question

Arrythmia

answer

A pulse w/ irregular rhythm

question

Korotkoff Sound

answer

Sound heard, via stethoscope, over an artery distal to bp cuff.

question

Systolic Blood Pressure

answer

Peak pressure exerted on arterial walls during ventricular contraction, at which point, the left is emptied.

question

List 6 factors that can increase vital signs values

answer

• exercise • eating • anger • hormone levels • stress • stimulant drugs

question

List 3 factors that can decrease vital signs values

answer

• rest • depression • depressant drugs

question

Normal Temperature vital sign values for average adult

answer

• Oral: 98.6 F • Rectal: 99.6 F • Axillary: 97.6 F • Tympanic: 98.6 F

question

Normal Pulse vital sign values

answer

• ADULTS 60 - 100 bpm • CHILDREN 100 - 120 bpm • INFANTS 120 - 160 bpm

question

Normal Respiration Rate vital sign values

answer

• ADULTS 12 - 20 breaths per min • CHILDREN 20 - 30 breaths per min • INFANTS 30 - 50 breaths per min

question

Normal SYSTOLIC Blood Pressure vital signs value

answer

ADULTS 90 - 140 mmHg

question

Normal DIASTOLIC Blood Pressure vital signs value

answer

ADULTS 60 - 90 mmHg

question

List 5 types of thermometers

answer

• glass • electronic • tympanic • temporal • heat sensitive patch / chemical dot

question

List and describe 2 types of glass thermometers

answer

• ORAL - Long slender bulb. BLUE COLOR. • RECTAL - Short, stubby bulb. RED COLOR.

question

Which type of themometer probe is least accurate?

answer

heat sensitive patch / chemical dot

question

Taking oral temperature would be contraindicated for the following:

answer

• has previous seizures • has just finished breakfast 5 mins ago • suffers from dementia • had oral surgery • is a teenager with a leg fracture • is a 2 year old

question

What are the contraindications for a rectal temperature?

answer

• diarrhea • perineal / rectal surgery • bleeding tendencies • cardiac patients

question

List 9 areas of the body where a pulse can be found

answer

• radial: wrist • brachial: under the arm • temporal: over temporal bone, above & lateral to the eye • carotid: along the neck • apical: 4th & 5th intercostal space at left midclavicular line • femoral: below inguinal ligament • popliteal: behind knee in popliteal fossa • dorsalis pedis: top of the foot • posterior tibialis: interior side of the ankle

question

List 4 terms to describe the strength of a pulse

answer

• rate: number of bpm • rhythm: regular or irregular • strength: bounding, strong, weak, & thready • equality

question

List 4 characteristics to note when assessing respirations

answer

• rate: number of respirations per min • rhythm: regular or irregular • depth: shallow or weak • sound by auscultation: - Normal sound; soft & breezy upon inspiration w/ short low-pitch expiration. - Abnormal sounds; include stertorous, snoring, gasping, labored, choking, or gurgling.

question

How many mmHg past the point of not hearing the pulse should the cuff be inflated?

answer

30 mmHg.

question

List and describe 6 characteristics to ask about & document when assessing pain (OPQRST)

answer

• ONSET: When did the pain start? • PROVOCATION: What makes the pain worse? What relieves the pain? • QUALITY: How does the pain feel? (e.g.,dull, achy, crampy, sharp) • RADIATION: Does the pain radiate or travels to other parts of the body? • SEVERITY: What is the level of pain? • TIME: How long has this pain been bothering you?

question

Define Orthostatic Hypotension

answer

Occurs when the blood pressure decreases rapidly in relation to position changes from lying to sitting or standing.

question

List 3 possible causes of orthostatic hypotension

answer

• circulatory problems (hypertension, vascular disease) • dehydration (vomiting, gastroenteric illness, heat exhaustion) • side effects to medication (diuretics, anti-hypertensive)

question

What are the procedures for orthostatic vital signs?

answer

• Have the patient lie supine for 1-3 mins before taking 1st bp reading • Have the patient sit upright for 1-3 mins before taking 2nd bp reading • Have the patient stand for 1-3 mins before taking 3rd bp reading • Compare readings to determine variance between readings • At least 2 bp measurements must be done to ensure accurate assessment • In most cases, orthostatic hypotension is detected w/i 1 min of standing

question

What units are used when measuring height?

