Final exam Fundamentals

What side do you listen to a bruit with your stethoscope?

bell

what does aerobic exercise benefit

cardiac

Complications of immobility?

osteoporosis, DVT

rule of nurses with holisitic care

mind, body, spirit

ebp

outlines the process of nursing

what do we use to use evidence based skills?

clinical expertise, patients values, patients preferences, research based articles, subjective objective data

what is masslows hierarchy of needs

meeting patient where they are based off of needs

masslows hirearchy of needs

physiological, safety, love/belonging, esteem, self-actualization

what is I's and O's

hydration status

primary prevention

immunizations

secondary preventions

blood pressure, screening

2 ways of communication

verbal and nonverbal

verbal communication

spoken or written words

nonverbal communication

five senses and everything that does not involve spoken or written word

how to deliver cultural competent care

based off how to patient wants to be treated if safe

client confidentiality

only people who are involved in direct care

what should we use when charting about a patient?

initials

what do we do with charts/ computers when we walk away?

close/ log out

subjective data

patient tells you

objective data

observe

negligence

falls below standard of care

first priority with patients

safety

what do we worry about with hygiene?

skin integrity

Assessment order

inspection, aussultaion, percussion, palpation

where does sound travel better?

in solids

how do we do palpation?

light to deep

normal percussion over lungs?

residence

bronchial vesicular

in the middle of the chest anterior

largest part of lung

vesicular

crepitis

crackling air under skin

tactile fermitis

palpable vibration of the chest wall that results from the transmission of sound vibrations through the lung tissue to the chest wall

what are adventitious sounds

abnormal sounds

most common adventitious sounds

strider, wheezing

what does wheezing sound like?

high pitched whistle sound

what does strider sound like?

snoring sound

most common O2 delivery

nasal canula

Diaphoretic breathing

breathing deep into the stomach and fully engaging the diaphragm

tripod

hands on knees to breathe

what does standing straight do to the lungs

compress the lungs

active vs passive ROM

active is doing it themselves. passive is you helping

allens test

tests arterial blood flow in hand. hold wrist for a second and watch

rhomberg test

balence test cerebellar function

how to access bowel habits

how often, consistency

where to listen to bowel sounds?

right lower quadrent

signs of hydration?

skin turger doesnt tent

signs of dehydration

skin truger tents, dizziness, headaches dryness

urniary retention

inability to empty the bladder

pulses

radial, brachial, carotid, popliteal, dorsalis pedis

cranial nerves

olfactory, optic, oculomotor, abducens, trigeminal, facial, acoustic, glossopharyngeal, vagus, spinal accessory, hypoglossal

how to grade reflexes?

0-4, 2+ is normal

mucous membranes

pink

tongue

ventral is rough, dorsal is smooth

vision chart 20/40

they can see at 20 feet when normal can see at 40

corneal light reflex

should appear symmetric and center

RUQ

liver, gallbladder, duedenum, head of pancreas, right kidney & adrenal, part of ascending & transverse colon

RLQ

Cecum, appendix, right ovary, right ureter, right spermatic cord

LUQ

Stomach, spleen, left lobe of liver, body of pancreas, left kidney & adrenal, part of transverse & descending colon

LLQ

part of descending colon, sigmoid colon, left ovary, left ureter, left spermatic cord

typany

hollow, high, drum like sounds, excessive air in chest

over liver and spleen sounds like?

dull

how often should they do breast exams

once a months

occult blood

not visible

head control in babys

by 6 months

roaches 6 C's

compassion, competence, confidence, conscience, commitment, and comportment

what are you looking for in inspection

any visible abnormalities

what is the technique for auscultation

light to deep

what is the normal pattern for listening for ausultation

counter clockwise

what can a skin assessment indicate

skin abnormalities

what is the anatomy of the lungs, shape, configuration of chest

apex at top, base at bottom, left is bigger

what are normal percussion sounds

Resonant sounds are low pitched, hollow sounds

bronchial

expiratory sounds last longer than inspiratory ones

bronchovesicular

inspiratory and expiratory sounds are about equal

vesicular

inspiratory sounds last longer than expiratory sounds

where is the apical impulse the loudest

apex of heart

where does blood flow start and end

right atrium , right ventricle, pulmonary arteries in the lungs, back to the heart through the pulmonary veins, left atrium, left ventricle and the aorta

what does it mean when peripheral pulses are weak

blood flow is reduced to vital organs

if the peripheral pulse is weak what do we check next

apical pulse

what exercise is helpful for cardiovascular system

aerobic exercise

passive ROM technique

2 times a day and 2-5 times each exercise

flexion

flex in

abduction

arms up

adduction

arms in

inversion

turn foot in

supination

hand palm up

circumduction

turn in circle

protraction

shoulders forward

how long for bowel sounds

2 minutes if normal

what is urinary retention

how much urine is left in the bladder after the bladder is emptied spontaneously

how is cerebellar functioning tested

assessment of gait and balance, the finger-to-nose test, heel-to-shin test

what is the frontal lobe for

thinking, memory, behavior and movement

what is the parietal lobe for

language and touch

what is the occipital lobe for

sight

what is the temporal lobe for

hearing, learning and feelings

what is the grading scale for deep tendon reflexes

0-4, 2+ normal

what are mental exams used for

evaluate mental and memory status

how to examine a child ear

down and forward

how to examine ear of adult

up and back

where are lymph nodes accessible on the body

sides of face and neck

describe mucous membrane

moist inner lining of most organs

describe tongue

pink rough on top shiny on bottom