Integument
Neurological
Respiratory
Cardiovascular
Fluid, Electrolytes & Nutrition
200
The 3 layers of the skin
Dermis, Epidermis, Subcutaneous
200
The term for loss of ability to understand or express speech
aphasia
200
3 signs of respiratory distress
decreased level of consciousness, changes in color, use of accessory muscles, posture changes, increased RR, decreased O2sat, anxiety, air hunger, purse lipped breathing, chest pain, "impending doom"
200
This is a "normal" finding for grading of carotid pulse
2
200
Calculate the intake:
Pudding: 20 mL
Apple juice: 80 mL
Popsicle: 50 mL
Water: 240 mL
370 mL
400
4 factors that affect skin integrity
Nutrition, "therapeutic measures", age, hygiene, health status, lifestyle/occupation
400
Which cranial nerve is begin assessed when the patient puffs out cheeks, raises eyebrows, frowns and smiles?
V and VII
400
This abnormal lung sound can indicate fluid in the lungs.
Crackles
400
Describe the flow of blood through the heart
Returns through the SVC and IVC to the RA, RV, pulmonary arteries to lungs, pulmonary veins to LA, LV, aorta to periphery
400
Name 4 clear liquids
examples: black coffee, popsicle, jello, water, soda, Gatorade
600
What does ABCDE stand for when assessing for malignancy?
Asymmetry, border, color, diameter, evolving
600
What does FAST stand for?
Face, Arms, Speech, Time
600
What is the maximum oxygen capacity (in L) of a nasal cannula?
6L
600
Describe what is happening in the heart during S1 and S2
S1: lub: mitral and tricuspid valves close, ventricles contract
S1: dub: aortic and pulmonic valves close, ventricles relax
600
4 s/s of dehydration
h/a, fatigue, confusion, decreased UO, dark urine, increased thirst, low bp, high hr, dry mucous membranes, skin tenting, dizziness, orthostatic hypotension, sunken fontanels or eyes
800
The difference between wound dehiscence and evisceration?
Dehiscence: sutures have separated, muscles remain intact. Evisceration: sutures have separated, muscles have separated, AND organs are protruding
800
4 urgent neurological assessment findings
Significant changes in neurological status
● Acute change in mental status
● Unexplained changes in consciousness
● Seizure activity; posturing
● Pupil size changes; decreased reactivity to light in one or
both pupils
● Progressing weakness or paralysis
● Extremity, unilateral
800
While listening to your patient's lung sounds, you hear what you think are rhonchi but you aren't sure. What can you do next?
Have the patient cough and listen again.
800
3 urgent cardiac assessment findings
chest pain especially that radiates down L arm, very high or very low BP, arrhythmias, SOB, inadequate perfusion, heart failure, fluid overload
800
3 s/s hypervolemia
increased BP, crackles in lungs, edema, weight gain, chest pain, irregular heart rate or rhythm, SOB
1000
Stage this pressure injury:
Stage IV
1000
Your previously awake and alert patient is now scoring an 8 on the Glasgow coma scale. What do you do first?
Call rapid response team
1000
3 ways aging affects the respiratory system
Effects of aging on respiration
● Respiratory strength declines.
● Lungs lose elasticity.
● Decreased flexibility in rib cartilage- ineffective cough
● Bone density decreases.
● Decreased AP ratio
● Less alveoli for gas exchange
1000
Describe the flow of electricity through the heart
SA node, AV node, Bundle of His(AV bundle), bundle branches, Purkinje fibers
1000
A patients ABG shows pH 7.21 (range: 7.35-7.45) is the blood acidotic or alkalotic?
Acidotic