NUR 300- Umaine Exam 1 – Flashcards
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Cultural Assessment Content
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includes the cultural information gathered
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Culturally sensitive
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caregivers possess some basic knowledge of and constructive attitudes toward the diverse cultural populations found in the setting in which they are practicing
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Culturally appropriate
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the caregivers apply the underlying background knowledge that must be possessed to provide a given person
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Cultural characteristics
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learned at birth: usually aware of it- usually you go by what your family's culture is- but not always
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Universal Phenomenon
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no two cultures are alike, yet may be very similar. All people are born, live and die within a cultural context
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Leininger (Univ. Phen.)
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the culture is a culture of caring, and it may differ widley
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Differences (Univ. Phen)
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Differences occur because of religion, ethnicity, education, occupation, age, gender, region where they live, and region where you are born
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Subculture
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large groups of people within a culture (gender, ethnicity, religion, sexual preference and health related characteristics such as diabetes, heart disease, and diagnosis)
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Cultural Values
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Values: desirable or undesirable state of affairs
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Cultural Norms
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rules by which human behavior is governed, many times us not specifically articulated.
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Dominant Value Orientation:
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shared because of early life experiences- innate nature of humans, time dimension, purpose of life, relationship to others
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Human Nature
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basically good, basically evil, or mixed
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Destiny
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have little choice- genetic
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Harmony
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people exist with nature
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Matery
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are to overcome the environment, natural forces
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Culture in the past
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value long standing traditions, and value ancestors
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Culture in the present
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concerned with now, difficult to get to change lifestyle
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Culture in the future
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Progress and change, concerned with old fashioned health care providers
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Being (Purpose of life)
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spontaneous express of impulses, integral of existence
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Being in becoming (purpose of life)
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detachment, inner control, mediation, desire to realize the self
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Doing (purpose of life)
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active striving and accomplishment, externally applied standards
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Relationship with others (Lineal)
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ordered succession continuity, may seek help from family, and allow others to make decisions
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Relationship with others (collateral)
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group goals: family honor is more important than personal goal _amish, illness affects the whole group
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Relationship with others (individual)
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personal autonomy, independence, individuals make own health decisions
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Nuclear family
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husband, wife, and children
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Extended family
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nuclear family plus relatives, maybe even non biological relatives
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Blended family
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husband, wife, with blended children
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Communal family
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group of men, women and children
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Cohabitation family
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not legally married, sharing household and maybe children
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Siblings in western culture (our culture)
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siblings mean same biologic or adoptive or step parents
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Siblings in Asian cultures
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siblings mean children who were breastfed by the same woman
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Siblings in African cultures
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siblings may consider all people in a village as brother and sister
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Interviewing for health care needs: Basic questions
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1. What do you think caused your illness? 2. Why do you think your illness started when it did? 4. What do you think your illness does to you? 4. How severe is your illness 5. What are chief problems your illness has caused you? 6. What do you fear most about your illness 7. What kind of treatment do you think you should receive? 8. How do you hope to benefit from treatment?
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Religion and Spirituality
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concerned with mysteries of life, good and evil, birth and death, and pain and suffering
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Spirituality
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an effort to find meaning that arises from someones personal experiences to find meaning from someones life
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Religion
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An organized system of beliefs concerning the cause, nature, and purpose of the universe, especially the belief in or the worship of God or gods
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Assess the pt. for
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1. satisfaction with life 2. future plans 3. purpose for life 4. harmony between beliefs and cultures 5. family values 6. spiritual support system
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Needs assessment includes:
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1. privacy for prayer 2. special foods 3. spiritual distress
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Assess for nurse: Own spirituality:
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helps to gain and maintain the necessary spirituality to help patients face spiritual crisis
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First developmental Stage of Faith
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Intuitive- projective faith: early childhood imagination, perception, and feelings, involves positive and negative powers
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Second developmental Stage of Faith
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Mythic-Liberal Faith: beyond development of logical thinking- understand world order and meaning of life
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Third developmental Stage of Faith
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Synthetic-Conventional Faith: adolescence and beyond- personal, mostly reflective, values and beliefs, relies on conventional belief systems
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Fourth developmental stage of faith
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Individualistic-reflective faith: young adulthood and beyond- critical reflection on values and beliefs, understanding of self and social system, choice made about ideology and life-style
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Fifth developmental stage of faith
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Conjunctive Faith: mid-life and beyond- realizes multiple interpretations of reality, reinterpretation of life and appreciation of symbols, metaphors, and myths to understand truth
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Sixth developmental stage of faith
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Universalizing Faith: mid-life and beyond- oneness with the power of being, devotes self to overcoming oppression and division
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Formal Interviewing
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a specific list of questions (health history)
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Informal interviwing
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less formal, not a list, just some questions
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Open ended questions
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more for them to say- longer responses
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closed endeed questions
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yes or no answers- short answers
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Empathy
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try not to ask why- reflect on what they say "my mom ignores me" "she ignores you"?
