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PNUR 102 exam 1
Study guide for exam 1
198
Nursing
Undergraduate 1
07/26/2009

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Term
Techniques that LPNs use for head to toe collection:
Definition
Inspection
Palpation
Percussion
Auscultation
Term
Turgor
Definition
Skin elasticity
Term
PERRLA
Definition
Pupils, Equal, Round, React to light, and Accomidation
Term
Respiratory rate
Definition
12-20/minute
Term
Normal rate of bowel sounds?
Definition
5-35/min
Term
Descriptions of pulse sounds:
Definition
3+ (bounding), 2+ (normal), 1+ (decreased/ thready), 0 (nonpalpable)
Term
Capillary refil rate?
Definition
< 3 sec
Term
Pallor
Definition
paleness
Term
Cyanosis
Definition
bluish or purple color of skin due to deficient oxygen of the blood
Term
Jaundice
Definition
yellowish pigmentation of the skin, tissues and certain body fluids
Term
Petechiae
Definition
a minute rash or purplish spot containing blood that appears in skin or mucous membrane as a result of localized hemorrage.
Term
Erythema
Definition
abnormal redness of the skin due to capillary congestion (as in inflammation)
Term
Macule
Definition
a patch of skin that is altered in color but usually not elevated and that is characteristic of certain diseases like smallpox.
Term
Papule
Definition
a small solid usually conical elevation of the skin caused by inflammation, accumulated secretion, or hypertrophy of tissue elements.
Term
Pustule
Definition
a small elevation of skin containing pus and having an inflamed base.
Term
Lethargic
Definition
abnormal drowsiness
Term
Comatose
Definition
state of profound unconsciousness
Term
Bruit
Definition
several generally abnormal sounds heard on auscultation of carotid artery
Term
Tachypnea
Definition
increased rate of respiration
Term
Bradypnea
Definition
Slow breathing
Term
Crackles
Definition
AKA rales, abnormal resp. sounds heard more often on inspiration; discrete, discontinuous sounds, each lasting just a few milliseconds
Term
Wheezes
Definition
difficult respir. usually with a whistling sound
Term
Lordosis
Definition
forward curvature of the lumbar and cervical regions of the spine
Term
Kyphosis
Definition
outward curvature of the thoracic region resulting in a rounded upper back
Term
Scoliosis
Definition
lateral curvature of the spine
Term
PATCHES?
Definition
Pulse, Appearance, Temperature, Capillary refill, Hardness, Edema, Sensation (used to assess peripheral vascular system)
Term
What does "ABC, IN, Out, PS" mean?
Definition
Quick pt observation. Airway, Breathing, Circulation, What's going in?, What's coming out?, Pain, Safety.
Term
What is the recommendation included in Dietary Guidelines for Healthy People 2010?
Definition
Consume a variety of nutrients from all food groups, Consume less than 2300 mg sodium per day, Maintain healthy body weight, Regular physical activity, Encourage whole grains and increase fiber, Alcohol in moderation.
Term
Anabolism
Definition
More nitrogen in the system. Ex. of people who have more in their system are pregnant women, children, athletes who are increasing muscle mass. Positive nitrogen balance.
Term
Catabolism
Definition
Less nitrogen in the system. Ex. of people with less nitrogen are those with starvation, trauma, surgery, burns, immobility. Negative nitrogen balance.
Term
Protein calorie malnutrition
Definition
Nutrient intake is insufficient to meet metabolic needs. May be a protein defic. or a calorie defic.
Term
S/sx of protein calorie defic.
Definition
weight loss
Term
What are anthropometric measurements?
Definition
Height/weight, Body Mass Index, Mid-arm circumference, Triceps skin fold, Mid-arm muscle circumference
Term
What lab values are healpful in determining nutritional status?
Definition
serum albumin levels, complete blood count, lipid panel
Term
What are the six nutriets?
