Test 2 Flashcards

Question

Hypervolemia signs and symptoms

Answer 1

Rapid weight gain Rapid bounding pulse Distended hand and neck veins (JVD) Increased BP Edema Pulmonary edema (crackles) Dyspnea (shortness of breath)

Answer 2

Asses VS and loc Asses breath and respiratory sounds Assess for edema Strict i&o daily weights

Answer 3

Expand intravasculer volume .9% normal saline

Answer 4

Water restriction Treat medical condition Hemodialysis

Answer 5

A solution with the same similarity as blood plasma Expands extracellular only - fluid replacement No fluid shifting .9% NaCl (saline) (too much can elevate Na and Cl levels) LR

Answer 6

Has less of a allure concentration than other fluid (lower osmotic pressure) Provides more water than electrolytes (good for dehydration) Dilutes ECF - fluid moves from ECF to ICF .45 and .33% NaCl

Answer 7

Fluid that has more of a solute concentration than another fluid - higher osmotic pressure Expands ECF and draws fluid from ICf (causes cells to shrink) Dextrose 5% in LR Dextrose 5% in .9% saline

Answer 8

135-145 mEq/l

Answer 9

By GI system and skin

Answer 10

Maintains fluid balance and transmits impulses in nerve and muscle

Answer 11

Decreased loc Twitching, tremors, weakness Cool pale skin Tachycardia Abdominal cramping

Answer 12

Loss of sodium or gain of too much water from vomiting, diarrhea, fistulas, swearing or a result of the use of diuretics

Answer 13

Safety precautions, i&o, daily weights, assess skin turgor

Answer 14

Too much sodium Twitching, tremors Restlessness, irritability Intense thirst Pulmonary and peripheral edema

Answer 15

Decreased fluid intake (elderly, ill) Water loss: diuretic excess, fever, heat stroke, diarrhea, burn patients

Answer 16

Decrease sodium intake, monitor output, i&o, daily weights

Answer 17

3.5-5.0 mEq/L

Answer 18

Regulates cells electrical neutrality, aided neuromuscular transmission of nerve impulses, assists with skeletal and cardiac muscle contraction

Answer 19

Skeletal muscle weakness, diminished deep tendon reflexes Uwave, EKG changes Constipation, Ileus Toxic effects of digoxin (heart med) Irregular pulse Numbness

Answer 20

GI losses- vomiting, diarrhea, gastric suction Renal lossses - diuretics

Answer 21

Administer k+ supplements: oral or IV, educator about high k+ foods, dried fruit, bananas, orange juice and apricots

Answer 22

Tall peaked twave Weak lower extremities Anxiety and irritability V fib and dysrhythmias EKG changes

Answer 23

Renal failure Excess k+ intake Taking excess k+ and receiving k+ sparing diuretics

Answer 24

Limit oral k+ intake, administer kayexalate

Answer 25

Inverse relationship with phosphorus Provides rigidity and strength to bones and teeth Necessary for neuromuscular activity

Answer 26

Twitching to face (chvosteks sign) EKG changes (v-tach) Trousseau’s sign Anxiety an confusion Numbness to extremities and mouth Laryngeal spasms

Answer 27

Inadequate calcium intake, excessive calcium loss, impaired absorption

Answer 28

Encourage diet high in calcium and vitamin d, admin phosphate binding antacids, administer calcium gluconate

Answer 29

“Moans, groans, stone, and bones”

Answer 30

Metastatic disease of bone Jyperpsrsthyroidisn

Answer 31

Administer fluids to decrease risk of renal stones and cinstipation Limit intake of calcium Encourage hydration Life threatening levels desire dialysis

Answer 32

1.3-2.1 meq/l

Answer 33

AIDS in neuromuscular activity

Answer 34

Irritates CNs- confusion Respiratory muscle labored Rapid heart rate Irritates myocardium Three T’s (twitching tremors and tetany) Anorexua Trousseaus and chcosteks sign EKG changes

Answer 35

Ng suction Diarrhea Burn patients Alcoholism Sepsis

Answer 36

Administer supplements Diet Iv mag Monitor for hypotension, cardiac or respiratory arrrst

Answer 37

Slow shallow respirations Lethargy to coma Out of steam Weak pulse and decreased cardiac function

Answer 38

Renal failure

Answer 39

Iv fluids Restrict mag foods and drugs Administer calcium gluconate

Answer 40

2.5-4.5 mg/dl

Answer 41

I’m verse relationship with calcium Neuromuscular activity (contraction of muscles, maintaining the regularity of the heartbeat, and nerve conduction)

Answer 42

Lethargy and confusion Osteomalacia and rhabdomyolysis Weak muscles (resp heart and body)

Answer 43

Absorption issues alcoholism Malnutrition Diuretic stage

Answer 44

Iv Or oral supplements Diet

Answer 45

Decreased mental status Anorexus Neuromuscular irritability Chvosteks and trousseaus sign Extremity tingling

Answer 46

Chronic renal failure Hypoparathyroidism

Answer 47

Restrict phos containing foods (meat and milk) Admin phosphate binding antacids metal tails Diuretics to promote excretion.