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medical Jarvin
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don't use too much medical terminology because not everyone understands- try to explain things to them in the simplest terms possible- and make sure they understand.
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What do you end an interview with?
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Can I get you anything before leaving, or talk about anything with you?
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Example of subcultures
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catholics, school of nursing, sororities
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What does our culture view health as?
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the absence of disease
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Philosophy of life
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personal goals and beliefs
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Beware of messages you send to pt:
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you're busy, disinterested, or making poor eye contact
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When interviewing a pt you should:
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take your time, act interested, and make good eye contact
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Nonverbal communication when interviewing the pt:
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posture, physical appearance, gestures, facial expressions, eye contact, and tone of voice
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3 parts of Philosophical stance
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1. goodness of fit in nursing: (generally liking people, and accepting peoples weaknesses and strengths, being optimistic about people) 2. Empathetic: viewing from others frame of reference, but remain true to own self, understanding from other's frame of reference 3. Ability to listen: note what they are saying, and not what is being said
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Interviewing environment
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1. privacy: confidentiality 2. Avoid interruptions if possible 3. Physical enviroment: room temp, good lighting, reduce noise, avoid clutter, note taking
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Things to be careful with when interviewing pt.
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1. providing false assurance 2. authority- taking down on pt. 3. using avoiding language- acting like you don't want to talk about what they want to 4. Talking too much 5. using why questions 6. Biased questions: "you're not like those ther teen-agers are you"
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What is the oral cavity divided into?
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the mouth, and the vestibule
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Vestibule
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the space between the buccal mucosa and the outer surface of the teeth and gums
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Mouth
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the anterior opening of the oral pharynx
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Roof of the mouth
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the bony arch of hard palate and fibrous sofy palate
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Uvula
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hangs from posterior margin of the soft palate
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What is the tongue anchored down to the mouth by?
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the frenulum
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Dorsal surface of the tongue is covered by?
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thick mucous membrane- and supports the filiform papillae
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Ventral surface of tongue
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visible veins, thin mucous membrane with ridges
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Gingiva
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fibrous tissue covered by mucous membrane- attached directly to alveolar surface
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How many adult teeth do we have?
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32 teeth
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Tonsils
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sit in between cavity and collect cellular debris, and other debris
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Salvation
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increases by 3 months- they drool until they learn how to swallow
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History for mouth:
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Present: dental problems, mouth lesions, sore throat, difficulty swallowing Past: hypertension, diabetes, bleeding disorder, throat infections, strep Personal care: oral care patterns, last dental appt, condition of teeth, dentures, crowns, etc. history of mouth cancers
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Exam
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inspect and palpate
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Lips (exam)
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get lip stick off, look for symmetry, edema, lesions
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Teeth (exam)
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close mouth, ask to clench teeth, upper incisors should override lower, look at color and condition, check for mobility and count
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Gingiva (exam)
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pink to coral, hypertrophy, reddened swelling, pockets of debris,
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Tongue
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symmetry and movement, color pink,
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Infants and Children
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-drooling is common up to 1 years old, should not extend over 2 years old -tongue should fit into floor of mouth and be midline -buccal mucosa should be pink without lesions
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Koplik
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small blue dots in children mouth- usually a sign of onset of measles
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Leukoplakia
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chalky white on the tongue
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Nose
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indication of odors
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allergic solute
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happens from wiping their nose up because they have snot running out their nose
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apnoids
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when these get plugged it sounds like they have a cold all the time because air can't get through- sometimes need to get removed
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When expecting nose
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be careful because the nose is tender and bleeds easily
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What you examine on the nose
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-look at placement on the face -size, shape, and color -discharge, and describe the discharge -inspect inside the nose with penlight -nasal mucosa: color, discharge, masses, lesions, swelling
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Redness in the nose indicated?