Definition
Protein, Carbohydrate, Fat, Vitamin, Mineral, Water
Term
Energy producing nutrients?
Definition
Protein, Carbohy, and Fat
Term
Which nutrients are not energy producing?
Definition
Vitamin, Mineral, Water
Term
What are the major functions of fat?
Definition
Energy, Protects vital body organs, Insulation, Essential part of cell membrane structure
Transports drugs and nutrients thru body
Term
Major functions of proteins?
Definition
Growth and repair of tissue
Regulation of important body functions
Can be used for energy, but not primary purpose
Term
Diff. between simple and complex CHO?
Definition
Complex has many molecules (polysccharides); Simple have only one or two (mono and disaccharides)
Term
Ex. of complex CHO.
Definition
Starch, glycogen, fiber
Term
Ex. of simple CHO?
Definition
Glucose (blood sugar), fructose (fruit sugar), galactose (breakdown of lactose), sucrose (table sugar), maltose (breakdown of starches), lactose (milk sugar).
Term
What is glycogen?
Definition
The storage form of CHO in the liver.
Term
Soluble fiber
Definition
Can be absorbed in the body
Term
Insoluble
Definition
Cannot be absorbed.
Term
Complete verses incomplete protein?
Definition
Complete has all the essential amino acids, and incomplete lack one or more.
Term
What element does protein contain that CHO and fat do not?
Definition
Nitrogen
Term
Non-essential amino acids
Definition
Can be chemically manufactured in the body.
Term
Essential amino acids?
Definition
Must be obtained by by food, because they cannot be produced by the body.
Term
Octolactovegetarian?
Definition
People who consume dairy products but do not consume flesh of any kind.
Term
What is a normal level of serum cholesterol?
Definition
< 200-low risk
200-239-moderate risk
>240- high risk
LDL <100
HDL >60
Term
Amount of CHO intake per day?
Definition
No more than 20-35% of total coloric intake with most coming from poly and mono - unsaturated fats.
Term
Saturated vs unsaturated fats?
Definition
saturated has all hydrogen atoms; unsaturated is missing one or more hydrogen atoms
Term
Healthiest fat?
Definition
polyunsaturated
Term
What is a trans fatty acid?
Definition
Hydrogen atoms are added to mono or polyunsaturated fats.
Term
What % of diet should be CHO?
Definition
50%
Term
What % of diet should come from fat?
Definition
20-35% of total calories
Term
What % should be protein in diet?
Definition
15-20%
Term
How to calculate an adult's requirement for protein?
Definition
Divide weight by 2.2 to get kg and multiply by 0.8 grams to get amount.
Term
How to calculate amount of calories in fat, protein, and CHO:
Definition
Protein X4
Fat X 9
CHO X 4
Term
The total daily output during a 24 hour period should be ?
Definition
1500-2000 mL and should equal approximately the amount of input
Term
Sources of output?
Definition
urine, emisis, diarrhea, exhalation, perspiration, BM, wound drainage
Term
What does fluid balance mean?
Definition
Input and Output are approximately the same.
Term
Skin legions that are elevated with irregular borders and no free fluid are called?
Definition
wheals
Term
What is the best area to assess for skin turgor?
Definition
the area over the chest
Term
Intermittent, high-pitched, popping sounds durinf inspiration are called?
Definition
crackles
Term
What should a nurse do if adventitious sounds are heard when assessing the lung sounds of of a client?
Definition
Assess the appearance of raised sputum.
Term
What kind of technique is used when a nurse uses pressure to check for tenderness or unusual vibrations?
Definition
Palpation.
Term
What should a nurse do when obtaining a client's weight?
Definition
Check to see that the scale is calibrated.
Term
When should a nurse provide an in depth objective assessment?
Definition
1. clients with a head injury
2. clients with psychiatric diagnosis
3. clients who took an overdose of drugs
Term
How should a nurse examine a child's ear/
Definition
Pull the ear down and back to straighten the ear canal.