answer

inches or centimeters

question

Define: Auscultation

answer

Act of listening for sounds w/i the body

question

Define: Cue

answer

Information you obtain through use of senses (patient crying implies pain or sadness)

question

Define: Inspection

answer

Technique used in physical examination to carefully & critically examine the body using the sense of sight

question

Define: Olfaction

answer

Using the sense of smell during a physical examination

question

Define: Sim's Position

answer

Patient is in a side-lying position on either side, w/ top leg flexed up toward the abdomen; used to assess rectum & vagina.

question

When is a plan of care developed?

answer

upon patient admission

question

What is the nursing process focused on?

answer

the patient's nursing needs

question

List and describe the 5 steps in the nursing process

answer

• ASSESSMENT: deliberate & systematic collection of data to determine pt's current & past health / functional status, and past & present coping patterns. • NURSING DIAGNOSIS: clinical judgement about individual, family, or community responses to actual or potential health problems. • PLANNING: involves setting pt-centered goals & expected outcomes & nursing interventions. • IMPLEMENTATION: performing or carrying out the nursing measures using interventions developed during planning. • EVALUATION: crucial to determine whether the pt's condition or well-being has improved after the application of the nursing process.

question

The nursing process is a continuous cycle. (TRUE/FALSE) Why?

answer

TRUE. Problems and special needs must be identified.

question

List 3 proper questioning principles when interviewing a patient

answer

• Ask direct questions to elaborate on the details of the initial response. DO NOT USE YES/NO QUESTIONS. • Keep interview focused on pt's med problems & needs. Ask about possible problems of involved systems based on your knowledge of anatomy & physiology. • Use language that's understandable & appropriate.

question

List 5 appropriate behavior and communication techniques used when conducting an interview

answer

• Greet pt by title & name; also introduce yourself. • Identify the pt. • Begin interview w/ a general question (How are you doing today). Observe for signs of disconfort, pain, or anxiety. If pt uncomfortable, delay interview until pt is more comfortable. • Use proper questioning principles throughout the interview. • Use appropriate behavior & communication techniques to conduct the interview.

question

List 12 steps in the procedure for obtaining information required for a medical history

answer

• Introduce yourself. • Establish pt's identity. (name, age, marital status, etc) • Determine chief complaint. (primary reason for seeking medical attention) • Determine pt's expectations. • Obtain history of present illness or health concerns. • Obtain past health history. (PHI). • Obtain a family history. • Obtain an environmental history. • Obtain a psychosocial history. • Obtain information about pt's spiritual health. • Conduct review of systems. Head-to-toe assessment, vital signs, height, weight, & impresion of each system. • General overview - at the end of interview, review the discussion and ask pt fort anything that might have been missed.

question

Define: Ophthalmoscope

answer

Checks pupillary reaction to light & inspects inner eye. May be portable or wall mounted.

question

Define: Stethoscope

answer

Instrument used for listening sounds within the body. Heart, lungs, abdomen, bowels, & blood pressure.

question

Define: Percussion/ Reflex Hammer

answer

Rubber hammer used to assess reflexes.

question

Define: Vaginal Speculum

answer

A bi-valved instrument w/ 2 opening blades used for inspection of vaginal cavity & cervix.

question

Define: Exam Gloves

answer

Used when pualpating buccal (oral) cavity, genitals, & perineal region.

question

Define: Electrocardiograph (EKG)

answer

Records electrical activity of the heart.

question

Define: Mouth Mirror

answer

Small round mirror w/ detachable handle that is used to view oral cavity.

question

Define: Explorer

answer

Instrument w/ sharp pointed end, used for exploring the mouth.

question

Define: Periodontal Probe

answer

Instrument w/ long blunt working end calibrated from one to ten mm. Use to check periodontal pockets.

