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N133 Exam 2 Questions With Complete Solutions What is the function of the pulmonary arteries to carries deoxygenated blood from the right ventricle of the heart to the lungs known as Great Vessel Systolic: semilunar valves to open, resulting in ejection of blood into the aorta/pulmonary arteries Where is the pain in an arterial occlusion and why? absence of pulses distal to the level of arterial occlusion- pallor or mottling- hypesthesia or anesthesia
- weakness or paralysis- pain - sudden, severe, and unremitting
- coldness Stoppage of circulation to the extremities
kyphosis hunchback is a posterior curvature (convexity) of the thoracic spine lordosis
Phalen's test and Tinel's sign carpal tunnel Patients report numbness, pain, and paresthesia during med term for nose bleed epistaxis
pruritus Most commonly reported symptoms of skin disease severe itching Rashes pain/discomfort lesions wounds changes in the skin color or textures hair nails systolic blood pressure Maximum pressure exerted on arteries when ventricles eject blood from the heart The "Snellen Chart" is used to test visual acuity (sharpness of vision)
Inflammation mostly on the lower legs jaundice yellowing of the skin and the whites of the eyes caused by an accumulation of bile pigment (bilirubin) in the blood are tattoos dangerous with a person having a MRI? yes because of possible lead in the tattoo ink Gout Gout is hereditary disorder with increase in serum uric acid due to increased production, or decreased excretion of uric acid and urate salts.
Osteoporosis is loss of bone density and decreased bone strength results in osteoporosis. people at risk aging Decline of estroge calcium deficit, and lack of exercise. Signs loss of height have spontaneous fracture from brittle bones develop kyphosis Adduction Movement toward the midline of the body Flexion
internal rotation rotation of the hip or shoulder toward the midline Range of Motion of Jaw Motion smooth, without pain. Protrude and retract chin without difficulty or pain. Trapezius muscle test 180 degrees straight extension 50 degrees back hyperextension, 180 degrees shoulder abduction 50 degrees adduction 90 degrees external or internal rotation. what are you assessing if you have a patient touch their toes
Observe range of motion of thoracic and lumbar spine Normal neck movement smooth and controlled with 45-degree flexion, 55-degree extension, 40-degree lateral abduction, and 70-degree rotation. what defines an individual patient's pain Perception of pain is influenced by cognitive and cultural factors: Patient’s previous experiences with pain and current physical and mental status affect pain perception and response. Cognitive factors: Attention people give to the pain. Expectation or anticipation of pain. Appraisal or expression of pain. Cultural factors: Cultural influences may affect how pain is communicated.
Irregularly shaped with color variations. rapid growing color diameter over 6 mm/keeps growing Edema grading scale, depth and time frame 1: Immediate rebound with 2mm 2: Less than 15-second rebound with 3 to 4 mm pit. 3:Rebound greater than 15 seconds but less than 60 seconds with 5 to 6mm 4: Rebound between 2 to 3 minutes with an 8 mm pit. non-pitting edema grade scale 1- rebounds immediately 2+ 15 secs 3+ 60 secs 4+2-3 mins
venous insufficiency the inability of the veins to adequately return blood from the lower extremeties (this can cause varicose veins) (leg swelling) occurs when your leg veins don't allow blood to flow back up to your heart valves in your veins make sure that blood flows toward your heart. blood to collect (pool) in your legs. arterial insufficiency -Skin changes in color, temp, extremity may be cold, pale and clammy -Ulcers on the toes, and lateral side of the foot and Painful -Hair loss any condition that slows or stops the flow of blood through your arteries. Arteries are blood vessels that carry blood from the heart to other places aka brain/body
the sternal notch to the angle of Louis (the bump where the manubrium and sternum meet).b. Slide your finger over to the left sternal border to the 2nd intercostal space.c. Now place your index or ring finger (depending on which hand you use) in the 2nd intercostal space, and count down to the 5th intercostal space by placing a finger in each of the spaces.d. Slide over to the midclavicular line, keeping your finger in the 5th intercostal space.The apical pulse is generally best heard at the PMI in the 5th intercostal space at the midclavicular line. the PMI is located over the apex of the heart. For an adult, this site is on the anterior chest at 3 inches (8 cm) or less to the left of the sternum, at the 4th, 5th, or 6th intercostal space at the midclavicular line. nursing interventions for chest pain
- Perform pain assessment: Identify precipitating events, if any, as well as frequency, duration, intensity, and location of the pain.
- Assess and document the client’s response to medication.
**3. Monitor vital signs every five (5) minutes during the initial anginal attack.
- Auscultate heart sounds. Monitor heart rate and rhythm.**
5. Elevate the head of the bed if the client is short of breath or during nitrates administration. what are causes of bruising in children? anemia, a vitamin deficiency, a blood clotting disorder or even certain types of cancer. Falls and injury. ... Child abuse. ... Bleeding disorders. ... Side effects of certain medications. ... Bruises without any known cause or injury. ... Extensive bruising. ... Stage 1 pressure ulcer prolonged redness with unbroken skin
Eschar or slough may cover the entire wound bed; thus, it is unstagable. how do you document a patient's heart rhythm When charting heart sounds for your nurse's notes, chart only the sounds that are abnormal. Chart basic information such as heart rate, rhythm, intensity and abnormal sounds. Describe carefully their location in the cycle. nursing interventions for hypernatremia Monitor I&O. Monitor sodium level. Monitor vital signs and LOC. Monitor ECG's Auscultate lung sounds Provide oral hygiene Restrict sodium in the diet. Beware of hidden sodium in foods and medications. Increase water intake. Administer IV solutions that do not contain sodium.
Administer loop diuretics for patients with poor kidney excretion. how to perform a wound culture Levine Technique recommended for culture collection: Identify 1cm2 of clean wound tissue. Rotate applicator for 5 seconds while applying enough pressure to produce fluid from the wound tissue. USE ZIG-ZAG MOTION **Do not take specimen from exudate, eschar, or necrotic material. Do not let the sterile swab touch gloves or other objects. Insert swab immediately into sterile container. Avoid contaminating specimen. Doff gloves. Perform hand hygiene how do you palpate a pulse To take a pulse, place your fingers over the artery and feel for the pulsations while also noticing the rhythm. Pulses are palpated using the finger pads of the index and middle fingers. Firm pressure is applied over the pulse but not so hard that the pulsation is occluded. If the pulse is difficult to locate, vary the