Term
Purple patches on the skin are called?
Definition
Ecchymosis
Term
During a self-breast exam, a client should?
Definition
Squeeze the nipple gently to determine whether there is any discharge.
Term
How is 4-mm pitting edema recorded?
Definition
2+pitting edema
Term
What should a nurse do to test the client's ability to identify fine touch?
Definition
Stroke the skin at various area's with a cotton ball.
Term
An abdominal area that is resembles an egg and feels firm to the touch should be recorded as ?
Definition
Ovoid and hard
Term
What should a nurse do first when assessing the abdomen for bowel sounds?
Definition
Warm the diaphram of the stethoscope before the procedure.
Term
What does a normal heart sound like?
Definition
The lub sound louder at the mitral area.
Term
During a GI procedure, what should a nurse do with the blue vent?
Definition
Keep it open.
Term
An artificial opening into the stomach is called?
Definition
A gastronomy (PEG) tube.
Term
What kind of tubes are used exclusively to remove fluid and gas from the stomach?
Definition
gastric sump tubes
Term
Belching often indicates that the GI tube is still in the ?
Definition
Esophagus.
Term
Intestinal tubes are weighted with?
Definition
Tungsten.
Term
What kind of tube is used in an emergency to remove toxic substances that have been ingested?
Definition
Orogastric.
Term
Some nasogastric tubes have more than one?
Definition
Lumen.
Term
A gastronony tube is placed eitherof two ways. How?
Definition
1. Surgically
2. With an endoscope
Term
How much formula is fed in a bolus feeding?
Definition
250 to 400 mL
Term
What is it called to place a tube into a body structure?
Definition
Intubation.
Term
What are the disadvantages of an NG procedure?
Definition
Discomfort of the nose and throat. Tissue breakdown. NG tubes can dilate the esoph. sphincter causing reflux.
Term
What kind of food is given to a person with malabsorption disorder?
Definition
Partially hydrolyzed.
Term
What kind of food meets total nutritional needs?
Definition
Balanced.
Term
What kind of formula furnishes more protein than others?
Definition
High nitrogen.
Term
What kind of formula provides nutrition and decreases constipation or diarrhea?
Definition
High fiber.
Term
What kind of formula supplements nutrition without altering water distribution?
Definition
Isotonic balanced.
Term
What is gavage?
Definition
Providing nourishment.
Term
What is lavage?
Definition
Removing substances.
Term
What are the nurse's functions regarding NG tubes?
Definition
1. Inserting NG tubes
2. Keeping the tube patent.
3. Implementing the prescribed use.
4. Removing the tube.
Term
When are tube feedings performed?
Definition
If oral feedings are impossible or jeopardiz safety.
Term
What are the problems associated with bolus feedings?
Definition
1. Distends the stomach rapidly causing gastric discomfort.
2. Increasing the risk of reflux, regurgitation, vomiting, and aspiration.
Term
Controlling gastric bleeding with pressure?
Definition
Tamponade.
Term
A surgically created opening for the insertion of a tube?
Definition
Ostomy.
Term
A transabdominal tube that leads to the small intestine?
Definition
Jejunostomy.
Term
What is the metal guide wire that helps to straighten feeding tubes?
Definition
Stylet.
Term
What should a nurse do if the elderly client develops hyperglycemia when tube feeding?
Definition
Instill diluted formula and gradually increase concentration.
Term
A elderly client has severe abdominal pain after tube feeding. What should the nurse do?
Definition
Use lasctose free and high protein formulas.
Term
How long should a bolus feeding last?
Definition
<30 minutes
Term
How long do intermittent feedings last?
Definition
30-60 minutes.
Term
What should a client do when assessing a client's nostril ?
Definition
Ask the client to exhale.
Term
A nurse has to insert an intestinal decompression tube from the pyloric valve into the small intestine. What should the nurse do?
Definition
Ambulate the client.
