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130 Cards in this Set
- Front
- Back
What does SOAPE stand for?
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subjective data, objective data, assessment, plan, evaluation
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What does PIE stand for?
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problem, intervention, evaluation
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What does DAR stand for?
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data, action response
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The Patient Care Partnership
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related to the patient's Bill of Rights
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Patient Self-Determination Act
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Advance Directions - client must be given written info explaining the right to refuse treatment and establish advance directives
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Uniform Anatomical Gift Act
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allows competent client to make informed decision to donate all or part of body for organo donation or medical research after death
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Uniform Determination of Death Act
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provides consistent definition of death in each state based on a whole-brain or cardiopulmonary definition
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Torts
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civil wrongs against a person or property and are potential areas of nursing liability. Two forms: intentional and unintentional/negligence
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Assault
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a threat to cause harm
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Battery
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purposeful, wrongful touching without consent
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Five types of intentional torts
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assault, battery, invasion of privacy, defamation of character, false imprisonment
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what might changing position from lying down to sitting or standing do to the heart?
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tachycardia
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what might changing position from sitting or standing to lying down do to the heart
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bradycardia
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What is the normal range for oral temp?
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36-38; 37 is normal
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What is the normal range for rectal temp?
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36.5-38.5; 37.5 is normal
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What is the normal range for axillary temp?
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35.5-37.5; 36.5 is normal
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conduction
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transfer of heat from the body to another surface
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convection
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dispersion of heat by air currents
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evaporation
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dispersion of heat through water vapor
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radiation
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transfer of heat from one object to another object without contact between them
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What is the normal temp for older adults?
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36
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A fever is harmful if it is over
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39
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Hyperthermia is when the temp is less than
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35
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What is the formula to determine cardiac output?
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CO (cardiac output) = HR (heart rate) x SV (Stroke Volume)
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What is pulse deficient?
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apical rate > radial rate
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Diffusion vs perfussion
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diffusion = passage of oxygen and carbon dioxide between alveoli and rbc.s; perfussion = flow of blood to and from the pulmonary capillaries
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How does pulse oximetry work?
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measures infrared light absorption by blood
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When might pulse oximetry be low?
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elderly, dark skin, hypothermia, poor peripheral blood flow, too much light, low hgb levels, client movement, edema, nail polish
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What is the regular RR for newborns?
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30-60
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What is the regular RR for school children?
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20-30
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What do amphetamines and cocaines do to respiratory rate and depth?
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increase
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What does sickle-cell disease do to RR?
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increases
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What is the formula for B/P?
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B/P = cardiac output x systemic vascular resistance
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What is prehypertension?
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120-140/80-90
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What is Stage 1 HTN?
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140-160/90-100
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What is stage 2 HTN?
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160+/100+
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Hypotension is defined as
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systolic B/P < 90
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What is pulse pressure?
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systolic - diastolic
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What is B/P usually the lowest?
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in early morning
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When is B/P usually the highest?
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in afternoon
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Where should the B/P cuff be applied?
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2 cm above
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What is the order for assessment?
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inspection, palpation, percussion, auscultation
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What is the order for assessment of the abd?
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inspection, auscultation, percussion, palpation
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What results from a too large B/P cuff?
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false low reading
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What results from a too small B/P cuff
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false high reading
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What do opiates do to B/P?
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decrease
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What doe cardiac meds do to B/P
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decrease
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What does cocaine do to B/P?
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increase
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What do cold meds do to B/P?
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increase
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What do oral contraceptives do to B/P?
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increase
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What do antidepressants do to B/P?
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increase
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What part of the hand is most sensitive to temperature?
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dorsal surface
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What part of the hand is most sensitive to vibration>?