Answer 48

98-108 meq/l

Answer 49

Seizures, coma Muscle cramps Arrhythmias Respiratory arrest Twitching, tetany

Answer 50

Gi losses Ng suction and draining Burns Diuretic therapy

Answer 51

Monitor loc and vitals Admin chloride replacement via oral or iv

Answer 52

Weakness Active heart Lethargy Coma

Answer 53

Hypernatremia Increased retention by the kidneys

Answer 54

Monitor I&O Monitor vitals

Answer 55

CBC BMP Bun and creatine

Answer 56

A systematic and logical thought process Using reflection inquiry and exploration to make informed decisions Used both outside and inside of the clinical setting Not accepting information at face value

Answer 57

Ways of thinking about patient care issues Determining, preventing and managing patient problems

Answer 58

The result of critical thinking it clinical reasoning Observe and assess presenting situations, identify and priorities client concerns, generate best possible evidence based solutions in order to deliver safe client care

Answer 59

A nurse trusts that expects have the right answer; concrete thinking based on rules

Answer 60

The nurse begins to express autonomy by analyzing and examining data to determine the best alternative

Answer 61

The nurse expects to make choices without help from others and fully assume the responsibility for those choices

Answer 62

Impact of nurses knowledge experience and values in assessment and action Importance of knowing patients and their perspectives Influence of context and culture in situations Recognition of use of various reasoning patterns Importance of reflection

Answer 63

Noticing Interpreting Responding Reflecting

Answer 64

Initially grasp and perceptions of the situation that are impacted by conext, the nurses practical experience, knowledge of expected versus unexpected data, ethical perspectives and the nurse patient relationship

Answer 65

Focused observation Recognizing deviations from expected patterns Information seeking

Answer 66

Attributing meaning to the data thoroughly multiple reasoning patterns

Answer 67

Prioritizing data Making ends of data Develop plan for intervention

Answer 68

Deciding on an sanction or inaction and monitoring patterns

Answer 69

Use of calm confident demeanor Clear communication Well planned interventions Showing mastery of skills

Answer 70

In action and on action

Answer 71

In action: occurs while actively engaged in a situation On action: occurs in debriefing after the situation

Answer 72

Physiological Safety Love Esteem Self actualization

Answer 73

Airway Breathing Circulation Disability Exposure

Answer 74

Priority on the situation or factor that places the client at the highest safety risk Consider which problem poses the greatest risk to the pt

Answer 75

Interventions are selected that maintain client safety while producing the least amount of restriction to the client

Answer 76

Acute - manifestations are severe, appear suddenly and can worsen rapidly Chronic- last a year or more and require ongoing medical attention and or impact ADL

Answer 77

Unstable client has experienced an axute change in condition vs a stable client has a condition that changes little over time

Answer 78

Interventions need to be made quickly vs low risk needs that do not require immediate attention

Answer 79

Plan Lists Prioritize Factor in for interruptions Organize your workspace Delegate safely Say no Take care of self

Answer 80

Clinical reasonin/judgement

Answer 81

Description Feeelings Evaluation Analysis Conclusions (general then specific) Personal action plan

Answer 82

Self awareness and reflection

Answer 83

Latex Iodine Shellfish

Answer 84

Promoting health Preventing illness Restoring health Facilitating coping

Answer 85

Leaning and comprehending new knowledge Using new info and applying Browning down and organizing info Using knowledge for new outcome Determining effectiveness

Answer 86

Lecture discussion Question and answers Audiovisual materials

Answer 87

Involves feeling beliefs and values Valuing the content and believing its worth learning

Answer 88

Role play and role modeling Discussion

Answer 89

Physical and mental activities required to learn skills Observing, doing with help, doing independently, doing independently without error, incorporation into daily routine

Answer 90

Demonstration Return demonstration Games

Answer 91

Relevance Self directed Life experience Readiness Task centered Motivation

Answer 92

Persons with difficulty reading and comprehending written material or esl

Answer 93

Determine reading level prior to any written handouts Let patient know in advance you will be asking to evaluate how your taught Ask how they best learn Review materials to reinforce If patients cannot remember: 1) clarify 2) allow them to teach back again Reinforce teach back method until they can describe in their own words

Answer 94

Age and development Family support network and financial resources Culture influences and language deficits Health literacy (ask me 3)

Answer 95

What’s my main problem What do I need to do Why is it important for me to do this

Answer 96

Knowledge skills and attitude Readiness to learn Ability to learn Learning strengths

Answer 97

Condition in which the body is in a decreased state of activity with the consequent feeling of being refreshed

Answer 98

A state of rest accompanied. Y altered consciousness and relative inactivity

Answer 99

Reticular activating system is in the brain stream and is responsible for maintaining alertness and sensoristasus