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infection
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Nasal Septum (exam)
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close to the midline and straight asymmetry
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Sinuses (exam)
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-inspect for redness or swelling -palpate zygomatic process for tenderness -hang head forward for tenderness or sinus pressure
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Transilluminate
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-dark room: use a light to see if you can see through sinuses are plugged
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Infants and children (nose exam)
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-symmetry -unusual shapes can indicate congenital anomalies -inspect inner nose * obligatory nose breathers
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Alimentary Tract
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27 feet long- extends from mouth to anus
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What does the alimentary tract consist of?
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mouth, esophagus, stomach, small intestine, large intestine
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What is the function of the large intestine?
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ingest and digest food, absorb nutrients electrolytes and water, and excrete waste products
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Peristalsis
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moves products of digestion along and is under autonomic control
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Esophagus
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long, collapsible, and connects pharynx to the stomach
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Stomach
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flask shaped, lies transversely in upper abd. cavity- below the diaphragm
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Three sections of the stomach
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1. Fundus: above and left of cardiac orifice 2. Body: mid 2/3 3. Pylorus: most distal portion narrows and terminated in pyloric orifice
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Small intestine (where it starts)
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begins at pyloric orifice
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Duodenum
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-forms a C around the head of the pancreas -common duct and pancreatic duct open into duodenum
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Jejunum
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- gradually becomes larger and thicker
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Ileum
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ileocecal valve between the ileum and large intestine- prevents back flow of fecal matter
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What happens in the small intestine?
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-Digestion is completed here through action of pancreatic enzymes, bile and several small intestine enzymes -nutrients are absorbed through walls of small intestine- the surface area is increased through circular folds and villi
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Where does large intestine begin?
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cecum
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Ascending colon
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beings at cecum and continues to the right post abdomen wall to the under surface of the liver- hepatic flexure
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Transverse colon
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crosses the abdomen cavity toward the spleen, where i flexes downward- splenic flexure
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Descending colon
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continues along abdomen wall to the rim of the pelvis- turns medially inward to form the S shape sigmoid colon
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Rectum
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extends from the sigmoid colon to the muscles of the pelvic floor and continues as the anal canal
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Liver (where is it located)
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upper right quadrant of the abdomen- below the diaphragm- surrounds the gallbladder, stomach and colon-
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What is the heaviest organ in the body?
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liver
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Liver (function)
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- stores several vitamins and iron -metabolizes carbohydrates, fats, protein -produces antibodies and substances for blood coagulation -produces most of proteins that circulate in the plasma
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Gallbladder (function)
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stores bile from the liver
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Pancreas (location)
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lies behind and beneath the stomach
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Pancreas (function)
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-pancreatic enzymes help to break down proteins, fats, and carbohydrates -insulin and glucagon regulate the body's level of glucose
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Spleen (location)
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upper quadrant above the left kidney, and below the stomach
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Spleen (function)
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-white pulp: lymphoid tissue which comprimses most of the organ -red pulp: capillary network and allows for storage and release of blood
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Kidney (location)
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- extends from vertebral level of T 12 to L3 - right kidney is lower than left (because of liver)
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Kidney (function)
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produces renin, which controls aldosterone secretion
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Order of exam for Abdomen
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1. inspection 2. auscultation 3. percussion 4. palpation
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Bowel sounds
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high pitched sounds- should hear 5-35 sounds per minute
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ARIF (vascular sounds)
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aortal, renal artery, ilial artery, femoral artery
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History (abdomen exam)
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HPI: abdomen pain, indigestion, vomiting, fecal incontinence, jaundice, urinary frequency etc.
