CA 2_FUNDA (PART 2)

Hair

color, inspect for hair loss

160° angle

Normal finding for nail bed (angle)

180°

an angle of the nail bed that indicates early clubbing which is a sign of a cardio or respiratory disorder

Schamroth window test

is a simple clinical method for detecting finger clubbing. It involves placing the fingertips of two corresponding fingers together and looking for a diamond-shaped space between the nail beds.

≤ 2 seconds

what is the normal value for CRT?

lateral abdomen

at what area of the body should you check the skin turgor of an infant?

clavicle or sternum

at what area of the body should you check the skin turgor of an adult?

non-pitting edema

indicates no indentation

pitting edema

indicates indentation

• There is high water and low solutes also known as “Hypoosmolar overhydration,” there should be increased in protein (like albumin, but if doesn’t use diuretics) since it helps the water back to intravascular

Yes, but check the pedal pulses

is it a normal finding if a pregnant woman has edema at her feet?

Tibia

where to check for pedal pulses when edema is present?

• 1 mm

• 2 to 4 mm

• 5 to 7 mm

• > 8mm

Give the following: Documenting Edema

• + 1 = ______

• + 2 = ______

• + 3 = ______

• + 4 = ______

CN 7 - Facial

what cranial nerve is affected when you asked the px to smile?

CN 7 - Facial

what cranial nerve is affected when you asked the px close or open the eyes?

CN 5 - Trigeminal

what cranial nerve is affected when you asked the px to blink?

15-20 blinks

normal number of blinks per minute?

To lubricate the eyes

purpose of blinking the eyes?

cotton wisp

what to use when assessing the px’s eyes to blink?

CN 1 - Olfactory

what cranial nerve involves smelling?

8 to 12 inches

when assessing CN 1 - Olfactory, instruct px to close eyes → inhale and exhale → distance of the substance should be ___ to ___ inches

sinuses

direct percussion to check for tenderness

conjunctival sac

When giving eye drops, you should aim for the _____, which is the lower part of the eye just inside the lower eyelid.

nasolacrimal duct

After instilling an eyedrop to the conjunctival sac, apply gentle pressure to the _______ _____ for 1–2 minutes to prevent the medicine from draining into the nose.

CN 3 - Oculomotor

what cranial nerve is affected when assessing the pupils?

3 to 7 mm

what is the normal size of a pupil?

outer to inner

at what direction should you point the penlight to assess for reactiveness of a pupil?

miosis

☀ In Bright Light:

• The pupil constricts (gets smaller).

• This is called _____.

• Purpose: To limit light entering the eye and protect the retina.

• Controlled by: Parasympathetic nervous system (via cranial nerve III – Oculomotor).

mydriasis

🌑 In Darkness:

• The pupil dilates (gets larger).

• This is called ______.

• Purpose: To allow more light in so you can see better in low-light conditions.

• Controlled by: Sympathetic nervous system.

CN 2 - Optic

what cranial nerve is affected when assessing the visual acuity?

Myopia

20/60 - Near is called?

Hyperopia

20/10 - Far is called?

Emmetropia

20/20 - Normal vision is called?

Extraocular muscle test (EOMT)

is performed to evaluate any weakness, or other defect in the extraocular muscles which results in uncontrolled eye movements. The test involves moving the eyes in 6 cardinal gazes in space to evaluate the proper functioning of the extraocular muscles of the eyes.

• CN 3

• CN 4

• CN 6

Extra-ocular muscle test (EOMT)

Use: 6 cardinal gaze

• _____ - Upper eye movement

• _____ - Lower eye movement

• _____ - Lateral Eye Movement

pearly gray semi-transparent

Normal color of the tympanic membrane?

UP and back

what is the direction of pulling the pinnae when assessing the ears in 3 years old and above patients?

DOWN and back

what is the direction of pulling the pinnae when assessing the ears in 3 years old and below patients?

Weber test

It involves placing a vibrating tuning fork on the midline of the patient's head and asking where the sound is heard loudest.

conductive hearing loss

In __________, the sound is heard louder in the affected ear

sensorineural hearing loss

In __________, the sound is heard louder in the better-hearing ear.

Rinne test

It compares how well a person hears a vibrating tuning fork when placed on the mastoid bone (bone conduction) versus when it's placed in front of the ear (air conduction).

Normal hearing or sensorineural hearing loss

• If the person hears the sound louder when the tuning fork is in front of the ear (air conduction) than when it's on the mastoid bone, the test is considered positive. This indicates?

• Air (10 secs) > Bone (5 secs) conduction

Conductive hearing loss

• If the person hears the sound louder on the mastoid bone than in front of the ear, the test is considered negative. This suggests?

• Bone (10 secs) > Air (5 secs)

• CN 7

• CN 9

• CN 12

• CN 9

Tongue.