question

List and drescribe 5 basic skills involved in a physical examination

answer

• INSPECTION: visual or auditory observations. used continually during examination in order to observe normal and abnormal findings. • PALPATION: using sense of touch to make delicate & sensitive measurements of specific signs. skill used with or directly after inspection. • PERCUSSION: skill involves striking one object against another & interpreting the sound that's made. • AUSCULTATION: Listening for sounds with stethoscope. should be used last, except when assessing the abdomen; after other techniques • OLFACTION

question

List 8 steps using a Snellen chart

answer

• position pt 20 ft from Snellen chart. • ask pt to leave on corrective lenses (except reading glasses) and cover one eye w/ an opaque card. • instruct pt to read through the chart to the smallest line in print possible (pt can't miss more than 2 letters per line). • record fraction at end of last line read. • indicate # of missed letters and whether corrective lenses were worn (i.e. 20/30 -2 w/ contact lenses). • test the other eye & record the score. • if pt can't read top number, even w/ glasses, position them closer to chart & record score. • verify all visual acuity scores.

question

Define: Alzheimer's Disease

answer

chronic neurologic disorder characterized by progressive & selective degeneration of neurosn in cerebral cortex. displays symptoms of behavioral disturbances, memory loss, emotional apathy, & difficulty w/ thought processes. Usually accompanied w/ dementia. THERE IS NO CURE.

question

Define: Delirium

answer

acute mental disturbance characterized by altered consciousness, reduced attention span & awareness, memory deficits, disorientation, disorganized thinking, incoherent speech, altered perception, delusions, allucinations, & sleep disturbances.

question

Define: Dementia

answer

progressive condition marked by deterioration of cognitive functioning including impaired memory and 1 more of the following: loss of purposeful movements, speech distrubance, impaired social functioning & is often accompanied by emotional apathy. DEMENTIA HAS A POOR PROGNOSIS.

question

Define: Glaucoma

answer

intraocular structural damage resulting from elevated intraocular pressure caused by aqueous humor outflow obstruction. if left untreated, will lead to blindness.

question

Define: Hyperglycemia

answer

clinical syndrome of diverse causes wit high levels of serum glucose (i.e. high sugar in the blood).

question

Define: Macular Degeneration

answer

blurred central vision often ocurring suddenly. caused by progressive degeneration of center of retina. most common cause of blindness adults over 50. THERE IS NO CURE.

question

Define: Meniere's Disease

answer

chronic disease of the fluid balance in the inner ear. has 3 typical symptoms: severe vertigo, tinnitus, & sensorineural hearing loss. nausea, vommiting, & dizziness can last few mins to many hrs. it can lead to total hearing loss.

question

Define: Mental Health

answer

a state of mind in which the person copes with & adjusts to stress of everyday living by behaving in ways acceptable to society.

question

Define: Presbycusis

answer

Changes in the inner ear result in a predominantly high-frequency sensorineural hearing loss in elderly pts. causes genetic factors, prenatal abnormalities, trauma, & diseases. noticeable by late middle age. pts may display speech problems & complaining others are mumbling. IT CAN'T BE CURED BUT PTS BENEFIT FROM USE OF HEARING AID.

question

Define: Presbyopia

answer

impaired near vision in middle-age & older adults, caused by loss of elasticity of lens & associated w/ the aging process.

question

Define: Quadriplegia

answer

paralysis of arms, legs, & trunk of body below level on an associated injury to spinal cord.

question

Define: Stress

answer

Response or change in body caused by emotional, physical, social, or economic factor.

question

Define: Tinnitus

answer

Perception of sound in absence of corresponding external sound. Usually described as ringing in ears, although it may be perceived by the pt as roaring, sizzling, whistling, or humming.

question

List and describe 3 common causes of hearing loss

answer

• age related changes at inner ear • exposure to noise • build up of cerumen (earmax)

question

List and describe 2 types of otitis media

answer

• Chronic: can change tympanic membrane or the ossicles & permanent hearing loss can occur. • Acute: fuild builds up in the ear causing pain & hearing loss.

question

List and describe 11 nursing interventions for patients with a hearing aid or those who can read lips

answer

• Gain pt's attention w/o startling him. • Face pt when talking. • Ensure adequate lighting when talking to pt. • Speak clearly, distinctly & slowly. • Speak in normal tone. • Do not eat or chew gum when talking to pt. • State the topic of conversation first. • Have pen & paper available to write down important names or words. • Keep conversation short. • Repeat statements as needed. • Keep background noise to minimum.

