Vital Signs and Pain
Infection
Musculoskeletal
Integumentary
Erickson Stage and Piaget
100
What does PQRST stand for?
Provocation (cause), Quality (dull, aching, throbbing, etc.), Radiation (is the pain radiating), Severity (how intense is the pain), Timing (when did it start, how long has it lasted, etc.)
100
Describe the 4 different wound drainages?
100
What is the difference between fowler's position and semi-Fowler's position?
Fowler’s – head of bed is raised 45-60 degrees
Semi-Fowler’s – head of bed raised 30 degrees
100
What is skin turgor, and why do we check skin turgor?
Skin turgor is the skin's elasticity, and we check skin turgor to assess for dehydration
100
What is the age range for the concrete operational stage of Piaget's stages of cognitive development, and what happens in this stage?
7 to 11 years old
Concepts are attached to concrete situations. Time, space, and quantity are understood and can be applied, but not as independent concepts.
200
Before assessing a patient's oral temperature, what should the nurse ask the patient?
Have you had anything hot or cold to drink recently?
200
How do you do a skin assessment on a patient who is darker-skinned?
Assess for:
• Pallor (mucous membranes)
• Cyanosis (lips, tongue, conjunctivae, palms, soles)
• Inflammation (excessive warmth, changes in skin consistency or texture)
• Jaundice (hard palate, conjunctivae, and sclera)
• Skin bleeding (darker than normal skin)
200
How do you maintain proper body mechanics?
Principles of body mechanics
Maintain appropriate body alignment
Maintain wide base of support
Bend knees and hips
Do not bend from waist
The lower the center of gravity, the greater the stability
Equilibrium is maintained if the line of gravity passes through it’s base of support
200
What is ecchymosis?
Bleeding under the skin/bruising
200
Which of Erikson's psychosocial development stages asks the question "have I lived a full life"?
Ego identity vs. Despair
300
How do you find the apical-radial pulse deficit?
One person measures the apical pulse, and another measures the radial pulse at the same time for 60 seconds. Then, you subtract the radial pulse from the apical.
300
What is a nosocomial infection?
An infection acquired during hospitalization
300
What are the signs and symptoms of compartment syndrome?
Compartment syndrome
Increasing pain disproportionate to injury
Pallor
Paresthesias
Increased capillary refill
Skin cool
Decreased or absent pulses
300
What are you looking for in a skin assessment?
• Color – Pink? Normal for ethnicity? Pale? Cyanotic?
• Temperature – warm is better than cold
• Moisture – dry is better than wet
• Texture – smooth, scaly, dry, flakey,
• edema, taut
• Turgor – poor turgor is a sign of dehydration
• Evidence of Injury
• Lesions – Document shape, color, pattern and location and presence of exudate (crust)
300
Which of Piaget's cognitive development stages involves symbolic thinking, the development of conversation, and proper use of grammar to express concepts but lacks complex abstract thought and what age range?
Preoperational
2-7 years old
400
What is
Dyspnea
Tachypnea
Bradypnea
Apnea
Dyspnea—breathing with difficulty
Tachypnea – fast breathing
Bradypnea – slow breathing
Apnea – no breathing!
400
List 3 potential signs of infection
Examples include fever, odorous drainage, tenderness at the site of infection, warmth to the touch at the site of infection, wound breakdown, abnormal drainage, etc.
400
Demonstrate abduction and adduction of arms. Make sure to state which one is which.
Abduction moves a limb away from the body's midline, like raising your arm to the side, while adduction brings it toward the midline, like lowering your arm back down; think "Abduction = Away," and "Add"uction = adding it back.
400
What is a wound Dehiscence and what nursing intervention should be completed?
- Wound layers separate
- Patient may say that something has “given way”
- It may result after periods of sneezing, coughing, or vomiting
- It may be preceded by serosanguineous drainage
- Patient should remain in bed and receive nothing by mouth, be told not to cough, and be reassured
- The nurse should place a warm, moist sterile dressing over the area until the provider evaluates the site
400
What is the outcome of the psychosocial development stage "trust vs. mistrust" and what age range?
Children develop trust when receiving reliability, care, and affection from caregivers vs. mistrust if receiving a lack of the aforementioned.
Infancy (0-18 months)
500
What are the normal vital sign ranges of HR, RR, and BP for older adults?
HR: 60-100
RR: 12-18
BP: 130-140/90-95
500
What is the best time to collect a sputum specimen?
First thing in the morning.
500
Demonstrate flexion and extension of legs. Make sure to state which one is which.
Flexion and extension are opposite movements at a joint that describe the change in angle between body parts. Flexion decreases the angle (bending/closing), bringing bones closer, while extension increases the angle (straightening/opening), moving bones apart
500
Describe the difference between a stage 1 pressure injury and a stage two pressure injury?
- Stage 1: Skin is intact.
- Stage 2: The skin is broken, forming a shallow, open ulcer, or a blister (intact or ruptured).
500
Describe the 4 different types of family patterns>
Autocratic: Controlled household where the parents are strict and control behaviors and expectations.
Patriarchal: Dominant male figurehead, and all inheritance and ancestry is traced through the father's side of the family
Matriarchal: The female is the head of the household and the primary decision maker
Democratic: Mutual respect between parent and child, non-punitive discipline.