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Personal and Social hirsory (abdomen)
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-24 hr dietary recall -recent stressful life events -exposure to infectious disease -trauma, physical activity, work, or abuse -street drugs
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Infant history (abdomen)
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-jaundice -vomiting -enlarged abdomen
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Inspection for abdomen
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-skin: color, scars, dilated veins, rashes, lesions -Color changes: jaundice, cyanosis, silvery white -lesions: nodules may indicate lymphoma
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Auscultation for abdomen
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-bowel sounds -vascular sounds (use bell)
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Percuss for abdomen
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-percuss four quadrants for tymphany -percuss liver (start below umbilicus and move up, then in thorax move down) - should be 6-12cm
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Palpation for abdomen
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- feel muscle tone and tenderness -check for masses on abdomen
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Rebound pain
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when you push down on the pain, pain will decrease, when you let go pain will intensify agai
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Positive Blumberg
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sharp stabbing pain at site of peritoneal tenderness
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Positive Mcburney
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-lower abdomen -usually a diagnostic for appendicitis
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Iliopsos muscle test
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1. hand on lower rt. thigh and ask pt to raise and flex thigh 2. pt on left, raise rt. let while examiner resists 3. pt on rt hyperextended leg by drawing backwards -if positive will cause lower right quadrant pain
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Obturator muscle test
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use when you suspect appendix or pelvic abscess
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Examination techniques
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1. inspection 2. palpation 3.percussion 4. auscultation
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Inspection
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observation-first step -subjective questions first -inspect only what you need to inspect -explain the reason why you are doing something
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Palpation
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uses hands and fingers to find out information -mobility: elasticity of skin, and tugor (dehydration of skin) -check temperature of the body
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Light Palpation
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about 1 cm
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Deep Palpation
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about 4 cm
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Bimanual
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putting one hand behind and one hand in front and push your hands together- assess kidneys or ovaries
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Percussion
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the action is in the wrist -middle finger is only finger that should be touching, and use it like a "hammer" hit a couple times and move over
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Tymphany (percussion)
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stomach or intestine: usually loud cause it is filled with air
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Resonance
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when hitting down between the ribs, this is the normal sound you will hear
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Dullness (percussion)
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usually over an organ- should be a dull sound
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Flatness (percussion)
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usually over a muscle or bone
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Direct percussion
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just one finger on one area, such as the sinuses
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Indirect percussion
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one finger over more than one area
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Auscultation
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use a stethoscope to hear sounds -bell: to hear low pitch sounds -diaphragm: to hear high pitch sounds
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Things you listen to for auscultation
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heart sounds, lung sounds, bowel sounds, vascular sounds
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Calories (% of food groups)
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-50% calories should be carbohydrates -20% calories should be protein -30& calories should be fat
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How much of our body is made up of water?
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55-65%
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BMI
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body mass index -18.5-24.9 is normal weight -25 or over is considered overweight
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What is the largest organ in our body?
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our skin
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Skin (function)
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-elastic and mobile -provides mechanic barrier, and regulates body temperature -retards body fluid loss -protects against microbial and foreign substance invasion
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Conduction
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warmer area to cooler area- loss of heat such as our warm bodies going into a cool bed
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Skin Function
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produced vitamin D repairs wounds excretes sweat, urea, and lactic acid expresses emotions
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Epidermis
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outside of the skin
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Dermis
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separates epidermis from the subcutaneous tissue - elastin in this layer (as we get older we lose this) -sensory fibers (pain, touch, and temperatures)
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Hypodermis
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eccrine sweat glans- regular body temo made up of loose connective tissue
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Xerosis
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dry skin- skin doesn't get enough hydration
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What does the color of your hair depend on?
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How many melanocytes - the darker the hair, the more melanocytes
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Three stages of hair growth
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1. anagen- growth 2. catagen- atrophy 3.telogen- rest
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What are your nails made up of?
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Epidermal cells that get turned into hard plates of keratin cells
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Perincia
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enlargement, pain, lesions of fingers
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What is the fine hair on babies called?