Term
What should the nurse do FIRST when removing an intestinal decompression tube?
Definition
Disconnect from suction.
Term
What is the main goal of a NG assessment?
Definition
Detect the nostril best suited for tube insertion.
Term
What is a gastric sump tube best suited for?
Definition
Removes fluid and gas from the stomach.
Term
What is best time to provide liquid nourishment?
Definition
Late evening.
Term
How much gastric residual should there be when checking?
Definition
No more than 100 mL.
Term
What is the most important action when discharging a client with an tube-feed?
Definition
Provide detailed written instructions.
Term
What should a nurse do to maintain the patency of a tube?
Definition
Flush the tube with 30-60 mL water.
Term
Which tube feeding the least desirable?
Definition
Bolus.
Term
A client complains of a vomiting sensation. What should the nursing diagnosis be?
Definition
Risk for aspiration.
Term
The nurse pinches the tube just as the last volume of water is put into the tube. Why?
Definition
To prevent air from getting into the stube.
Term
A nurse is caring for a tube-fed client who has inflammation of the middle ear. Which intervention will reduce inflammation?
Definition
Insert a small diameter tube feeding.
Term
How are peripheral pulse sites assessed?
Definition
Term
Normal pulse rates?
Definition
60-100 bpm
Term
What is the process of collecting data that provides information about the client's individualized healthcare needs.
Definition
Assessment.
Term
What is the primary source of data?
Definition
The client.
Term
Does the health history provide objective or subjective data?
Definition
Subjective.
Term
A focused assessment of a pt complaining of abdominal pain would include assessing the pt.'s ?
Definition
Bowel movements.
Term
It is preferable to collect assessment data from a secondary source instead of directly from the client when?
Definition
The client is young, unconscious, or confused.
Term
The first thing a nurse should do before examining a client is?
Definition
Wash hands.
Term
How to figure the pulse deficit?
Definition
Apical pulse-radial pulse
Term
Observing/looking carefully
Definition
Inspection
Term
Using hands to touch and feel
Definition
Palpation
Term
Tapping the body to produce sound waves
Definition
Percussion
Term
Listening to sounds using a stethoscope
Definition
Auscultation
Term
Symptoms experienced by the client
Definition
Subjective
Term
Signs, observable and measurable
Definition
Objective
Term
Family, friends, or records as sources
Definition
Secondary source
Term
Objective and Subjective data associated with an illmess
Definition
Manifestations
Term
LOC
Definition
Level of Consciousness
Term
Poor turgor and dry mucous membranes would be an indication of ?
Definition
Fluid volume deficit
Term
A GRATING sound heard during chest auscult?
Definition
Pleural friction rub
Term
During an assessment of the eyes, the nurse would NOT record?
Definition
color of Iris
Term
The normal pupillary response to accommodation is?
Definition
constriction and convergence
Term
The use of adequate lighting is most important during?
Definition
Inspection
Term
The purpose of the blanching test is to?
Definition
Check peripheral circulation.
Term
Where do you correctly palpate the PMI?
Definition
the right midclavicular line, fifth intercostal space.
Term
What is the PMI?
Definition
I have no idea.
Term
Lung sounds that are "popping" are called?
Definition
Crackles.
Term
The correct order when assessing the abdomen are:
Definition
inspection, auscultation, palpation
Term
If a pt has both arms in full casts, what is the best way to assess the pulse rate?
Definition
Apical for a full 60 sec.
Term
What is the most accurate method for assessing the pulse rate?
Definition
auscultating directly over the point of maximum impulse.
Term
Manifestation is?
Definition
Objective and Subjective data.
Term
What is the difference between feeding through PEG, NG, and J tubes.
Definition
PEG and NG tubes go into the stomach. J tubes go into the intestines and should be slower than the other two.
Term
What are examples of incomplete proteins?
Definition
Veggi sources such as grains, corn, and peas.
