Vital Signs
___________________ is referred to as a "silent killer" due to its few symptoms.
Hypertension
New tissue, pink-red in color, composed of fibroblasts and small blood vessels that fill an open wound when it starts to heal
Granulation tissue
Wound drainage made up of white blood cells, liquefied
dead tissue debris, and both dead and live bacteria
Purulent wound drainage
Infestations with lice is called
Pediculosis
The purpose of Gram stain on bacteria is to inform prescribers in selecting appropriate antibiotic therapy.
T or F
True
______________ is a defense mechanism that indicates the patient is experiencing a problem.
Pain
A nursing planning care for a patient who believes in traditional Chinese medicine (TCM) helps the patient balance yin and ________, the belief that two opposing, yet complementary forces provide a natural order and interconnectedness to the universe.
yang
Orthostatic hypotension, especially in the older adult, can predispose the patient to _____________
falls/injury
Avascular collagen tissue that does not sweat, grow hair, or tan in sunlight
Scar
Wounds characterized by oozing from black tissue intermittently covering the wound, often accompanied by purulent drainage
Eschar or necrotic tissue needing debridement
Inflammation of tissue around the teeth is referred to as
Gingivitis
Methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) are most often transmitted by the hands of health care providers.
T or F
True
Endogenous neuromodulators called ____________ and ________________ can produce analgesic effects.
endorphins and enkephalins
A nurse's philosophy of patient care focuses on the body, mind, and emotions of the individual in order to heal the entire person. This nurse is practicing ______________ nursing.
Holistic
State in which temperature fluctuates between above-normal and below-normal ranges
ineffective thermoregulation
Partial or total disruption of wound layers
Dehiscence
Composed of fluid and cells that escape the blood vessels and are deposited in or on wound surfaces
Exudate
During perineal care, avoid applying ____________, which may become a medium for bacterial growth
Powder
Wearing gloves is the most effective way to help prevent the spread of organisms.
T or F
False
What is correct?
Pain sensations from the site of injury or inflammation are conducted to the spinal cord and then the brain in a process know as ___________________.
transmission
___________ consists of placing very thin, short, sterile needles at particular points believed to be the centers of nerve and vascular tissue for the purpose of pain management and restoring Qi.
Acupuncture
Patient is aware of own rapid heartbeat without having to feel their pulse
Palpitation
Protrusion of viscera through the incisional area
Evisceration
May occur from a slipped suture, a dislodged clot from stress at the suture line, infection, or the erosion of a blood vessel by a foreign body (such as a drain)
Hemorrhage
Ticks embedded in the patient's skin may transmit Rocky Mountain spotted fever or ___________ disease and should be removed with a tweezer making sure to remove the head.
Lyme's
Resident bacteria, normally picked up in the course of usual activities of daily living, are relatively few on clean and exposed areas of the skin.
T or F
False
Transient bacteria
Resident bacteria normally live a short time on the skin of an individual
_______________ pain is generally rapid onset and is protective, disappearing when the situation is resolved.
Acute
A nurse guides a patient to use all five senses to focus on pleasant images to replace negative or stressful feelings promoting relaxation and healing . This nurse is engaging the patient to use guided __________.
Imagery
Name 3 methods that can be used to assess the pulse
palpation of arterial site
auscultation of apical pulse
doppler ultrasound
Name 6 major functions of the skin
Protect the body; immunity
Regulate body temperature
Sense stimuli from the environment and transmit these sensations
Absorption and elimination
Help maintain water and electrolyte balance
Produce and absorb Vit D
Wound drainage that is composed of clear, pink-tinged serous drainage contain a few blood cells
Sero-sangenous
Ulcerations of the lips, often caused by Vitamin B complex deficiencies
Cheilosis
When observing medical asepsis, areas are considered contaminated if they are touched by any object that is not sterile.
T or F
False
Surgical asepsis
A patient with inflammation and infection in the gallbladder reports right shoulder pain. This is an example of _____________ pain.
referred
A nurse recommends the use of ___________ supplements, chemical compounds that contain ingredients believed to promote health, for a patient diagnosed with anorexia.
Nutritional
Which patient would the nurse consider at risk for low blood pressure?
a) Patient with high blood viscosity
b) Patient with decreased blood volume
c) Patient with decreased elasticity of arteriole walls
d) Patient with strong pumping action of blood into the arteries
b) Patient with decreased blood volume
Describe how you would assess aspects of wound healing?
Appearance
Wound drainage
Pain
Sutures or staples
What are the four phases of wound healing?
Hemostasis
Inflammation
Proliferation
Maturation
When performing hygiene on a _______________ male patient, the nurse must retract the foreskin before cleaning, and pull it back into place when finished
Uncircumsized
Organism present in the body but not causing symptoms; the patient remains healthy and uninfected.
Colonized/colonization
Phantom limb pain is an example of _____________
pain.
neuropathic
A combination of complementary health and conventional health approaches in a coordinated manner refers to ______________ health.
Integrative