• ___ - anterior taste

• ___ - posterior taste

• ___ - tongue movement

• ___ - gag reflex; use tongue depressor to test the gag reflex

• Normal

• Slight inflammation

• Almost touching the uvula

• Kissing tonsils

Tonsils: Documentation

• Grade 1- _______

• Grade 2 - _______

• Grade 3 - _______

• Grade 4 - _______/extending to the back of the throat

Lub S1

closure of AV Valves: tricuspid and mitral

Dub S2

closure of SL Valves: pulmonary and aortic

S3

A heart sound that is heard after S2: Heart failure; it is common in newborn

S4

A heart sound that is heard before S1: Hypertension; common in elderly

Bronchial

This lung sound is located at the sternum; harsh

Bronchovesicular

This lung sound is like a blowing sound

Vesicular

This lung sound is located at apical, lateral, base; sighing sounds

Respiratory excursion

The movement or expansion of the chest wall during inhalation and exhalation.

• Place both hands on the patient’s lower ribs with thumbs pointing toward the spine.

• Ask the patient to inhale deeply.

• Watch and feel how far the thumbs move apart.

Pneumothorax

Pleural effusion

Lung collapse (atelectasis)

Rib fractures

Asymmetry in performing respiratory excursion may indicate problems like:

P - P - R - L

Tactile fremitus

The vibration felt on the chest wall when the patient speaks (usually saying "99").

• Use the palmar base or ulnar edge of your hand.

• Place it on different areas of the chest and have the patient say "99".

Pleural effusion

Pneumothorax

Obstruction

Decreased fremitus suggests?

P - P - O

consolidation (pneumonia)

Increased fremitus suggest?

• Standing

• Sitting

• Supine

Determine the positions in assessing the breast:

• _____ – for symmetry

• _____ – for symmetry

• _____ – for palpation

constipation

hypoactive bowel sounds in abdomen indicates?

diarrhea

hyperactive bowel sounds in abdomen indicates?

sternocleidomastoid

Muscle that contracts when flexing the chin to chest

trapezius muscle

Muscle that contracts when hyperextending the neck

• Orientation

• Memory

• Attention span

General Status

• Language - ex. Aphasia → both receptive & expressive

• ________ - Person (Ask patient what is the name of his/her guardian), Place (asa ka karon), Time (unsay oras karon)

• ________ – ask px about his/her past memories 5 years ago

• ________ – ask px to count backwards (78, 77, 76, 75…)

testicular self-examination (TSE)

a monthly check of your testicles to identify any unusual lumps, bumps, or changes in size, shape, or texture that could be an early sign of testicular cancer. It involves gently rolling each testicle between your thumb and fingers to feel for any abnormalities.

• standing

• smooth testicles

• spongy

Testicular Self Examination – done monthly, same day

• Position: _________

• Warm shower/bath - in order for the scrotum to descend

• Palpation

• NF: ______

• Press the center of the scrotum

• AF: ______; might indicate testicular cancer

Digital Rectal Exam (DRE)

a medical procedure where a healthcare provider inserts a lubricated, gloved finger into the rectum to check for abnormalities in the rectum, anus, and prostate (in males)

• Left side lying or left sims position

• Prostate gland

• soft

• stoney hard

• Anus

Digital Rectal Exam (DRE)

• Position: _______ or _______

• Standing with feet wide apart 90° angle anterior flexion

• Done to check for _______

• NF: _______

• AF: _______; indicates prostate cancer

• _______ - check for presence of hemorrhoids, bleeding, secretions, and warts

c. Man, environment, health and nursing

The nurse is guided by several nursing theories when caring for clients. Which of the following concepts are the four key concepts of most nursing theories?

a. Health, environment, disease, and treatment

b. Health, illness, health restoration and caring

c. Man, environment, health and nursing

d. Man, health, illness and health care

a. Imogene King

The nurse assesses the health needs of the child according to several areas of concern until all overt and covert needs are met. The nurse is applying the theory of?

a. Imogene King

c. Faye Glenn Abdellah

b. Betty Neuman

d. Dorothea Orem

d. Florence Nightingale

The nurse makes the child comfortable, provides adequate ventilation and warmth and ensures that the environment is safe and clean. The nurse is applying the theory of:

a. Faye Glenn Abdellah

c. Martha Rogers

b. Dorothea Orem

d. Florence Nightingale

c. Dorothea Orem

The nurse encourages the boy to feed himself and participate in his care as much as he is able. The nurse is applying the theory of:

a. Ida Jean Orlando

c. Dorothea Orem

b. Rosemarie Parse

d. Madeleine Leininger

a. Hildegard Peplau

The nurse plans to care for the child. The nurse encourages the child to talk about himself, his accomplishments, his love for sports and arts. The nurse wants the boy to regain his self-esteem. The nurse is applying the theory of:

a. Hildegard Peplau

c. Betty Neuman

b. Martha Rogers

d. Imogene king

A. Betty Neuman

The theorist who believes that adaptation and manipulation of stressors are needed to foster CHANGE is:

