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NUR114 Test #1
Unit I: Vital Signs (Ch. 17,25,34), Communication (Ch.5), Self-Concept & Human Sexuality (Ch. 9,37,41), Documenting & Reporting (Ch. 15), Bowel Elimination (Ch. 32), Culture & Diversity (Ch. 4)
67
Nursing
Undergraduate 1
08/30/2012

Additional Nursing Flashcards

 


 

Cards

Term
Therapeutic Communication
Definition
Offering Self
Open-ended questions
Broad Openings
Offering General Leads
Reflection
Focusing
Seeking Clarification
Term
Therapeutic Communication
Definition
Verbalizing the Implied
Placing an Event in Sequence
Encouraging Comparison
Opening Remarks
Silence
Summarizing
Looking at Alternatives
Term
Non-Therapeutic Communication
Definition
False Reassurance
Giving Advice
Changing the subject
Being Moralistic
Requesting an Explanation
Closed-ended questions
Term
Defense Mechanisms
Definition
Rationalization
Compensation
Displacement
Projection
Repression
Term
Defense Mechanisms
Definition
Conversion Reaction
Regression
Identification
Denial
Introjection
Term
How is heat lost?
Definition
Radiation - loss of heat thru infrared rays.
Conduction - transfer from one object to another.
Convection - loss of heat thru air currents.
Evaporation - loss as water transforms to gas.
Term
Factors affecting body temperature?
Definition
Age
Environment
Time of Day
Exercise
Stress
Hormones
Term
Methods for taking temperature?
Definition
Oral
Rectal
Tympanic
Axillary
Temporal artery (forehead)
Term
What is "the pulse"?
Definition
Contraction of the left ventricle ejects blood into the aorta causing a pulse wave to travel along the blood vessels.
Term
Factors affecting the pulse?
Definition
Age
ANS
Medications
Term
Sites for pulse readings?
Definition
Temporal
Carotid
Apical
Brachial
Femoral
Radial
Popliteal
Dorsal
Term
Tachycardia
Definition
Pulse rates above 100 bpm in adults.
Term
Bradycardia
Definition
Pulse rates below 60 bpm in adults.
Term
What is the "quality" of a pulse?
Definition
The strength of the pulsations.
0 - no pulse
1+ - thready, weak pulse
2+ - difficult to palpate
3+ - normal pulse
4+ - bounding, hyperactive pulse
Term
Pulse Deficit
Definition
When a ventricular contraction does not perfuse the body adequately, the nurse will see a difference between the apical and radial pulse.
*The radial pulse rate is always lower than the apical pulse rate when pulse deficit is present.
Term
Tachypnea
Definition
Respiration rate above 20 breaths per min.
Term
Bradypnea
Definition
Respiration rate less than 12 breaths per min.
Term
Apnea
Definition
Absence of respirations (over a specific period of time).
Term
Dyspnea
Definition
Respirations that require excessice effort.
Term
Eupnea
Definition
Normal respiratory rhythm and depth.
Term
Biot's-Ataxic breathing
Definition
Cyclic breathing pattern characterized by shallow breathing alternating w/ periods of apnea.
Term
Cheyne-Stokes
Definition
Cyclic breathing pattern characterized by periods of resp. of increased rate and depth alternating with apnea.
Term
Kussmaul
Definition
Increased rate (+12bpm) and depth of respirations.
Term
What is "blood pressure"?
Definition
The force that blood exerts against the walls of the blood vessels.
Term
Systole
Definition
Contraction of the heart muscles, especially the venticles.
Term
Diastole
Definition
After the contraction of the heart muscle...when the chambers are filling back up with blood.
Term
Factors affecting blood pressure?
Definition
Age
ANS
Circulatory vol.
Medications
Normal fluctuations
Term
Contraindications to taking BP?
Definition
IV lines (use opposite)
Mastectomy
Patient has been active in the last 15 mins (must sit still for 5 mins)
Patient has just eaten, drank caffeine or used nicotine product.
Term
Korotkoff Sounds
Definition
Phase I - Systolic pressure
Phase V - Diastolic pressure
Auscultatory Gap - Btwn Phase I & II; absence of sounds.
Term
Prehypertension
Definition
Readings between 120/80 - 139/89 mm Hg
Term
Hypertension
Definition
Chronically elevated BP, +140/90 mm Hg
Term
Hypotension
Definition
Readings below 100/60 mm Hg
Term
What is oxygen saturation?
Definition
The percentage of hemoglobin that combines with oxygen.
Normal = <95% SaO2
Abnormal = >93%
Term
Factors affecting pulse oximetry?
Definition
Room lighting
Patient motion
Cigarette smoking
dark nail polish
CO poisoning
Edema
Term
When does pain occur?
Definition
When tissue or nerves suffer damage.
Term
Physiologic responses to pain?
Definition
Increased BP, HR, RR, neuroendocrine & metabloic responses ("Stress Response").
Term
Behavioral responses to pain?
Definition
verbal recognition
non-verbal: rubbing, grimacing, immobilization
Term
Assessment of pain?
Definition