question

List and describe 3 types of paralysis

answer

• Paraplegia: motor or sensory loss in the lower limbs & trunk. • Quadriplegia: arms, legs, & trunk of body below level of associated injury to spinal cord. • Hemiplegia: one side of the body.

question

What are the 5 causes of paralysis?

answer

• Trauma • Spinal cord lesions • Multiple sclerosis • Infections & abscesses of spinal cord • Congenital defects

question

List and describe 4 long term complications of paralysis

answer

• Decubitus ulcers: techincal term for "Bedsore". • Urinary tract infections (uti): is an infection that affects part of the urinary tract. When it affects the lower urinary tract it is known as "Simple Cystitis (bladder infection) and when it affects the upper urinary tract is known as "Pyelonephritis" (kidney infection). • Urinary calculi: are masses that form within the urinary tract. • Stiffening of joints: immobility and consolidation of a joint due to disease, injury, or surgical procedure. AKA Ankylosis.

question

List and describe 6 signs and symptoms of illness onn infants

answer

• Jaundice - Yellowish color of skin & eyes. • Redness or draining around cord stump or circumcision. • High temperature. • Limp body, slow to respond. • Eating poorly. • Hard or watery stools.

question

How many calories a day do young children need?

answer

They need 1400 to 1800 cal per day.

question

Why do elderly have special nursing needs?

answer

Because of physical, psychological, & social changes.

question

List and describe 5 common cognitive disorders in the elderly:

answer

• Alzheimer disease • Confussion • Delirium • Dementia • Depression

question

What are 5 physiological measures we can enforce for the behavioral management for the elderly?

answer

• Reality Orientation • Validation Therapy • Reminiscence • Remotivation Therapy • Resocialization

question

What are 4 conditions that may warrant an amputation?

answer

• Inadequate tissue perfusion (diabetes, other vascular disorders) • Severe trauma • Malignant tumors • Congenital deformities

question

List 5 causes of mental disorders

answer

• Inability to cope or adjust to stress • Chemical imbalances • Genetics • Drug or substance abuse • Social and cultural factors

question

What are the 2 types of behavior?

answer

• Adaptive: Cope w/ problems in ways considered appropriate by society. • Maladaptive: Cope w/ feelings and situations that are consider inappropriate to society.

question

Define: Neglect

answer

Giving insufficient attention, respect and care to someone who has a claim to that attention.

question

List and describe 4 sign and symptoms a neglected pt

answer

• Lack of adult supervision • Malnourishment • Unsafe living environment • Untreated chronic illness

question

Match the following terms with correct definition

answer

• Gestional diabetes: Develops during pregnancy. • Hypoglycemia: Low blood sugar. • Hyperglycemia: High blood sugar. • Insulin dependent diabetes: Type I • Non-insulin dependent diabetes: Type II

question

What problems can uncontrolled diabetes cause?

answer

• Retinal change, leading to blindness • Kidney disease • Nerve damage • Circulatory disorders (stroke, heart attack, slow wound healing, hypertension)

question

Corpsman/ Technicians do not need to inspect the skin of a diabetic pt. (TRUE / FALSE)

answer

FALSE. Daily inspections of skin surface is part of nursing interventions.

question

List and describe 2 characteristics of tumors

answer

• BENIGN: Don't usually cause death. - Grows slowly & w/i localized area. - May resemble normal tissue. - Problems if growth spreads into vital organs or obstructs vital process. It can cause problems if it loses blood supply & becomes necrotic. • MALIGNANT: Cancerous & death can occur if not treated/controlled. - May metastasize & spread rapidly by invading surrounding tissue or through blood or lymphatic vessels. - May rise from benign tumor that's chronically irritated or aggravated. - There are many types of cancer.

question

Malignant tumors can be divided into 2 main groups. Name the 2 groups.

answer

• Carcicomas: Arise from eohithelial tissue. Can occur in the covering of body parts. • Sarcomas: Arise in connective tissue. Tend to affect primarily young people & metastasize rapidly.

