Fundamentals Help Midterm

nasolabial folds

A nurse inspects a client's face for symmetry. Which landmarks should be assessed?

movable, discrete, non-tender

Normal lymph nodes should be _____

pupils constricting and eyes converging for near focus

During visual reflex testing, accommodation involves ____

normal: air conduction > bone conduction

What are the Rinne test results

conducting hearing loss

In the Weber test, sound lateralizing to the affected ear indicates ____

medications

IV fluids are considered _____

noticeable swaying or loss of balance

What is a positive Romberg test finding

occlusion, phlebitis, infiltration, and extravasation

What are complications of IV therapy

redness, warmth, and tenderness along vein

What are the signs of phlebitis

cluster headache

Which type of headache is described as a stabbing pain around one eye, with tearing and nasal congestion

constipation related to decreased peristalsis

A nurse caring for a post-op patient who reports no bowel movement for 3 days has hypoactive bowel sounds and a firm, tender abdomen. What is the appropriate nursing diagnosis?

review the patient's medical history

A nurse prepares an enema to a patient w/ severe constipation. What action should the nurse take first?

wash hands w/ soap and water

A patient w/ diarrhea related to Clostridium difficile is being managed in the hospital. What is the important nursing action?

adequate fiber and fluids

How can a patient change their dietary measures in order to prevent constipation

esophagus, stomach, and duodenum; checks swallow mechanism

Barium swallow is used to detect what structures

fecal occult

Which test assesses for the presence of blood in the stool

decompress the GI tract and administer medication/enteral feeds

What is the NG tube used for; x-ray to check position

5 minutes

If you do not hear bowel sounds, how long do you need to listen in each quadrant to confirm the absence of bowel sounds

pain, pallor, paresthesia, paralysis, pulselessness

How can you assess for circulatory impairment in cast care

align bones, reduce pain, and prevent muscle spasms after fractures

When is traction used

constipation, administer medication, or prepare for procedures

When is an enema used (shows surgery history)

provocation, quality, region, severity, timing

What is the PQRST pain assessment

character, onset, location, duration, severity, pattern, associated factors

What is the COLDSPA pain assessment

situation, background, assessment, recommendation

What is SBAR when used in patient handoff

data, action, response

What is DAR

inflammation of a vein

What is phlebitis

leakage of IV solution or medication into the extravascular tissue

What is infiltration

IV catheter becomes dislodged and medication infuses into the tissues

What is extravasation

desire to increase well-being and actualize health potential

Health promotion behavior is motivated by

avoid illness, detect illnesses early, and maintain functioning while ill

Health protection behavior is motivated by

primary

______ level of health promotion is preventing disease from developing through promoting healthy lifestyle

secondary

_____ level of health promotion is screening efforts to promote early detection of disease

tertiary

____ level of health promotion is minimizing disability from acute/chronic illness or injury and allowing most productive life within limitations

HEPA filtration system and N95 respirator mask

Airborne precautions include

systematic method of collecting and analyzing data

What is health assessment

pupils are equal, round, reactive to light, and accommodation

What does PERRLA stand for

loss of bone density; occurs without signs or symptoms

What is osteoporosis

chronic, autoimmune inflammatory disease of connective tissue

What is rheumatoid arthritis; often gradual

degenerative change in articular cartilage; weight-bearing joints

What is osteoarthritis

100% bioavailability, administer fluid/medications to body faster, transfuse blood

IV therapy benefits

iron

If a patient is low in hemoglobin, they may need an increase in

hypertension, diabetes, hyperlipidemia that may lead to obesity

If a patient has a BMI > 30 it may indicate

carbs, protein, fat

What are macronutrients

turn patient on their side

When performing oral care on an immobile patient you should

decreased subcutaneous tissue and skin hydration and increased skin thinning

How might skin change in older adults

clear rhythmic thumping

1st Korotkoff sound

softer swishing sound

2nd Korotkoff sound

softer thump than first (crisp, knocking sound)

3rd Korotkoff sound

muffled and low

4th Korotkoff sound

no sound

5th Korotkoff sound