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ulnar surface and base of fingers
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macule
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nonpalpable, skin color change, < 1 cm (freckle)
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papule
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palpable, circumscribed, <0.5 cm (elevated nevi)
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nodule/tumor
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palpable, circumscribed, => 0.5 cm (wart)
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vesicle
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serous fluid-filled, < 1 cm (blister)
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pustule
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pus filled (acne)
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wheal
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palpable, irregular borders, edematous (mosquite bite)
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erosion
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loss of epidermis, moist surface, no bleeding (ruptured vesicle)
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crust
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dried blood, serum, or pus (scab)
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scale
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flakes of skin that exfoliate (dandruff or psoriasis)
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fissure
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linear crack (tinea pedis)
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ulcer
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loss of epidermis and dermis with possible bleeding and scarring (venous stasis ulcer)
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primary lesions
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arise from healthy skin tissue
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secondary lesions
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arise from change in primary lesion
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vascular lesions
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created with aging changes or when damage occurs to blood vessels in or near the skin
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spider angioma
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red with radiating legs
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cherry angioma
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red, 1-3 cm, round, can be raised
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spider vein
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bluish, spider-shaped or linear, with up to several inches in size
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petechia/purpura
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deep reddish purple, flat, petechia = 1-3 mm, purpura > 3 mm'
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ecchymosis
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purple fading to green or yellow over time, variable in size, and flat
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hematoma
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raised ecchymosis
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myopia
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impaired far vision
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presbyopia
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impaired near vision
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Rosenbaum chart is held
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14 inches from eyes
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Ishihara test is for
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color vision
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Nystagmus
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tremor-like movements of eye
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ptosis
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covering of pupil with upper eyelid
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palpebral
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pink
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bulbar
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transparent
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partial illumination of iris is indicative of
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glaucoma
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strabismus
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wandering of eye
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What is Rinne's test for?
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air conduction and bone conduction
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What is Weber's test for
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sound heart equally in both ears
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pendulous
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sagging
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Which lung has three lobes
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right
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S(1)
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closure of mitral and tricuspid
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S(2)
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closure of aoritc and pulmonic
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S(3)
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rapid ventricular filling - in children and young adults
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S(4)
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strong atrial contraction - elderly and athletic
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Bruits
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obstructed peripheral blood flow
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Dorsalis Pedis Pulse
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top of foot
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Homan's sign
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risk for DVT
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Striae
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stretch marks that are silver in color
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kyphosis
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exaggerated curvature of thoracic spine
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Lordosis
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exaggerated curvature of lumbar spine
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Obtundation
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needs to be lightly shaken to respond
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Stupor
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requires painful stimuli for brief response
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Best and worst score on Glasgow coma scale
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best = 15; worst = 3
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Romberg test
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patient stands with eyes closed; should stand without swaying for 5 seconds
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Stereognosis
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patient identified familiar object placed in hand
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graphesthesia
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client identifies number drawn on palm
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When is teratogenesis most likely to occur?
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during first trimester
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Where should IV be started?
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in distal veins on nondominant hand
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Never disconect IV tubing for convenience or to position the patient
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a
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how often should site be assessed when heat or cold is applied?
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every 5-10 minutes
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how old should a client be for their pain rating to be useful?
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older than 7
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What is the max. amt of APAP to be given to healthy client?
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4 grams/day
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To prevent gastric upset r/t non-opioids,
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administer with food
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Adjuvant analgesics
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ehance effects of nonopioids
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low serum albumin levels lead to
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delayed wound healing
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hydrocolloid wound dressing
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occlusive and swells
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To prevent pressure ulcers, bed positioning is
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<30 degrees
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What should be done to the heels to prevent ulcers?
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raise off of bed
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What should be done when washing pressure ulcers?
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tepid water, minimal scrubbing, pat skin dry
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Blended families
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remarriages with stepchildren
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Rigid family structure
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strict
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open family structure
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loose, not strict
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family can be considered as
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context, client, or system
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repatterning belief means
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trying to change a belief
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Congruence
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the balance of life patterns and rhythms; cannot be achieve3d but is constantlyh sought
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bereavement
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includes grief and mourning
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mourning
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outward display of loss
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It is an emergency if the O2 sat is below
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86%
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it is life-threatening if the O2 sat is below
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80%
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A patient on oxygen should wear ____, not ____ or ____
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cotton; not synthetics or wool
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hypercarbia
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elevated levels of carbon dioxide
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SaO(2)
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oxygen saturation
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Which is more effective - coughing or suctioning
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coughing
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