A. Betty Neuman

C. Faye Glenn Abdellah

B. Dorothea Orem

D. Sister Callista Roy

D. Myra Levine

The theorist whose theory can be defined as the development of a science of humankind, incorporating the concepts of energy fields, openness, pattern and organization is:

A. Dorothy Johnson

C. Martha Rogers

B. Imogene King

D. Myra Levine

B. Madeleine Leininger

The theorist whose major theme is the idea of transcultural nursing and caring is:

A. Jean Watson

C. Virginia Henderson

B. Madeleine Leininger

D. Ernestine Wiedenbach

B. Joyce Travelbee

The theorist that advocated that the goal of nursing individual or family in preventing or coping with illness, regaining health finding meaning in illness, or maintaining maximal degree of health. She further viewed that interpersonal process is a Human-to-Human Relationship formed during illness and “experience of suffering.”

A. Hildegard Peplau

C. Patricia Benner

B. Joyce Travelbee

D. Ida Jean Orlando

d. Facilitate the body’s reparative processes by manipulating client’s environment

The goal of nursing according to the nursing theory of Florence Nightingale is to:

a. Reduce stress so that client can move more easily through recovery process

b. Develop interaction between nurse and client

c. Care for helping clients retain total care

d. Facilitate the body’s reparative processes by manipulating client’s environment

d. Johnson

A common skill is one of the important competencies expected of a nurse. This theory focuses on how the client adapts to illness; the goal of nursing is to reduce stress so that the client can move more easily through recovery. Behavioral system model whose nursing model?

a. Travelbee

c. Rogers

b. Roy

d. Johnson

d. Novice nurse

Using Benner’s stages of nursing expertise, you are a beginning NP. You will rank yourself as a/an?

a. Competent nurse b. Proficient nurse

c. Advanced beginner d. Novice nurse

c. a holistic understanding and perception of the client

Benner’s Proficient nurse level is different from other levels in nursing expertise in the context of having:

a. the ability to organize and plan activities

b. having attained an advanced level of education

c. a holistic understanding and perception of the client

d. intuitive and analytic ability in new situations

b. therapeutic use of self

In Lydia Hall theory, which of the following represents core:

a. nurturance and factors that are exclusive to nursing

b. therapeutic use of self

c. focuses on nursing related to physician’s order

d. all of the above

b. Sister Callista Roy

Presented Adaptation model. Viewing a person as unified biopsychosocial/adaptation system in constant interaction with changing environment. The adaptive system includes input, control process, output and feedback.

a. Hildegard Peplau

c. Martha Rogers

b. Sister Callista Roy

d. Lydia Hall

D. Ernestine Wiedenbach

The nursing theorist whose major theme is the idea of helping patient through nursing art is:

A. Jean Watson

B. Madeleine Leininger

C. Virginia Henderson

D. Ernestine Wiedenbach

B.Italy,Florence May 12, 1820

Florence Nightingale was born in:

A.Italy,Rome May 12, 1820

B.Italy,Florence May 12, 1820

C.Italy,Venice May 12, 1820

D.Italy,Milan May 12, 1820

A. Patient is unable to fulfill his physiological and social needs

In the self-deficit theory by Dorothea Orem, nursing care becomes necessary in which of the following conditions?

A. Patient is unable to fulfill his physiological and social needs

B. Patient is unable to find meaning of life

C. There are alteration in the patient physical structure and physiological processes of life

D. Patient needs to adopt with social, biological and physiological stressors

A. Hildegard Peplau

When you clean the bedside unit and regularly attend to the personal hygiene of the patients as well as in washing your hands before and after a procedure and in between patients. You intend to facilitate the body's reparative processes. Whose nursing theory are you applying nursing action?

A. Hildegard Peplau

B. Dorothea Orem

C. Virginia Henderson

D. Florence Nightingale

B.14 Basic Needs

What is Virginia Henderson's nursing theory is?

A.4 Conservation Principle

B.14 Basic Needs

C.21 Nursing Problems

D.3 C's Theory

B."Interpersonal process is viewed as human relationship."

In interacting with patients, a nurse can be governed by Travelbee's nursing model. The framework for practice in this model is that:

A."Nursing process is defined as dynamic interpersonal process between nurse, client and health care system."

B."Interpersonal process is viewed as human relationship."

C."Client continuously changes and co-exists with environment."

D."Caring is central and unifying domain for nursing knowledge and practice."