Numeric rating scale (NRS)
Verbal descriptor scale
faces pain scale (FPS)
Wong-Baker FACES Pain Rating Scale is useful for assessing children under 8.
Term
Factors influencing communication
Definition
Congruent relationships (good fit)
Incongruent relationships (mixed messages)
language - body & verbal
culture & experience
Term
Contract Setting
Definition
Decisions about nursing & healthcare are made collaboratively; informal contractual model.
Term
Elements of Communication
Definition
1. Sender
2. Receiver
3. Message
4. Feedback
Term
Phases of the nurse-patient relationship
Definition
1. Orientation - intro, establish trust, rapport
2. Working - explore & develop solutions
3. Termination - closure of relationship
Term
SBAR
Definition
Situation - What is happening?
Background - Previous circumstances?
Assessment - What's the problem?
Recommendation - How to correct problem?
Term
Data for a patient's chart should be...
Definition
Accurate
Complete
Concise
Objective
Organized
Timely
Legible
Factual
Term
Patient Care Summary (Kardex)
Definition
Current patient info.
Term
Admission entry
Definition
Nursing history and physical assessment
Term
Flow Sheet
Definition
Tables designed to document routine assessments & procedures (vitals, I/O, etc)
Term
Charting By Exception (CBE)
Definition
Only records findings that fall outside of the standard of care and institutional norms.
Term
Progress Notes
Definition
Reflect a specific problem being addressed or the care provided over a specific period.
Term
5 elements of an Informal Nurse-Client Contract
Definition
1. Nurse & patient know/use each other's names.
2. Roles & responsibilities are clarified.
3. Parameters of the professional relationship are clear.
4. Mutual expectations are agreed on.
5. Circle of confidentiality is respected.
Term
Narrative Progress Notes
Definition
Records documentation of relevant patient or nursing activities throughout a shift or during a single visit.
Term
SOAP (SOAPIER)
Definition
A progress note that relates only to one health problem.
S - subjective
O - Objective
A - Assessment
P - Plan
I - Intervention
E - Evaluation
R - Revision
Term
Focus (DAR) charting
Definition
D - Data
A - Action
R - Response
Term
How one pictures and feels about their body
Definition
Body image
Term
How people feel about themselves
Definition
Self-esteem
Term
Personal identity
Definition
The awareness that one is a distinct individual separate from others.
Term
Self-efficacy
Definition
The degree of confidence a person has about their ability to perform specific activities.
Term
Role performance
Definition
A person's expected characteristic behavior in a social position.
Term
Factors that affect self-concept
Definition
Biological make-up
Culture, values, & beliefs
Coping & stress tolerance
Self-efficacy
Previous experience
Developmental level
Term
Role transition
Definition
-Role ambiguity: lacks knowledge of role expectations, fostering anxiety & confusion.
-Role strain: perceived as inadequate or unsuited for a role.
-Role conflict: expected to fulfill two roles at one time, expectations differ, role differs from personal values.
Term
Manifestations of altered self-concept
Definition
Self-care deficit
Emotional & behavioral changes
Anxiety & depression
Self-destructive behavior
Decreased eye contact
Critical/angry
Term
Erikson's developmental stages affecting adults
Definition
Intimacy vs. isolation (stage 6)
Generativity vs. self-absorption (stage 7)
Integrity vs. despair (stage 8)
Term
Comfortable sense of self
Definition
1. Awareness of personality, values, etc
2. Awareness of physical characteristics
3. Awareness of multiple roles
4. Ability to self-evaluate
5. Maintain interpersonal boundaries
Term
Methods to enhance patient's self-concept
Definition
1. Establish trusting relationship
2. Encourage patient to express freely
3. Show acceptance of feelings
4. Meet physical needs
5. Address psychological needs (respect privacy, treat w/ dignity & respect, encourage independence).
6. ID strengths
Term
Application of Nursing Process in patient's w/ altered self-concept
Definition
Normal pattern Identification
- "Are you experiencing changes in your body?"
Risk Identification
-Patient's previous experience, developmental level, etc.
Dysfunction Identification
- Assessment of thoughts & feelings
- Abnormal answers from normal pattern ID
Term
Climacteric period
Definition
Perimenopause
Term
Nursing interventions that enhance sexual well-being
Definition
1. Promote open discussions
2. Data collection re: sexual history
3. Managing of sexual needs of resident
-private rooms, private time, sign on door, spouse in same room
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