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lanugo
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petechia
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more than .5 diameter- children's eyes or throat -nonblanchable, intravascular defects and infections
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Purpura
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less than .5 diameters -nonblanchable, intravascular defects and infections
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Ecchymosis
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size variable -nonblanchable, vascular wall destruction, trauma, vasculitis -brusing
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Spider Angioma
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Blanch with pressure
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Venous star
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Nonblanching
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Telangiectasia
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-fine, irregular, dilated capillaries
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Capillary Hemangioma
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red irregular macular patches
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Primary lesions
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occurring as initial manifestations many times of a pathologic process
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Secondary lesions
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something of that pathologic lesion changes-scratch it and it becomes infected it then becomes secondary
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Characteristics of lesions
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measure(diameter), shape, color, texture, elevation
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Exudates from lesions
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color, amount, consistency,
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Pattern of Arrangement of lesions
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annular rings, grouped, linear, arciform (bow shaped), diffuse, zosteriform (on a nerve path)
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Location and Distribution of lesions
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generalized, localized, region of body, discrete, confluent
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Border or margin of lesions
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discrete, indistinct, active, irregular, advancing
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Thorax
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thorax cage of bone, cartilage, and muscles move as lung expands
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Anterior portion
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-sternum -manubrium -xyphoid process -costal cartilage
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Lateral portion
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12 pairs of ribs
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Posterior portion
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12 thoracic vertebrae -all 12 ribs are attached to vertebrae
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Primary muscles of respiration
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Diaphragm and intercostals
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Interior chest- three major spaces
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1. right left pleural cavities 2. pleural cavities lined with pariteal and visceral pleura 3. serous membrane that encloses the lungs
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Trachea
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lies anterior to esophagus
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Coryza
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another word for a cold
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History (respiratory)
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-do they have a cough?(productive, wet, dry) -are they coughing anything up?(color, texture) -whooping cough?(sounds like a bark)
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Cheyne Stoke
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caused by CHF, and brain damage -breath regular and then stop breathing for 10-15 seconds, and then start breathing regular again
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Biot's Respirations
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Similar to cheyne stoke, but the breathing pattern is irregular
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adventitious sounds
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sounds you should NOT be hearing in the lungs
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Bronchi
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snoring sounds in lungs -take a deep breath and cough for me (if it canbe cleared than thats a good sign, if not then theres a problem
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Wheezing
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inflammation of the lungs
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Bronchovesicular
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equal inspiration and expiration
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Crackel
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caused by small airway with sticky exudate- or liquid in lungs
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Bronchophony
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99 is spoken- sound should decrease the further down your back you go
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Whisper pectoriloquy
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99 whispered- sound should decrease the further down the back you go
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Obligate nose breather (age)
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age 1
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Egophony
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E- spoken if it sounds more like an A than there is a problem
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Kussmaul
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rapid deep breathing -metabolic acidosis
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Ataxic
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varying depths, and irregular, not organized
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Air trapping
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not time for sufficient expirations- especially with increase respiration rate- becomes shallow
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Dyspnea onset of 10 P's
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1. pneumonia 2. pneumothorax (collapsed lung) 3. pulmonary constriction (asthma) 4.Peanut=foreign body 5. pulmonary embolism (blockage in pulmonary artery) 6.pericardial tamponade (heart can't pump enough blood) 7. pump failure 8. peak seekers 9. psychogenic (psychological cause) 10. posions
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Collapsed lung
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extra pleural air, fluid, or mass
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Auscultation is characterized by