question

List and describe 3 types of treatment for tumors

answer

• Surgery: Cures of controls cancer. • Radiation: Destroys or retards cell growth. Can be given in many forms: PO, IV, IM, or x-ray. • Chemotherapy: Goal is to destroy cancer cells w/o destroying too many normal cells & cure cancer or control rate of cancer cell growth.

question

Match the following terms with correct definition

answer

• Carcinomas: arises in epithelial tissue. • Sarcomas: affects primarily young people & metastasize rapidly. • Unconscious Pt: aroused only briefly & only by vigorous external stimulation. • Stupor-person: eyes do not open upon stimulation. • Coma-eyes: depression of cerebral function.

question

What do you use to determine a pt's responsiveness?

answer

Glasgow coma scale.

question

How often should a pt be repositioned?

answer

Every 2 hours.

question

Describe fever management on an inconscious pt:

answer

• Look for possible signs of infection. • Cool room - 65 degrees. • Remove top linen, except for light sheet or loin cloth. • Give sponge baths as ordered.

question

What type of pt needs to have an increase in protein in their diet?

answer

AIDS patients.

question

Diet therapy can be a factor in delaying the onset of full blown AIDS. (TRUE / FALSE) Why?

answer

TRUE. Is directed toward replacing fluids, electrolytes, weight gain, replacing musles mass thru protein intake, & maintaining strenghth of inmmune system

question

List and describe 2 types of pt admissions to the hospital

answer

• ROUTINE: occurs when an illness or a health problem is not immediate threat to pt's life. • EMERGENCY: occurs when an actutely ill or injured pt is given initial treatment at ER then transferred to a ward & placed into a bed.

question

You should never introduce the new pt to their neighboring pts. (TRUE / FALSE)

answer

FALSE. Introduce roommate if semiprivate room is assigned.

question

Who are inventory of pt valuables conducted by?

answer

• 2 commissioned officers; if pt is a commissioned officer or civilian. • 1 commissioned officer and 1 enlisted staff member if pt is enlisted.

question

Define: Pain

answer

Unpleasant sensation, occurring in varying degrees of severity as consequence of injury, disease, or emotional disorder.

question

List 4 characteristics of acute pain

answer

• Source is usually identifiable. • May have limited tissue damage & emotional respnse. • Underlying cause is treated. • Unrelieved acute pain can progress to chronic pain.

question

List 4 characteristics of chronic pain

answer

• Emotional effects may be long-lasting & serve. • Source may be unknown or poorly understood. • May be no cure for source causing pain. • Causes pt insecurity of never knowing how one will feel from day to day.

question

List 3 scales for objectively describing pain

answer

• Numerical Rating Scale (NRS), FLACC (face, legs, activity, cry, & consolabilty), or Wong-Baker FACES chart. • Pain Scale 0 pain free - 10 worst pain; document pt assessment, for children use FACES chart, FLACC for infants & non-communicative children. • Watch for nonverbal cues in confused pts; restlessness, pacing, guarding, wincing, crying, withdrawal from touch.

question

List 5 physical signs of pain

answer

• Elevated P, BP, or RR. • Dilated pupils. • Perspiration. • Muscle tension. • Nonverbal communication (crying, moaning, frowning, rubbing painful area)

question

List 3 reasons errors in pain assessment may occur:

answer

• Bias. • Vague or unclear questioning. • Pt not providing accurate pain info.

question

Define: Dorsal Recumbent

answer

Position pt is lying supine w/ knees flexed.

question

Define: Draw-sheet Method

answer

Method transferring pt from bed to stretcher by grasping & pulling loosened bottom of sheet bed.

question

Define: Lithotomy Position

answer

Position pt is lying supine w/ knees & hips flexed.

question

Define: Semi-Fowler's Position

answer

Semi-upright sitting position w/ head of bed raised to 45 degrees.

question

Define: Sim's Position

answer

Patient is in a side-lying position on either side, w/ top leg flexed up toward the abdomen; used to assess rectum & vagina.

question

Define Trendelenburg Position (Shock Position)

answer

Pt's feet & legs are higher than the head.

question

Define: Abduction

answer

Movement which draws limb AWAY from the median sagittal plane of the body.

question

Define: Active-assistant Exercises

answer

Exercises performed by pt w/ some assistance.

