Stress and Emotions, Body temp, Blood volume, Drugs
|
|
|
What is the normal BP?
|
< 120/80
|
|
|
What are the signs and symptoms of High BP?
|
anxiety, obesity, vascular disease, stroke, heart heart failure, kidney disease
|
|
|
What are the side effects of low BP?
|
shock, hemorrhage, or side effects from drugs
|
|
|
What is the normal Respiration Range?
|
14-20
|
|
|
What is it called when the peripheral pulse site and apical pulse site is significantly different, this means blood is not getting to extremity?
|
Pulse Deficit
|
|
|
What is a possible reason for a significant pulse deficit?
|
D/T the fact the heart is beating more than what is noted peripherally
Could be PAD (Periphal Artery Disease) - ex. in foot Dorsalis pedis or pedal pulse is < than apical site |
|
|
What is the time it takes blood to resume flowing in base of nail bed?
|
Capillary refill
|
|
|
What is the normal value for Capillary refill?
|
Normally < 3 sec. after compression and release
|
|
|
What is the name of the ear test where your comparing air vs bone conduction of sound and that uses a tuning fork?
|
Rinne test
|
|
|
What is the normal color and characteristics of the Oral mucosa?
|
They are pink, intact and kept moist by salivary glands
|
|
|
What is the volume of blood that fills heart and stretches heart muscles fibers during resting phase called?
|
Preload
|
|
|
What is the force against which heart pumps when ejecting blood called?
|
After Load
|
|
|
What is the pressure within arterial system when heart contracts called?
|
Systolic
|
|
|
What is the pressure within arterial system when heart relaxes and fills with blood called?
|
Diastolic
|
|
|
What is the difference between the systolic and diastolic blood pressure measurements called?
|
Pulse Pressure
|
|
|
What is the normal Pulse Pressure amount?
|
30 - 50 in considered normal or 40 is a healthy average
|
|
|
What is it called when a client has a sudden temporary drop in BP when rising from a reclining position?
|
orthostatic hypotension
|
|
|
What is another name for orthostatic hypotension?
|
Postural hypotension
|
|
|
When is orthostatic hypotension more common?
|
Most common in people with...
circulatory problems dehydrated on diurectics or other drugs that lower BP |
|
|
What happens when you take the BP of a client with a BP cuff thats too large or wide?
|
The BP reading will be falsely low
|
|
|
What happens when you take the BP of a client with a BP cuff thats too small or narrow?
|
The BP reading will be falsely high
|
|
|
What do you do if BP measures <100/60 or >180/110?
|
notify R.N.
|
|
|
The physical assessment technique that is done by doing a purposeful observation is?
|
Inspection
|
|
|
The physical assessment technique that is done by striking or tapping part of the client's body is?
|
Percussion
|
|
|
The physical assessment technique that is done by lightly touching or applying pressure to body is?
|
Palpation
|
|
|
The physical assessment technique that is done by listening to the body sounds is?
|
Auscultation
|
|
|
Why would you use the tool called the Snellen Eye Test?
|
tool for assessing far vision where a client read the smallest line he or she can at a distance of 20' and the nurse compares against norms
|
|
|
Why would you use the tool called the Jaeger Test?
|
a visual assessment tool with small print held out at 14” - tests near vision
|
|
|
What is your consensual response?
|
Brisk, equal, and simultaneous constriction of both pupils when one eye then the other is stimulated with light
|
|
|
What is Accommodation?
|
Ability to constrict when looking at a near object and dilate when looking at an object in the distance
|
|
|
What is the alteration in skin integrity that is a break in the skin or where it is no longer intact?
|
open wound
|
|
|
What is the alteration in skin integrity that is an open crater like area?
|
ulcer
|
|
|
What is the alteration in skin integrity where an area has been rubbed away by friction?
|
abrasion
|
|
|
What is the alteration in skin integrity thats a torn, jagged wound?
|
laceration
|
|
|
What is the alteration in skin integrity that is a crack in skin especially in or near mucous membrane?
|
fissure
|
|
|
What is the alteration in skin integrity where there's a mark left by healing of a wound or lesion?
|
scar
|
|
|
What spinal curvature is an exaggerated natural lumbar curve of the spine?
|
Lordosis
|
|
|
What spinal curvature is an increased thoracic curve?
|
Kyphosis
|
|
|
What spinal curvature is an pronounced lateral curvature of spine?
|
Scoliosis
|
|
|
What is the normal heart sound like?
|
S1, S2 or Lub Dub
|
|
|
What heart sound is louder at the Apex?
|
S1 or Lub louder at apex or mitral area
|
|
|
What heart sound is louder in the aortic area?
|
S2 or Dub Sound is louder over the aortic area
|
|
|
What is another name for abnormal lung sounds?
|
adventitious sounds
|
|
|
What lung sounds are intermittent, high pitched, popping, and heard in distant areas of the lungs, primarily during inspiration & sounds like rice crispy popping in milk?
|
Crackles or rales
|
|
|
What lung sounds are low-pitched continuous, bubbling, and heard in larger airways & some say it sounds like wet snoring?
|
Gurgles or rhonchi
|
|
|
What lung sounds are whistling or speaking sounds caused by air moving through a narrowed passage?
|
Wheezes
|
|
|
What lung sounds are grating, leathery sounds caused by two dry pleural surfaces moving over each other?
|
Rubs
|
|
|
How do they determine 20/20 or normal vision?
|
It is where most people can see from 20’ -or- 20/20 vision
Ex. If you can only see the top line at 20' & people with normal vision can see from 200’ then you have 20/200 vision |
