NS 233 exam 1 questions and answers

cardiovascular assessment pale, cool, clammy (damp) skin n/v SOB dizziness, weakness, faintness hypotension dyspnea tachycardia diaphoresis mild to severe chest pain confusion or disorientation cyanosis decreased urinary output unresponsiveness normal sinus rhythm HR 60-100 regular R-to-R clearly see P, QRS, T sinus bradycardia HR below 60 regular R-to-R clearly see P, QRS, T sinus tachycardia HR 100-150 regular R-to-R clearly see P, QRS, T SVT sudden onset of tachycardia (greater than 151) may be seen with caffeine, nicotine, and some street drugs supraventricular tachycardia (SVT) HR above 151 regular R-to-R clearly see P, QRS, T premature atrial complex occurs within sinus rhythms complex occurs earlier than next expected may have compensatory or non-compensatory pause after secondary to anxiety, caffeine, nicotine, meds, exercise sinus bradycardia with PAC HR below 60 clearly see P, QRS, T maybe beat comes early irregular R-to-R sinus rhythm with PAC HR 60-100 clearly see P, QRS, T maybe beat comes early irregular R-to-R sinus tachycardia with PAC HR 101-150 clearly see P, QRS, T maybe beat comes early irregular R-to-R atrial flutter irritability on single site within the atria saw-toothed or jagged baseline with no true P waves atria quiver occurs with MI or heart disease F waves - instead of P or T waves atrial flutter with slow ventricular response HR below 60 regular R-to-R unclear P, QRS, T a. flutter with controlled ventricular response HR 60-100 regular R-to-R unclear P, QRS, T a. flutter with rapid ventricular response HR 100-150 regular R-to-R unclear P, QRS, T atrial fibrillation increased irritability of atrial tissue electrical impulses generated in various places in atria atria quiver and very disorganized wavy baseline with no true P waves occurs with MI or heart disease irregular rhythm secondary to random electrical impulses going through AV node a. fib with slow ventricular response HR below 60 irregular R-to-R unclear P, QRS, T a. fib with controlled ventricular response HR 60-100 irregular R-to-R unclear P, QRS, T PR interval less than or equal to 0.20 QRS interval less than or equal to 0.12 QT interval less than or equal to 0.40 pain it is what the patient says it is location, intensity, frequency COLDERRA acute pain sudden onset typically clearly linked to a specific event injury or illness chronic pain pain lasting more than 3 months results from underlying medical conditions, injury, medical treatment, inflammation, or unknown causes nociceptive pain caused by damage to somatic or visceral tissue superficial somatic - sharp, burning, prickly; skin, mucous membranes, subcutaneous tissue deep somatic - aching, throbbing; bone, joint, muscle, connective tissue visceral - visceral organs; cramping nonopioids, opioids, adjuvants, analgesics neuropathic pain caused by damage to peripheral nerves or structures in the CNS numbing, hot, burning, shooting, stabbing, sharp, electric shock-like sudden, intense, short lived, or lingering mobility purposeful movement through the synchronization of the musculoskeletal and nervous system, resulting in the coordination of gross and fine motor movements dependent on adequate oxygenation, perfusion, cognition impaired mobility population older adults at greater risk risk factors for impaired mobility acute and chronic conditions injury/trauma chronic pain meds medical treatment S/S impaired mobility unsteady gait and posture deformities or swelling of joints loss of movement edema redness or warmth limitations in movement weakness numbness or tingling altered ROM impaired mobility interventions safety fall risk tools safe handling early mobility positioning with proper body alignment reposition prevent skin breakdown cough and deep breathe ROM assistive devices sequential compression device impaired mobility drug therapy anti-inflammatory analgesics and muscle relaxants vitamin supplements impaired vision range from minor distortion to complete blindness injury may develop can vary in scope and age of onset HTN and diabetes interfere with vision loss impaired vision interventions use safety devices (eye protection), lasik surgery, eye glasses, contacts, braille, orient to room, pressure on inner canthus when administering eye drops age-related macular degeneration central vision loss gradual blockage of retinal capillary arteries macula become ischemic and necrotic dry - age related wet - new growth of blood vessels that leak; any age macular degeneration risk factors female smoking hypertension family history diet lacking carotene and vitamin E S/S macular degeneration lack of depth perception distortion blurred vision central vision loss blindness macular degeneration treatment laser therapy to seal vessels macular degeneration patient education diet of carotene, vitamin E & B12, antioxidants may need transportation reading assistance (large print) cataracts opacity in the lens due to fiber compaction (cloudy lens) various causes cataracts risk factors increases with age diabetes heredity smoking eye trauma S/S cataracts decreased acuity including poor night vision & color perception blurred and double vision cataracts treatment surgical treatment to remove or replace lens cataracts patient education annual eye exam wear sunglasses increase light in the room magnifying glass/large print report pain/n/v/vision changes such as flashes of light, floaters best vision in 4-6 weeks self care/fall prevention cataracts nursing considerations must prevent an increase in IOP post op, prevent infection, pain relief glaucoma disturbance of the optic nerve need a balance of aqueous humor primary open - outflow decreased r/t blockage primary closure - emergency; angle between iris & sclera closes glaucoma risk factors age infection tumors genetic disposition hypertension S/S glaucoma increased IOP (normal 10-21) reduced vision mild eye pain loss of peripheral vision halos with lights can lead to blindness glaucoma diagnostic tests tonometry (measures IOP) glaucoma treatment beta blockers (used every 12 hours, wait 5-10 minutes between drops, apply pressure using punctual occlusion technique) surgery option to improve flow glaucoma patient education annual eye exam avoid activities that increase IOP glaucoma nursing interventions closure needs immediate treatment treat pain & nausea that comes with closed monitor decreased vision & light sensitivity monitor for infection/hemorrhage (surgery) hearing impairment range from minor distortions of speech to complete hearing loss injury, communication difficulties hearing impairment interventions wear ear plugs cochlear implant meds for chronic ear infections hearing aids sign language use board/write things out closed captioning reading lips/stand in front of them well lit room sign/write in hand osteoarthritis gradual loss of articular cartilage with formation of bony outgrowths at the joints slowly progressive non-inflammatory disease of the synovial joints