question

Define: Contracture

answer

Permanently flexed joint that occurs w/ shortened muscle tissue.

question

Define: Doral Flexion

answer

Move so fast, toes are pointed upward.

question

Define Hyperextension

answer

Joint is overstretched or "bent backwards" because exaggerated extension motion.

question

Define: Close Reduction

answer

Realigning broken bone by manual manipulation w/o incisions.

question

Define: Pressure Point

answer

Areas on skin where the cast has been indented or pushed in, that may cause sores & skin breakdown.

question

List 9 steps used when assisting a pt into or out of an automobile

answer

• Position wheelchair on passenger side. • Ensure there is no space between the car seat & the wheelchair. • Lock wheels on wheelchair before transferring pt to autommobile. • Assist pt to stand in front of wheelchair. • Pivot pt until pt's back is to the automobile. • Assist pt to sit ensuring pt's buttock is all the way to the back of the seat, & check pt's comfort. • After pt is in automobile, secure pt w/ seatbelt. • Document procedure after its completed. • Reverse procedure for assisting pt into an automobile.

question

List the benefits of position changes and good alignment

answer

• Promotes good respiratory function. • Improves circulation. • Prevents pressure ulcers. • Prevents contractures. • Promotes comfort.

question

List and describe 4 steps for ambulating a pt w/ a transfer belt

answer

• Gait belt used to ambulate and/or transfer weak or unsteady pt. • Place & buckle belt around pt's waist over clothing before getting pt up. • Belt needs to be tight enough to allow space for your hand to grasp it from the rear. • Insert your hand into belt from the bottom so if pt falls, you'll be able to support the weight.

question

List and describe 3 ambulation aids

answer

• WALKERS: four point walking aids used by pts requiring added sta bility during ambulation. • CANES: provide balance & support, they are used when there is weakness on one side of the body. • CRUTCHES: used to prevent or limit weight bearing on a leg while healing takes place & increase mobility.

question

Match the following terms with correct definition

answer

• WALKERS: used w/ various degree of weight bearing. • CANES: used w/ weakness on one side of body. • CRUTCHES: prevent weight bearing while healing takes place. • 3-POINT GAIT: both crutches & injured leg advance followed by uninjured leg, which is brought to crutches. • 4-POINT GAIT: one crutch is advance followed by opposite leg. • 2-POINT GAIT: crutch & opposite leg are advanced together. • SWING THROUGH GAIT: legs swing past the crutches. • SWING TO GAIT: legs are brought to crutches.

question

What side is the cane held?

answer

Stronger side of the body.

question

List and describe 5 common problems and preventive measures associated with inactivity

answer

• Maintain muscle & joint function. • Prevent muscle deterioration or atrophy. • Prevent muscle contractures. • Prevent musculoskeletal change (tightness) • Prevent pooling of blood in veins.

question

List and describe 5 reasons to perform range of motion exercises

answer

• RESPIRATORY COMPLICATIONS: active exercises done by pt, passive exercises done w/ assistance, done several times a day. (frequent turning, deep-breathing, & incentive spirometry) • CONSTIPATION: high fiber diet, increase intake fuild, privacy when eliminating (defecate), encourage reg time for elimination, nurse or corpsman may need to remove fecal obstruction. • CONTRACTURES/ ATROPHY: range of motion exercises, isometric exercises, weight bearing exercises, activity daily living (mobility, personal hygine, eating, etc.) • PRESSURE ULCERS (Ulcer forms from local interference w/ circulation): turn or reposition pt every 2 hrs, keep linens smooth and clean, position pt w/ pillows & pads, use supportive devices (fleeces, trochanter rolls), maintain skin in clean & healthy condition, inspect skin frequently per local protocol, don't massage bony prominences. • BOREDOM: encourage frequent family visits, provide constructive projects, provide therapeutic communication, don't rely solely on TV for pt entertainment.

question

List and describe 4 conditions caused by pooling of blood in veins

answer

• PHLEBITIS: inflammation of the vein. • EMBOLUS: blood clot moving in bloodstream. • THROMBUS: stationary blood clot. • THROMBOPHLEBITIS: inflammation of vein associated w/ thrombus.

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