Nursing Exam Flashcards

Flashcards based on Mark Klimek Lecture #4, covering Crutches, Canes, Walkers, Delusions, Hallucinations, and Psychosis.

2-point gait

move a crutch and opposite foot together, then the other crutchwith other foot together. For mild bilateral leg weaknesses.

3-point gait

move (2 crutches & bad leg) together followed by unaffected leg. The affected (bad) leg is not on the ground.The unaffected (good) leg is on the ground

4-point gait

move everything separately. Move crutch -> Move opposite foot -> Followed by other crutch -> Followed by opposite foot. Very slow but very stable

Swing-through gait

for non-weight bearing (amputees).The unaffected foot gets pass the tip of both crutches.

Crutch length measurement

Holding it vertically and placing the tip on the ground. 2 to 3 finger widths between the pad and the anterior axillary fold. The tip is located to a point lateral (6 inches) and slightly in front of foot (6 inches)

Handgrip measurement

The angle of elbow flexion is 30 degrees. The wrists should be at the level of the handgrip

How to going up the stairs with crutches

Up with the Good, and Down with the Bad. Both crutches always move with the bad leg

Cane usage

Hold cane on the unaffected (strong) side. Advance cane with the opposite side for a wide base of support. Handgrip should be at the level the wrist

Walker usage

The walker is on the side of the patient, patient 'Picks it up … Sets it down… Walks to it'. patient 'Holds on to chair, Stands up, Then grabs walker'. Do not tie belongings to the front of the walker

Non-psychotic person

has insight and is reality based. Use Good therapeutic communication.

Psychotic person

has no insight and is not reality based. Examples are: delusions, hallucinations, illusions

Delusions

a false, fixed belief or idea or thought. Types: Paranoid, Grandiose, Somatic

Hallucination

a sensory experience. Auditory, Visual, Tactile, Gustatory, Olfactory

Illusion

a misinterpretation of reality. There is a referent in reality

Functional psychosis

they can function in everyday life. Chemical imbalance in the brain. Schizophrenia, Schizoaffective disorder, Major depression, Mania

Psychosis of dementia

Actual Brain destruction/damage. Due to Alzheimer, stroke, organic brain syndrome

Psychotic Delirium

temporary, sudden, dramatic, episodic secondary to something else. Loss of reality. Due to UTI, thyroid imbalance, adrenal crisis, electrolytes, medications/drugs

Functional Psychosis management

Acknowledge feeling, Present reality, Set limits, and Enforce these limits

Demented management

Acknowledge their feeling and Redirect them-give them something they can do

Delirious management

Acknowledge feeling and Reassurance about safety and temporariness of their condition

Loose associations

Psychotic symptoms. Flight of Ideas: Rapid flow of thought. Word Salad: Throw words together. Neologisms: Make it up. Idea of reference: You think everyone is talking about you