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2010-10-08 17:52:12
Fundamentals nursing

fundamentals final 2
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  1. Open-Ended Questions
    • Ask for narrative information
    • Use in beginning of the interview
  2. Close- Ended Questions
    • Ask for specific iformation
    • Use after persons openning narrative to fill in any details he or she left out
  3. Restating
    Repeating part of what the person has just said
  4. Empathetic response
    • Recognizing the feeling
    • accept it and allow the person to express it without embarrasement
  5. Clarification
    • Used when the persons word choice is ambiguous or confusing
    • Used to summarize the persons words
  6. Subjective Information
    What the person says about himself during history taking
  7. Objective Information
    • What you say as a health professional
    • Observed by:
    • Inspecting
    • Palpation
    • Percussing
    • Auscultating
  8. Eccrine Gland
    Coiled tubules that open directly onto the skin surface and produce a dillute saline solution called sweat
  9. Aprocrine Gland
    • Produce thick, milky secretions and
    • Open into the hair follice
    • Mainly in the axillae, anogenital area, nipple, navel
  10. Gynecomastia
    Enlargement of the breast tissue, making it clinically distinguishable from other tissue in the chest wall
  11. Bronchophony
    Ask person the repeat "99" while you listen with a stethoscope
  12. Egophony
    Auscultate the chest while the person pronates a long ee-ee-eee
  13. Percussion Notes
    • Hyperesonnant
    • Resonant
    • Tympany
    • Dull
    • Flat
  14. Resonant lung sound
    • Medium Loud
    • Low-pitched
    • Hollow, clear
    • Moderate length
    • Normal lung sound
  15. Hyperresonant percussion notes
    • Loud
    • Booming
    • Low-pitched
    • Long
    • On child's lungs
  16. Tympany percussion notes
    • Loud
    • High-pitched
    • Musical, drumlike
    • Longest
    • Over air filled viscus like stomach or intestines
  17. Dull Percussion notes
    • Soft
    • High pitched
    • Muffled thud
    • very short duration
    • On dense organs like liver or spleen
  18. Flat percussion notes
    • Very soft
    • high-pitched
    • a dead stop of sound
    • very short duration
    • when no air present like over bone, thigh or tumor
  19. Harlequin
    Lower half of body turns red and upper half blanches with a distinct demarcation line down the midline
  20. Erythema Toxicum
    Flea bite rash on newborn, red macules and papules on the cheeks, trunk, chest, back and buttocks
  21. Acrocyanosis
    Bluish color around the lips, hands and fingernails, feet and toenails
  22. Cafe Au Lait
    (Milk with cream)
    • Large round or oval patches of light-brown pigmentation
    • Present at birth
  23. Cutis Marmorata
    Transient mottling in the trunk and extremeties in response to cooler room temperatures
  24. Carotenemia
    Comes from injesting large amounts of food containing carotene , a vitamin A precursor
  25. Physiologic Jaundice
    Yellowing of the skin, scleras, and mucous membranes develops after the 3rd and 4th day of life
  26. Nonverbal Cues
    • Close proximity to patient
    • Facial animation
    • Smiling
    • Eye Contact
  27. Nonverbal Cues
    • Standing
    • Lip biting
    • Avoiding eye contact
    • Inappropriate touch
    • Frowning
  28. Thyroid Function and Hormones Secreted
    • Endocrine gland synthesis and secretes:
    • (T3) Thyroxine
    • (T4) Triiodothyronine
  29. Lymph Node Function
    Separate vessel system which retrieves excess fluid from the tissue spaces and return it to the bloodstream
  30. Lymph Node location
    • Cervical
    • Axillary
    • Epitrochlear
    • Inguinal
  31. Corneal Light Reflex
    (Hershberg Test)
    Assess the parallel alignment of the eye axes by shining a light toward the persons eyes
  32. EOM nerves
    • CN 3
    • CN 4