Term
What is the protein difference between LDL and HDL cholesterols?
Definition
LDL has less protein and more fat. HDL has more protein and less fat.
Term
What type of fat is most likely attributed to atherosclerosis?
Definition
Saturated fats.
Term
What are the componenets of a health history?
Definition
Bio data, Chief complaint, History of present illness, Past medical hist., Family history, Lifestyle
Term
What is biological data?
Definition
name, address, age, gender, marital stat, occupation, religion, finances, insurance
Term
Where would "allergies" fall in a health assessment?
Definition
Past medical history
Term
Presbyopia
Definition
decreased visual acuity
Term
Presbycucis
Definition
decreased hearing acuity
Term
Opacity of the lens
Definition
Cataracts
Term
Cerumen
Definition
Wax
Term
Return rate of normal turgor/
Definition
<2-3 sec
Term
Ptosis
Definition
drooping of the eye lids
Term
Size of lymph nodes that may indicate an infection?
Definition
>1cm
Term
Nuchal rigidity?
Definition
Neck stiff and sore when flexed toward chest. may signal meningitis.
Term
Rhonchi
Definition
Added sound with a musical pitch; heard when auscult. lungs. Heard on EXHALE. Means fluid in the lungs.
Term
What does a Bruit signify?
Definition
an obstruction in the carotid artery.
Term
Presbyopia
Definition
the aging eye
Term
When should discharge planning begin?
Definition
Upon admission.
Term
What is a SNF?
Definition
Skilled nursing facility.
Term
What does METHOD discharge planning mean?
Definition
Medication, Environment (home), Treatment, Health teaching, Outpatient referral, Diet
Term
Odometer
Definition
tool used to look into eyes
Term
Opthalometer
Definition
tool used to look into ears
Term
What can periodontal disease lead to?
Definition
Heart disease
Term
Are lower or high tones easier to hear?
Definition
Lower
Term
What part of the stethoscope should be used when listen to lung sounds?
Definition
Diaphram
Term
What do crackles signify?
Definition
Narrow passages in lungs
Term
How many places should you listen to the lungs?
Definition
4-6
Term
What are DRIs?
Definition
Dietary Referenced Intake; used to be called RDAs. They give information on minimum and maximum amounts of daily vit and minerals.
Term
How much alcohol is "in moderation"?
Definition
Males 2- 4 oz drinks
Females 1- 4 oz
Term
Jewish Kosher foods
Definition
No pork, kosher, no shellfish, no fish without scales or fins, no birds of prey, SEPERATION of MEAT and DAIRY, unleavened bread during passover.
Term
Islamis foods
Definition
No pork, No alcohol
Term
Who determines health claims, serving sizes, descriptive terms on food?
Definition
FDA
Term
What act created food labeling standards?
Definition
Nutrition Labeling and Education Act of 1999
Term
Polysaccharides are also called?
Definition
Starches
Term
How is glucose stored?
Definition
It is stored as glycogen in the liver and muscles, then the extra is stored as fat.
Term
Glucose metabolism is regulated by?
Definition
insulin
Term
Glucose oxidation results in ?
Definition
energy
Term
Glucose oxidation results in ?
Definition
energy
Term
What % of diet should be simple sugars?
Definition
10%
Term
Do foods with < 0.05 trans fat have to be put on label?
Definition
No
Term
Mono-unsaturated fats have a positive effect how?
Definition
By lowering LDLs. Foods include olive oil, avacods, canola oil, nuts
Term
Polyunsat. foods include?
Definition
sunflower, safflower, margarine, fish
Term
How many essential amino acids are htere?
Definition
9
Term
Dysphagia
Definition
Trouble swallowing; speech therapists evaluate.
Term
Full liquids include?
Definition
Cream soups, ice cream, milk, cream of wheat
Term
Clear liquids include?
Definition
Broth, jello, sprite, apple juice, coffee, tea, popcycle
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