A. Dorothea Orem

One example of a nursing model is the self-deficit theory. In this model, nursing care becomes necessary when client is unable to fulfill biological, psychological, developmental or social needs. This model was popularized by:

A. Dorothea Orem

C. Rosemarie Parse

B. Hildegard Peplau

D. Virginia Henderson

D. Decreased cardiac output related to the potential for dysrhythmias

Nurse Helcurt plans care for a patient Natalia, a 14 year old girl, admitted with eating disorder. On admission, the girl weighs 82 lbs and is 5'4" tall. Lab test indicate severe hypokalemia, anemia and dehydration. Nurse Helcurt should give which of the following nursing diagnoses the highest priority?

A. Body image disturbance related to weight loss

B. Self-esteem disturbance related to feelings of inadequacy

C. Altered nutrition: less than body requirements related to decreased intake

D. Decreased cardiac output related to the potential for dysrhythmias

A. fluid replacement

Patient Estes is admitted to the hospital with a ruptured ectopic pregnancy. A laparotomy is scheduled. Preoperatively, which of the following goals is most important for nurse Rafaela to include on the patient's plan of care?

A. fluid replacement

B. pain relief

C. emotional support

D. respiratory therapy

B. Ask the client to explain what happened

Patient Aldous, a 10 year old boy, was riding his bike to school when he hit the curb. The boy tells the school nurse, "I think my leg is broken." What is the first action nurse Chou should take?

A. Immobilize the affected limb with a splint and ask patient not to move

B. Ask the client to explain what happened

C. Put the client in semi-Fowler's position to facilitate breathing

D. Check the appearance of the client's leg

A. immobilize the affected limb with a splint and ask him not to move

Patient Gusion, a 12 year old boy, was riding his bike to school when he hit the curb. He fell and hurt his leg. Nurse Ling, the school nurse, was called and found him alert, conscious but in severe pain with a possible fracture of the right femur. What is the first action that nurse Ling should take?

A. immobilize the affected limb with a splint and ask him not to move

B. make a thorough assessment of the circumstances surrounding the accident

C. put him in semi-fowler's position to facilitate breathing

D. check the pedal pulse and blanching sign in both

A. institute measures to minimize crying

Patient Hanabi, a 4 year old child, undergoes a tonsillectomy for treatment of chronic tonsillitis unresponsive to antibiotic therapy. After surgery, the child is brought to the recovery room. Which of the following actions should nurse Hanzo, include in his plan of care?

A. institute measures to minimize crying

B. perform postural drainage every two hours

C. cough and deep breathe every hour

D. give ice cream as tolerated

B. ask the patient for more information about the location and characteristics of the pain

Patient Kagura, a 36 year old woman, sustains a fractures left femur in a car accident. She is placed in balanced suspension skeletal traction using a Thomas splint and a Pearson attachment. The patient tells nurse Kadita that she has "terrible" pain in her left thigh. Initially, nurse Kadita should:

A. determine that all the weights and ropes from the traction apparatus are in line and hanging free

B. ask the patient for more information about the location and characteristics of the pain

C. check the splint and Pearson attachment to make sure they are appropriately positioned

D. explain to the patient she is experiencing in the affected leg a common occurrence

B. Assist patient in ambulation as tolerated

A nurse is caring for a post-operative patient who has not voided for 8 hours and reports lower abdominal discomfort. The bladder is distended upon palpation. Which nursing intervention should the nurse implement first?

A. Perform manual emptying (palpation of bladder)

B. Assist patient in ambulation as tolerated

C. Notify the healthcare provider for diuretics order

D. Insert a Foley catheter as prescribed to relieve urinary retention

a. position patient to semi-Fowlers

A client has 500 ml bag of 5% Dextrose in 0.9% Sodium chloride hung at 8:00 pm. A nurse making rounds at 8:30 pm finds the client to be complaining of a pounding headache, with difficulty of breathing, and with an increased pulse rate. The IV bag has 100 ml remaining. The nurse should take which of the following actions first?

a. position patient to semi-Fowlers

b. immediately refer to the physician

c. slow the IV infusion p IV infue

d. notify doctor

A. "Can you tell me what you understand about the procedure?"

Patient Johnson is scheduled for angioplasty. The patient, Johnson, says to nurse Hilda, "I'm so afraid that it will hurt, and will make me worse off than I am." The nurse makes which best statement to the client?

A. "Can you tell me what you understand about the procedure?"

B. "Your fears are a sign that you really should have this procedure."

C. "Try not to worry. This is a well-known and easy procedure for the doctor."

D. "Those are very normal fears, but please be assured that everything will be okay."

D. stop the transfusion immediately

Mr. Vale, 53 year old man patient, is receiving PRBC. Several minutes after the infusion is started, he complains for itching and develops hives on his chest and abdomen. Which of the following actions should nurse Rafaela do first?

A. slow down the rate of the transfusion

B. call the physician and stop the blood transfusion

C. mix IV fluid with the blood to dilute it

D. stop the transfusion immediately