    • CN 6
  33. EOM
    • Superior Rectus
    • Interior Rectus
    • Medial Rectus
    • Inferior Oblique
    • Lateral Rectus
    • Superior Oblique
  34. Normal Vs. Allergies (Nasal)
    • Normal
    • red color and smooth surface
    • Allergies
    • Mucousa looks swollen, boggy, pale and grey
  35. How to treat Nose Bleed
    • Person sits up with head tilted forward
    • Pinch nose between thumb and forfinger
    • 5-15 minutes
  36. Complications of Stroke
    • Paralysyis of lower facial muscles
    • upper half of face is not effected
    • person can wrinkle forehead and close eyes
    • positive Babinski and Hoffmans reflex
  37. Dehydration
    • Mucous membranes look dry
    • Lips look parched
    • Skin is fissured, resembling dry cracked lake
  38. Where do breast tumors most commonly appear
    • Axillary tail of Spence
    • (Upper outer quadrant)
  39. Colostrum
    Thick yellow fluid is the precursor for milk containing the same amount of protein and lactose but practically no fat
  40. Proper Auscultation Format
    • Posterior from the apices at C7 to T10
    • Laterally down to the 7th or 8th rib
  41. Benefits of Colostrum
    Its is rich with antibodies that protect the newborn against infection so breastfeeding is important
  42. Tactile Fermitus:
    How is it created
    Sounds generated from the larynx through lungs and then chest wall where you feel tham as vibrations
  43. Physiological changes:
    New born vs. Elderly
    • Skin
    • Fontanel
    • Inner ear structure
    • gynecomastia
  44. Malignant Tumor Characteristics
    • 30 - 80 increases after 50
    • Irregular, star-shaped
    • Firm to stony hard
    • Poorly defined
    • Single
    • Fixed mobility
    • Skin retraction
    • grows constantly
  45. Benign Tumor Characteristics
    • 30 - 55 yrs old decrease after menopause
    • Round, lobular
    • Firm, rubbery
    • Well demarcated
    • Mobile
    • Tender
    • Usually multiple
  46. Types of Headaches
    • Tension
    • Migraine
    • Cluster
  47. What area do Cervical lymph nodes drain
    Drain the head and neck
  48. What area does axillary node drain
    Drain breast and upper arm
  49. What area does the epitrochlear node drain
    • Drains the hand and lower arm
    • In the antecubital fossa
  50. Where does the Inguinal node drain
    • Lower extremities
    • External genetalia
    • Anterior abdominal wall
  51. Define Lanugo
    fine downy hair of the new born
  52. Define Vernix Caseosa
    Thick cheesy substance made up of sebum and shed epithelial hair
  53. Define Presbycusis
    Gradual sensorineural loss caused by nerve degeneration in the inner ear or audtory nerve
  54. Tension Headache Characteristics
    • Occipital, frontal
    • Bandlike tightness
    • Vise-like
  55. Migraine Headache Characteristics
    • Supraorbital,retroorbital, front-temporal
    • Throbbing or temporal arteritis
    • Occur 2x a month
    • Last 1-3 days
  56. Cluster Headache Characteristics
    • Pain around eye, temple, cheek, forehead
    • Unilateral or bilateral
    • 1-2 a day
    • Last 1/2 to 2 hrs
    • 1-2 mos
  57. Webers Test
    • Place a vibrating tuning fork in the midline of the persons skull and ask whether the tone is the same in each ear
    • Normal
    • Equal on both sides
    • Abnormal
    • Sound lateralizes to one ear with a conductive or sensorineural loss
  58. Rinne Test
    (Hearing) -+
    • Place tunning for on the mastoid process and ask him or her to signal when the sound goes away
    • Quickly invert the fork so vibrating end is near ear canal
    • Normal
    • AC > BC
    • Abnormal
    • hearing loss if AC<BC
    • conductive loss if sound is heard longer by bone conduction
    • Example purulent Otitis Media
  59. How to avoid breast feeding Complications
    Frequent nursing helps drain the ducts and sinuses, stimulate milk production, nipples may crack but if kept dry and exposed to air it will heal rapidly