NURS 251 EXAM 1 questions with correct answers

nursing process systematic problem solving approach to identifying and treating human responses to actual or potential health problems 5 phases of nursing process assessment, diagnosis, planning, implementation, evaluation assessment the systematic process of gathering, verifying, and communicating data 4 types of assessment initial comprehensive, ongoing, focused, emergency initial comprehensive assessment occurs when client first presents to health care system, overall picture, subjective and objective data ongoing/partial assessment after comprehensive, reassessment of initial problem of baseline, looking for improvement/deterioration focused/problem assessment occurs in relation to specific health concern emergency assessment rapidly when life saving action needs to be taken, immediate diagnosis to begin treatment subjective data info stated by patient objective data directly observed by examiner inspection the use of senses to observe the general status of the client palpation use of touch and feel to identify types of palpation light - less than one cm moderate - 1-2 cm deep 2.5-5 cm percussion discrimination of sounds produced when striking the hand over different organs and cavities direct percussion 1-2 fingertips blunt percussion nondominant hand flat on organ, dominant hand hits nondominant hand indirect percussion most common, tap finger on other finger percussion sounds resonance, hyperresonance, tympanic, dull, flat resonance air in lung hyperresonant emphysematous (a lot of air) tympanic air in gastric region (abdomen) dull thud like, solid organ (liver) flat extreme dullness (thigh) auscultation listening for sounds of movement within body (stethoscope) diaphragm of stethoscope flat surface, conducts high pitched sounds bell of stethoscope domed surface, conducts low pitched sounds body temperature difference between heat production and heat loss range for temperature 36.5-37.7 degrees C 96.9-99.9 degrees F pulse shock wave produced by blood pumped from heart as it travels through artery pulse range 60-100 bpm for adults pulse characteristics rate, rhythm, amplitude, elasticity respiration range 12-20 breaths per minute tachypnea greater than 24 breaths per minute bradypnea less than 10 breaths per minute blood pressure pressure exerted on the walls of the arteries when the ventricles contract and relax systolic range 90-120 diastolic range 60-80 pain 5th vital sign, it is what the patient says it is acute pain less than 6 months duration, discomfort from tissue damage, expectation of relief with a certain time frame, mainly physiological chronic pain longer duration with psychological and physiological component, no useful purpose cutaneous pain superficial, localized deep somatic pain diffuse, originates in muscles, joints, or parietal surfaces visceral pain diffuse, hard to locate, originates from organs, often referred; ex heart attack radiating pain pain moves outward from central location referred pain pain in an area removed from tissue causing pain, ex. gall bladder could hurt in shoulder COLDSPA characteristic, onset, location, duration, severity, pattern, associated factors likert scale 0-10 for pain ADLs activities of daily living appendicular skeleton shoulders, arms, legs, pelvis axial skeleton skull, vertebrae, ribs, sternum ligaments join bone to bone tendons attach muscles to periosteum of bones cartilage gel like tissue at end of bones joints two surfaces where bones meet synarthrotic joints immovable ex. cranial sutures amphiarthrotic joints slightly movable, ex. vertebrae diarthrotic freely moving ex. shoulders/ball and socket ball and socket joint hip, shoulder hinge joint elbow, ankle saddle joint thumb ROM range of motion, degree of movement of a joint flexion decrease in degree extension increase in degree abduction away from body adduction towards body supination palms up pronation palms down dorsiflexion foot up toward nose plantar flexion foot downward (step on gas) inversion pigeon toed eversion duck feet rotation circular motion full range of motion normal limited ROM abnormal active ROM patient can move themselves passive ROM client unable to complete AROM, nurse has to help hypotonic (muscle) less than, weak, concave hypertonic (muscle) more than, jerky, spastic paresis weakness hemiparesis weakness on one side of body, one side weaker than the other hemiplegia paralysis on one side of body paraplegia paralysis of two extremities bilaterally quadraplegia paralysis of all 4 extremities osteoarthritis degenerative Joint disorder (DJD) "wear and tear" heberden nodes on distal interphalangeal joint, or knuckle closest to fingertips, hard nontender nodules bouchard nodes proximal interphalangeal joint, middle knuckle, hard nontender nodules rheumatoid arthritis painful, fusiform swelling of PIP, spindle shaped fingers, swan neck deformities tinel sign (for carpal tunnel) tap median nerve at wrist, positive if tingling sensation down nerve phalen's sign (for carpal tunnel) palmar flexion for 1 minute, positive if numbness/tingling over palmar surface and 1st 3 fingers scoliosis lateral deviation of the spine, one scapula higher than the other actual curve of spine cervical concave, thoracic convex, lumbar concave, sacral convex kyphosis hum back, flexion deformity of spine (old people) lordosis sway back, extension deformity of spine lasegue's test for herniated lumbar disc, lower back pain - straight leg rasing, slowly raise straight leg until pain, dorsiflex foot increases pain, flexion of knee relieves pain alert (consciousness) awake, responds immediately and appropriately to stimuli confused (consciousness) inappropriate responses to stimuli, decrease in attention span and memory