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1. intensity: loud, soft 2. pitch: low, high, med high 3. quality: sonorous, musical, crackling 4. duration: long, short -Listen for complete inspiration and expiration
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What is the sequence of techniques used during an examination of the abdomen? a: percussion, inspection, palpation, auscultation b: inspection, palpation, percussion, auscultation c: inspection, auscultation, percussion, palpation d: auscultation, inspection, palpation, percussion
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C: inspection, auscultation, percussion, palpation
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Which of the following can be noted through inspection of a patient's abdomen? a: fluid waves and abdominal rigidity b: umbilical eversion and Murphy's sign c: venous pattern, peristaltic waves, and abdominal contour d: peritoneal irritation, general tymphany, and peristaltic waves
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C: venous pattern, peristaltic waves, and abdominal contour
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Right upper quadrant tenderness may indicate pathology in the: a: liver, pancreas, or ascending colon b: liver and stomach c: sigmoid colon, spleen, or rectum d: appendix or ileocecal valve
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A: liver, pancreas, or ascending colon
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Hyperactive bowel sounds are: a: high-pitched b: rushing c: tinkling d: all of the above
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D: all of the above
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The absence of bowel sounds is established after listening for: a: 1 full minute b: 3 full minutes c: 5 full minutes d: none of the above
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C: 5 full minutes
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Auscultation of the abdomen may reveal bruits of the _______ arteries: a: aortic, renal, iliac, and femoral b: jugular, aortic, carotid, and femoral c: pulmonic, aortic, and portal d: renal, iliac, internal jugular, and basilic
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A: aortic, renal, iliac, and femoral
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The normal range of liver span in the right midclavicular line in the adult is: a: 2-6 cm b: 4-8 cm c: 8-14 cm d: 6-12 cm
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D: 6-12 cm
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The left upper quadrant contains the: a: liver b:appendix c: left ovary d: spleen
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D: Spleen
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A female patient has striae on the abdomen. Which color indicates ling-standing striae? a: pink b: blue c: purple-blue d: silvery white
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D: silvery white
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Auscultating the abdomen is begun in the right lower quadrant because: a: bowel sounds are always present here b: peristalsis through the descending colon is usually active c:this is the location of the pyloric sphincter d: vascular sounds are best heard in this area
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A: bowel sounds are always present here
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A dull percussion note forward of the left midaxillary line is: a: normal; an expected finding during splenic percussion b:expected between the 8th and 12th ribs c: found is the examination follows a large meal d: indicative of splenic enlargement
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D: indicative of splenic enlargement
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Shifting dullness is a test for: a: ascites b: splenic enlargement c: inflammation of the kidney d: hepatomegaly
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A: ascites
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Tenderness during abdominal palpation is expected when palpating the: a: liver b: spleen c: sigmoid colon d: kidneys
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C: sigmoid colon
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A positive Murphy's sign is best described as: a: the pain felt when the examiner;s hand is rapidly removed from an inflamed appendix b: pain felt when taking a deep breath when the examiners fingers are on the approximate location of the inflamed gallbladder c: a sharp pain felt by the patient when one hand of the examiner is used to thump the other at the costovertebral angle d: this is not a valid examination technique
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B: pain felt when taking a deep breath when the examiners fingers are on the approximate location of the inflamed gallbladder
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A positive Blumberg sign indicates: a: possible aortic aneurysm b: presence of renal artery stenosis c: enlarged, nodular liver d: peritoneal inflammation
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D: peritoneal inflammation
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What are the three types of normal breath sounds?
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Bronchial, Bronchovesicular, and Vesicular
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The manubriosternal angle is: a: the articulation of the manubrium and the body of the sternum b: a hollow, U-shaped depression just above the sternum c: also known as the breastbone d: a term synonymous with costochondral junction
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A: the articulation of the manubrium and the body of the sternum
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Select the correct description of the left lung: a: narrower than the right lung with three lobes b: narrower than the right lung with two lobes c: wider than the right lung with two lobes d: shorter than the right lung with three lobes
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B: narrower than the right lung with two lobes
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You assess a patient who reports a cough. The characteristic timing of the cough of chronic bronchitis is described as: a: continuous throughout the day b: productive cough for at least three months of the year for two years in a row c: occurring in the afternoon or evening because of exposure to irritants at work d: occurring early in the morning
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B: productive cough for at least three months of the year, for two years in a row
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Which of the following assessments best confirms symmetric check expansion?
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Placing hands on the posterolateral chest wall with thumbs at level of T9 and T10 and then sliding the hands up to pinch a small fold of skin between the thumbs
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Absence of diaphragmatic excursion occurs with: a: asthma b:an usually thick chest wall c:pleural effusion or atelectasis of the lower lobes d: age-related changes in the chest wall
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C: pleural effusion or atelectasis of the lower lobes
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You are auscultating breath sounds on a patient. Whats the procedure to do so?
