TRUE OR FALSE
Define Hydrocephalous
obstruction drainage of CSF that results in excess fluid. Enlarged head and increased Intracranial pressure.
How do normal lymph nodes feel ?
if nodes are ever palpable, note location, size, mobility and tenderness.
Cervical nodes are often palpable on healthy individuals.
Signs of breast cancer?
lump, dimpling of skin, edema, bleeding, new skin lesion, fixation of tissue, sudden deviation of nipple, enlarged axillary lymph nodes (central, pectoral, subscapular, lateral).
consider the following interaction-
patient:I know exactly what the doctor will say, He is going to be me I have cancer.
Nurse: Don't worry, everything will be fine.
The nurses response was incorrect why? what else can the nurse say instead?False reassurance.
try- it must be very difficult waiting for results and then to speak to the doctor.
We can find the appendix on the LLQ
False.
It can be found on the right lower quadrantDefine and diferentiate between Pupilary light reflex, corneal light reflex, accommodation and corneal reflex
Pupillary light reflex- shinning a light at each eye and noticing normal pupil constriction
Coneal light reflex- shinning and light toward the patient while patient looks straight. The reflection of the light should sit in the exact same spot in both eyes (cornea)
Corneal Reflex- blinking when something comes very close to eye.
Accomodation- eyes constricting when looking at near by objects.
feeling of pressure, but NO pain or tenderness.
pain or tenderness can be felt with inflamation of sinuses due to chronic allergies or infection.
what does an ear infection look like?
redness, purulent dicharge, swelling, pain.
children may pull at ears when infection occurs, cry get irritable.
be careful when introducing otoscope, as it can be painful if pushing in otoscope into ear. can also damage canal.
assess the nurses statement:
nurse: if I were you I would put your dad in a nursing home. He is a lot of work, and you will not be able to care for him at home.
What type of wrong communication technique is this?
giving unwanted advise.
Instead give all facts and allow family to make own decision.
You would find dull percussion sounds over air filled structures.
False. Dull over solid, tympany over air filled.
Define Rebound tenderness
pain upon release of pressure.
*Done away from the site of pain. Holding hand 90 degree to the abdomen. Push down Slowly and release quickly.
confirms peritoneal inflammation.
when to screen for suicidal ideation?
Only when concern noted.
Safety is number 1 priority.
What is the earliest sign of someone neurological status declining?
Decreased in LOC (level of consciousness)
alert, oriented, obeys?
How would you (Nurse 2) respond:
Nurse 1: Ugh, I just sat with Mr Smith and told him all the information about going home, he just sat there in SILENCE and did not say anything. Not 1 word. What a waste of time.
Nurse 2:.....
Silence does not always mean a bad thing. it gives the patient or nurse time to process what has been said.
Prologed bottle use can increase the rish of tooth decay and middle ear infections.
TRUE
Vertigo vs dizziness vs lightheadedness
Vertigo- sensation of rotational spinning
Dizziness- feeling lightheadness and unsteady balance.
Lightheadness- feeling as if about to faint, can be accompanied by weakness.
What tool do we use for assessment of LOC?
Clue- gives numerical value.
GCS. Glascow Coma Scale.
If nurse Smith needed to assess for tonsillitis, how would it be done? what would the findings be?
ask the patient to open mouth and say "ahh".
bright red, swollen tonsils (close to uvula). May have "dots' of pus. sore throat, painful swallowing.
Enlarged anterior cervical and tonsilar nodules.
Your patient does not speak English and you are trying to do some health teaching.. what would you do? who can you call?
a. family
b. one of the administrators speaks the same language..call them
c. If able, to try to find qualified interpreter
C. qualified interpreters are hired many times by hospitals and are aware of medical terminology.
Conductive hearing loss can be a gradual nerve degeneration or caused by ototoxic meds.
FALSE. Conductive hearing loss is mechanical dysfuction of the external or middle ear. E.g impacted cerumen (wax), foreign body, perforated eardrum.
Sensorineural- can be a gradual nerve degeneration or caused by ototoxic meds.
Paresthesia
When do we perform a mental health assessment?
Symptoms evident, Family member concern,Brain lesion
What is the age of consent?
The concept of maturity has replaced chronological age, except in Québec, where the age of consent is 14 years and older.
Physicians usually determine whether a child has the mental capacity (competence) to provide consent on a case-by-case basis.
The charge nurse tells you,
"Your next patient has some sort of disability, I can just tell. Not sure what it is, but It's something. Good luck giving them information about the breast self exam"
How can you teach clients with disability?
Assess what disability they have, and ASK THEM how they best learn. How can YOU help them.