NUR155 Exam 1 Galen questions and answers verified for accuracy update

When bathing a dementia patient what should you do. Keep covered, move slowly, time bath to patients tolerance. primary prevention Precedes disease. Example: immunizations, nutrition education, family planning secondary prevention Early detection, prompt intervention Example: screenings, any procedure, self exams, assessments. tertiary prevention Begins after illness. Examples: support groups, teaching client to prevent complications. helath promotion Not diseased oriented, POSTIVE approach to wellness. health protection Illness or specific illness. Motivated by AVOIDANCE of illness. Stop health occurance Motivations for non compliant patients Reassurance, open ended questions. Holism Client is whole person, not just the area of concern is considered Individual care Nurse is acquainted to client as a person uses total care princples that apply to specific person total care Nurse looks at all principles and areas that apply for the clients AGE and CONDITION Maslow's Hierarchy of Needs physiological, safety, love/belonging, esteem, self-actualization nodule/tumor elevated, solid, palpable mass with irregular border- may be malignant (cancerous) or benign ex. tumor pustule elevation of skin containing pus example: acne Cyst 1 cm or larger, elevated, fluid filled or semisoild wheal raised red skin lesion due to interstitial fluid Example:hives Vesicle Circumscribed, round or oval. Contains serous fluid or blood. EXAMPLE: small burn blister, Bulla a large blister that is usually more than 0.5 cm in diameter Example: large burn blister normal nail angle 160 degrees clubbing Nail is 180 degrees or greater vesicular lung sounds low-pitched, soft sounds heard over peripheral lung fields Bronchovesicular lung sounds Blowing sound, air moves through bronchi. Located between scapula lateral to sternum. 1st and 2nd intercoatal space. bronchial lung sounds Harsh sounds, air moving through trachea, located over trachea. crackles (rales) high pitched, can be heard during breath in and out. Located in the lower lobes. Gurgles (rhonchi) Harsh Low pitched moaning sound. Best heard breathing out. Over most lung areas. Heard mostly over bronchi and trachea friction rub a coarse, grating, adventitious lung sound heard when the pleurae are inflamed. wheeze high-pitched, musical, squeaking adventitious lung sound. Located in all lung fields assess clients balance Romberg test: feet together, arms resting in the sides. Assessing Temperature locations Oral(side of frenulum) Rectal(1.5 inches for adults) Axillary(tip in axilla Tympanic (ear) temporal(slide forehead to hairline) cardiac output heart rate x stroke volume peripheral pulses Not apical (mitral) Average adult pulse 80 range ( 60-100) Factors that affect pulse Age, sex, fever, medication, stress Pulse volume Absent +1, normal +2, bounding +4 arrhythmia Abnormal heart rhythm costal breathing External inercostal muscles are involved. Chest moves inward and outward diaphragmatic breathing contraction and relaxation of the diaphragm, observed by the movement of the abdomen, which occurs as a result of the diaphragm's contraction and downward movement Factors affecting respiration exercise, stress, environmental temperature, medications, elevation Average respiration rate 12-20 tachypena very rapid respiration bradypnea abnormally slow breathing hypoventilation very shallow respirations Hyperventilation very deep and rapid respirations Systolic contraction diastolic pressure occurs when the ventricles are relaxed orthostatic hypotension low blood pressure that occurs upon standing up Clinical Model of Health absence of disease, prevention not emphasized Role Performance Model Health is the ability to fulfill societal roles Adaptive Model ability to adapt positively to change. How people interact with enviorment Agent-Host-Environment Model views the interaction between an external agent, a susceptible host, and the environment as causes of disease in a person Non-adherence reaction by nurse Establish why, demonstrate caring, postive reinforcements, use teaching aids, establish therapeutic relationships illness Not synonymous with disease. Subjective disease An alteration in body function resulting in a reduction of capacities or shortening of the normal life span. Etiology cause of disease acute illness A sudden illness from which a person is expected to recover chronic illness Long duration usually 6 months or longer Asepsis freedom from disease-causing microorganisms medical asepsis practices designed to reduce the number and transfer of pathogens; synonym for clean technique Clean absence of almost all microorganisms