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Hold the diaphragm of the stethoscope against the chest wall; listen to one full respiration in each location, being sure to do side to side comparisons
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Select the best description of bronchovesicular breath sounds: a: high-pitched, of longer duration on inspiration than expiration b:moderate-pitched, inspiration equal to expiration c: low-pitched sounds, inspiration greater than expiration d: rustling sounds, like the wind in trees
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B: moderate-pitched, inspiration equal to expiration
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After examining a patient you make the following notation: increased respiratory rate, chest expansion decreased on left side, dull to percussion over left lower lobe, breath sounds louder with fine crackles over left lower lobe. These findings are consistent with: a: bronchitis b: asthma c: pleural effusion d: lobar pneumonia
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D: lobar pneumonia
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Pleural Effusion
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excess fluid that accumulates in the pleural cavity, the fluid-filled space that surrounds the lungs. This excess can impair breathing by limiting the expansion of the lungs
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On examining a patient's nails, you note that the angle of the nail base is >160 degrees and the nail base feels spongy to palpation. These findings are consistent with: a: acute respiratory distress syndrome b: normal findings for the nails c: congenital heart disease and COPD d: atelectasis
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C: congenital heart disease and COPD
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Atelectasis
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partial or complete collapse of the lung.
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On auscultating a patient you note a coarse, low-pitched sound during bother inspiration and expiration. The patient reports pain with breathing. These findings are consistent with: a: fine crackles b: wheezes c: atelectatic cracks d: pleural friction rub
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D: pleural friction rub
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To use the techniques if egophony, ask the patient to: a: take several deep breaths and then hold for 5 seconds b: say "eeeee" each time the stethoscope is moved c: repeat the phrase "99" each time the stethoscope is moved d: whisper a phrase as auscultation is performed
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B: say "eeee" each time the stethoscope is moved
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When examining for tactile fremitus, it is important to: a: ask the patient to breath quickly b: ask the patient to cough c: palpate the chest symmetrically d: use the bell of the stethoscope
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C: palpate the chest symmetrically
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Tactile(touch) fremitus
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Fremitus refers to vibratory tremors that can be felt through the chest by palpation.
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Pulse oximetry means: a: arterial oxygen saturation of hemoglobin b: venous oxygen saturation of hemoglobin c: combined saturation of arterial and venous blood d: carboxyhemoglobin levels
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A: arterial oxygen saturation of hemoglobin
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A pleural friction rub is best described by: a: observation b: palpation c: auscultation d: percussion
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C: auscultation
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A patient has a barrel-shaped chest, characterized by: a: equal anteroposterior transverse diameter and ribs being horizontal b: anteroposterior transverse diameter of 1:2 and an elliptic shape c: anteroposterior transverse diameter of 2:1 and ribs being elevated d: anteroposterior transverse diameter of 3:7 and ribs sloping back
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A: equal anteroposterior transverse diameter and ribs being horizontal
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Apex
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3-4 cm above the inner third of the clavicles
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Base
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rests on the diaphragm
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Lateral Left
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sixth rib, midclavicular line
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Lateral Right
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fifth intercostal
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Posterior apex
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C7
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Normal chest
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Elliptic shape with an anteroposterior to transverse diameter in the ratio of 1:2
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Barrel chest
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Anteroposterior= transverse diameter
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Pectus excavatum
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Sunken sternum and adjacent cartilages
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Pectus carinatum
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Forward protrusion of the sternum with ribs sloping back at either side
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Scoliosis
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Later S-shaped curvature of the thoracic and lumbar spines
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Kyphosis
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Exaggerated posterior curvature of the thoracic spine
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The concept of health and healing has evolved over the years. What is the best description of health?
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Health depends on the interaction of mind, body, and spirit within the environment
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What would be included in the database for a new patient admission to a surgical unit?
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all subjective and objective, and data gathered from a patient and the results of any laboratory or diagnostic studies completed
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A patient is in the emergency room with nausea and vomiting. What would you include in the database?
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a diet and GI history
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A patient recently received health insurance and would like to know how often he should visit his provider. How to you respond?
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" your visits may vary, depending on your level of wellness"
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You are reviewing concepts related to steps in the nursing process for determining prioritization and developing patient outcomes. To what are these actions attributed? a: planning b: assessment c: implementation d: diagnosis
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A: Planning
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What is a risk diagnosis?
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identifying potential problems the individual may develop
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What would be included in a holistic model of assessment?
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A patient's perception of her or her health status
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PERIOTINITIS
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P-Pain E-Electrolytes R-Ridgity/rebound I- immobile T- Tenderness O-Obstruction N- Nausea and vomiting I- incrrease in pulse/decrease BP T- Temperature I- Increased girth S- silent abdomen
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PQRSTU
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P-Palliative/Provocative Q-Quantity/Quality R-Region S- Severity T-Temporal U-You
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