Answer 100

Thalamus Hypothalamus Pineal gland

Answer 101

Process sensory info and regulate sleep

Answer 102

Autonomic nervous system, releases hormones, regulates body temp, circadian rhythm

Answer 103

Melatonin (sleep hormone)

Answer 104

NREM 1, 2, 3, and REM

Answer 105

4-5, each cycle lasting 90-100 minutes Stage 1, stage 2, stage 3 (deep sleep), stage 2, rem…

Answer 106

Transition stage between wakefulness and sleep, decreased awareness of surrounding Normally lasts only minutes Relaxed state but still somewhat aware of surroundings Involuntary muscle jerking may occur Person easily sroused

Answer 107

Deeper stage 25 min long Increased relaxation More challenging to wake Decreased heart rate

Answer 108

Depth of sleep increased and aeousal becomes increasingly difficult Slow delta wave sleep Pulse and respirations at lowest rate, Bp decreases, muscles relax, metabolism slows, low body temp Immune system, muscles, bones, tissue repair and strengthen

Answer 109

Eyes dart back and forth Vivid dreams Most difficult to arouse Large muscle immobility, resembling paralysis Varying vital signs Cognitive restoration (short to long term memory) Fewer REM as people age

Answer 110

Impaired judgment, decreased response time, trigger seizure disorders, migraine and tension headaches In children: growth and development, performance deficits and behavioral problems

Answer 111

Increase in ghrelin and decrease in leptin

Answer 112

Anxiety, personal conflict, loneliness, depression, ginsymptoms Increased risk for diabetes, hypertension, heart disease, and substance abuse, Decreased reaction time

Answer 113

Difficulty falling Wessex intermittent sleep, or difficulty maintaining sleep despite adequate opportunity and circumstances to sleep May be axute or chronic

Answer 114

Women and older adults

Answer 115

Tired, lethargic, and irritable during the day difficulty concentrating Older adults experiencing insomnia in acute care setting have an increased risk for delirium

Answer 116

Muscles at back of throat relax during sleep; those muscles that support the soft palate, uvula, tonsils, other structures at back of throat Airway narrows or closes and breath stops for 10 seconds or more. O2 drops

Answer 117

Age Excess weight Large neck size Make Family history sedative use Smoking

Answer 118

Daytime fatigue, high Bp, heart disease, type 2 diabetes, metabolic syndrome, complications with anesthesia, increased risk of sudden cardiac death and stroke

Answer 119

Polysomnography Cpap or bipap (continuous or bilevel positive airway pressure) Oral applications Side lying sleep position or elevation Wright loss Limit ETOH consumption Surgery

Answer 120

Excessive daytime sleepiness lasting ad least three months and impairs social and vocational activities

Answer 121

Sudden attacks of sleep that are often uncontrollable Up to 70% also experience cataplexy (sudden involuntary loss of skeletal muscle tone for seconds to minutes)

Answer 122

Chronic or recurrent pattern of sleep wake rhythm disruption

Answer 123

Alteration in the circadian rhythm or misalighnment between the internal circadian rhythm and the sleep wake schedule desired or required Sleep wake disturbance (insomnia or excessive sleepiness) Associated distress or impairment lasting for a period of at least 3 months Most common in shift work disorder and jet lag

Answer 124

Somnambulism REM sleep behavior disorder Night terrors Nightmare disorder Sleep ensures us Sleep related eating disorder

Answer 125

Aka Willis ekbom disease Affects up to 15% of pop, mostly middle aged and older Cannot lie stile and reports unpleasant creeping or tingling in legs

Answer 126

Nonpharmacologix treatments Avoid caffeine, etoh, and nicotine

Answer 127

Usual sleep wake patter and recent changes Sleep study/ EEG Use of sleep aids Sleep disturbances and contributing factors Observations (energy’, facial characteristics, behavior, obesity)

Answer 128

Sleep pattern disturbance Fatigue Risk for injury Ineffective coping Disturbed sensory perception Anxiety Acute confusion

Answer 129

Eliminate caffeine, nicotine, alcohol and heavy meals before bedtime (at least four hours) Exercise but also at least 2. Hours before bedtime Remove unnecessary light or noise Cool room Avoid stimulation before bedtime Regular bedtime and routine No screens in bedroom Complementary therapies

Answer 130

Bedtime snacks Darken room White noise Close door Regulate hallway noise Offering of self Hand masssage Schedule nursing care to avoid disturbances

Answer 131

Benzo such as lorazepam (Ativan) -cause drowsiness, relax muscles, lessen anxiety -cause retrograde amnesia -not recommended for long term use Non benzos -zoloidem(ambien), eszipiclone, zaleplon May cause gi discomfort, memory loss hallucinations

Answer 132

Melatonin (made by pineal gland naturally, cost effective, comes in ER, few known side effects) Herbal therapies (chamomile, valerian, passionflower, skull cap)

Test 2 Flashcards

(160 cards)