| Terms |
Definitions |
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bi
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two
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aut/o
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self
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eu
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normal, good
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what is pruritus?
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itching
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Apnea
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Cessation of breathing
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death of spouse
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late adulthood
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normal respirations
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10-20 per min
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Tinnitus
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Ringing in the ear
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non-pathogenic
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atelectic crackles are what?
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financial abuse
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intentional misuse of resources
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wheal
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superficial, raised, and erythematous; slightly irregular shape due to edemaex: mosquito bite, allergic reaction
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-centesis
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surgical puncture to aspirate fluid
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2
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complete ROM with gravity eliminated
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emphysema
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destruction of pulmonary CT (connective tissue) that leads to permanent enlargement of air sacs to bronchioles and rupture of interalveolar walls, which results in hyperinflated lungs.
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how often should you check BP?
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yearly
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knee joint
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femur, tibula, patella; hinge joint
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plaque
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papules coalesce to form surface elevation wider that 1cmex: psoriasis
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Subjective data
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cough:productive, dry, blood, odor, severity-description(hacking, congested, dry, barking, what makes it better/worseshortness of breath: with chest pain(stabbing, burning, constant), time of day, better/worse, accompanying side effectsorthopnea: difficulty breathing when supine (pillows)paroxysmal nocturnal dyspneahistory of pulmonary diseasehistory of respiratory infectionssmoking historyenvironmental factorsself care behaviors
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abdominal hernia
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bulges during coughing indicate an..
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hypoxemia
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decrease of oxygen in the blood
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Cheyne-Stokes Respiration
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breathing patterns fluctuates from regular, to rapid and shallow, to periods of apnea (ex. drug OD, increased ICP, meningitis)
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Information that the nurse acquires through use of the five senses.
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Cue
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violence between spouses, nonmarital partners, or former spouses or partners
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initimate partner violence
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what layer of the skin is avascular?
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epidermis
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percussion of anterior chest
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percuss in five places
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actinic keratosis
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red-tan scaly plaques that increase over the years to become raised and roughened. premalignant and may develop into squamous cell carcinoma
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anatomy of neck
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vessels-carotid artery, internal and external jugularsmuscles- sternomastoid, trapezius, omohyoidbones- isthmus of thymus at 2nd and 3rd tracheal rings-cricoid about isthmus-thyroid cartilage "adams apple" above cricoid-hyoid-highest bony structure
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edema scale
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1+ mild pitting-slight indentation, no perceptible swelling2+ moderate pitting3+deep pitting4+ very deep pitting
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Angle of Louis
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Manubriosternal Angle, by starting with this notch, it makes counting the ribs easier.
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Nocturnal Dyspnea
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sudden awakening from sleeping with shortness of breath
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consolidation (ex. pneumonia) and compression (ex. pleural effusion)
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increased breath sounds
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1-2 seconds
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how long should capillary refill take?
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problem, intervention, evaluation
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what does PIE stand for
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Can supply information about the client's current health status, but also are often able to indicate when changes in the client's status occurred and how the clien'ts functioning was affected.
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Family/Significant Others
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challenges of note taking
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impedes eye contact, attention shifting, interruption of patient's narrative flow, impedes observations of non-verbal communication, can be threatening to the patient
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use of tanning bed once a month increases your chance to have melignant melanoma by ___%
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55%
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what lines the outside of the lungs?
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visceral pleurae
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reasons for increased breath sounds
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consolidation ex pneumonia; compression ex. pleural effusion
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change in nails
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any change in nails:shape, color, brittleness? do you tend to bite or chew
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ethnicity
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a social group within a social system that claims to possess variable traits such as a common geographic region, migratory status, religion, race, language, shared values, traditions, or symbols, and food preferences.
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right shoulder
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pain from gallbladder disease may be felt in the..
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atelectasis and pneumonia
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which two respiratory conditions would have dull percussion?
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no bowel movement for three days
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what constitutes constipation?
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Components of Nursing Health History:
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1.Biographical Info.
2.Reason for seeking health care
3. Client Expectations
4. Present Illness or Health Concerns.
5. Health History
6. Family History
7. Environmental History
8. Psychosocial History
9. Spiritual Health
10. Review of Systems
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components of "the contract"
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time and place, introduction and explanantion, purpose, length, expectations, presence of others, confidentiality, costs
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what happens to nails when aging?
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they grow more slowly
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what divides the LUL and the LLL?
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left oblique fissure
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environmental or occupational hazards
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any hazard-related problems with your occupation, dyes, chemicals
hobbies
sun exposure
recent bites by insects
recent exposure to plants, animals in yard work, camping
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objective data
the physical exam
inspection
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-skin-note any needle marks-make sure to inspect bilaterally-symmetry-profile sign (to detect early clubbing)-range of motionfingershandsarmsshoulders
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COPD Chronic Obstructive Pulmonary Disease
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airflow obstruction caused by emphysema or chronic bronchitis
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angina pectoris
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chest pain due to ischemia of the myocardium. usually caused by atherosclerosis
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preload and afterload
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what two things affect the heart's ability to increase cardiac output
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internal factors of the examiner
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liking others, empathy, ability to listen
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which skin conditions are more common in blacks?
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keyloids and pigment disorders
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what are some examples of adventitious sounds in respiratory
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crackles, wheezes, rhonci, stridor
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grade 1 murmur
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Murmur that is barely audible in a quiet room
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parietal pleura
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lines the inside of the chest wall and diaphragm
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forced expiratory time
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number of seconds it takes to exhale from total capacity to residual volume
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what are some common skin, hair, and nail problems with againg adults?
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senile lentigines, seborrheic keratosis, moisture, skin tags, thickness, mobility and turgor, gray hair, loss of hair, brittle nails
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reasons for decreased or absent breath sounds
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obstrcution and emphysema patients: lose elasticity, decreased force of inspired air, hyperinflated lungs don't make much noise
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What is true regarding language barriers in health care?
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There are laws addressing the language barriers in health care
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if they are hard and fixed
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what are characteristics of lymph nodes that are worrysome?
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Essential and relevant data about the nature and onset of symptoms.
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Present Illness or Health Concerns
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what to do if thyroid is enlarged
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listen for bruit (turbulent blood flow) through bell of stethescope
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how many lobes does the right lung have and what are they called?
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3- RUL, RML, and RLL
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Steps to cultural competency to understand the health care needs of others
step 4
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you must be knowledgeable about the social backgrounds of your patients
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stridor (ex. child with croup)
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this sound is heard when there is significant inflammation in the UPPER airway
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what are the small lumps on the areola?
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elevated sebaceous glands that secrete protective lipids during lactation
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femoral (major one- inguinal pulse site), popliteal (pulse site behind the knee), dorsalis pedis (top of foot), and posterior tibial (inside of ankle)
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what are the 4 arteries in the leg?
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dull- heart and liver
tympanic- gastric space
hyperresonance- hyperinflated lungs
flat- bone
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what organ has a dull note, what has a tympanic note, hyperresonance, flat note?
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