Exam One Study Material NUR 256 - Verified Correct Answer Key

Exam One Study Material NUR 256 - Verified Correct Answer Key week 1 material - answer - -vital signs + pain -clinical judgement and critical thinking Average adult temperature range - answer - 36 C to 38 C (96.8 F to 100.4 F) average older adult temperature range - answer - 35 C to 36.1 C (95 F to 97 F) factors affecting body temperature - answer - -Age -exercise -hormone level -circadian rhythm -stress -environment -temperature alterations -time of day ( lowest at 0600, highest at 1600) hyperthermia - answer - An elevated body temperature related to the inability of the body to promote heat loss or reduce heat production. -any disease of hypothalamus impairs heat loss malignant hyperthermia - answer - A hereditary condition of uncontrolled heat production that occurs when susceptible people receive certain anesthetic drugs. heatstroke - answer - a body temp of 104 or more accompanied by hot dry skin and CNS abnormalities such as delirium, convulsions or coma heat exhaustion - answer - caused by environmental heat exposure and presents with profuse diaphoresis that results in excess electrolyte and water loss hypothermia - answer - heat loss during prolonged exposure to cold overwhelms the ability of the body to produce heat -mild hypothermia = 90 -95 F routes to take temp - answer - -oral (most common, ask if they have eaten or drank in last 30 min) -rectal (most accurate core temp) -axillary (taken in armpit/ most accurate when rectal and oral aren't available) -tympanic (in ear) -temporal (forehead) parts of stethoscope - answer - ear pieces, binaurals, tubing, chest piece (diaphragm and bell) -should be placed directly on skin -do not hold chest piece with thumb -clean between use bell transmits - answer - low pitched sounds (heart and vascular sounds) diaphragm transmits - answer - high pitched sounds (bowel, lungs, heart sounds) pulse - answer - Palpable bounding of the blood flow in a peripheral artery -indirect indicator of circulatory status average pulse range for adult - answer - 60-100 average pulse range for infant - answer - 120-160 average pulse range for toddler - answer - 90-140 average pulse range for preschooler - answer - 80-110 average pulse range for school age child - answer - 75-100 average pulse range for adolescent - answer - 60-90 average pulse range for older adults is - answer - decreased Tachycardia - answer - fast heart rate (higher than 100BPM) Bradychardia - answer - slow heart rate (less than 60BPM) pule deficit - answer - an inefficient contraction of the heart that fails tp transmit pulse wave to the peripheral pulse site how to count pulse - answer - -if rhythm is regular = 30 sec X 2 -if rhythm is irregular = 1 min when taking pulse you need to look for - answer - -rate (the number you get) -rhythm ( regular/irregular) -strength ( 4+, 3+, 2+, 1+, 0) -equality ( are they equal in strength) what factors increase pulse rate? - answer - exercise (short term), temperature (fever and heat), acute pain, emotions, medications (epinephrine) , hemorrhage, postural changes ( standing or sitting) , pulmonary conditions what factors decrease pulse rate? - answer - exercise (long term exercise) , temp (hypothermia), chronic pain, medications ( digitalis, beta adrenergic, calcium channel blockers), postural changes (lying down) What are the 10 pulse sites? - answer - Temporal, carotid, femoral, radial, ulnar, brachial, dorsalis pedis, posterior tibial , popliteal, apical apical and radial pulse deficit - answer - difference between apical and radial pulse -two examiners needed to take pule in 2 locations at the same time What controls respiration? - answer - -brain stem and autonomic nervous system Hypoxia - answer - decreased oxygen to tissues hypoxemia - answer - decreased level of oxygen in the blood atelectasis - answer - collapse of alveoli cyanosis - answer - bluish discoloration of the skin Dyspnea - answer - difficult or labored breathing orhtopnea