NSG 2000: Exam 2

Part of brain responsible for person’s mental status

Part of brain responsible for perception and behavior

Part of brain responsible for short term memory, concentration, emotional expression, decision-making and problem-solving

Part of brain responsible for sensory data

Part of brain responsible for long term memory and sounds

Part of brain responsible for survival behaviors and emotions

Part of brain responsible for awareness and arousal

Exam to assess neurological function:

• Can score up to 31

• A score of 21 or less warrant further evaluation → reveals cognitive dysfunction

Scale used to assess neurological function:

• 15 is the best score and 3 is the worst

Components of mental exam:

• _____ __ _________

  • A&O

• ________ and _________

  • Mood, hygiene, body language

• ________

  • normal or aphasia: sensory and motor

• ______

  • Recent, remote, delirium, dementia

Other: knowledge, abstract thinking, association, judgment [know these definitions]

Exam what components for level of consciousness (LOC)?

Exam what components for behavior and appearance

Examining for what components of language

Cannot understand written or verbal speech. Hear words but no comprehension.

Understands written or verbal speech but cannot write or speak appropriately. Cannot say what they want to say.

Short term

• Name unrelated objective; recall 3 words or series of numbers (keep it simple)

Long term

• Recall mother’s maiden name; an event in history; birthday

• Acute (immediate, usually a cause, comes back)

• Sudden-short development

• Medical condition link (e.g. concussion, trauma)

• Impairs consciousness

• Potentially reversible

• Perform GCS

• Chronic (slow, not coming back)

• Insidious-progressive

• Structural brain disease

• Impairs judgment, memory, thought patterns

Cranial Nerves

Cranial Nerve function(s): olfactory, smell

Cranial Nerve function(s): eye movement and visual acuity

Cranial Nerve function(s): taste

Cranial Nerve function(s): hearing

Cranial Nerve function(s): parasympathetic innervation, vagal response

Cranial Nerve function(s): hypoglossal movement of the tongue

Sensory function is

Motor function tests

Cerebral cortex. Perception. Maintains balance and posture.

Romberg test

Stereognosis test

Graphesthesia test

Making adjustments to environment. Perception of body in space with eyes closed

Categories of normal reflexes

Deep tendon reflexes (DTRs) tests for?

Deep Tendon Reflexes grading scale:

Steps of inflammatory response

3 triggers of the inflammatory response

Infection can be

Normal white blood count

When having infection/respiratory response WBC count is?

Only affects one area of body.
Symptoms: swelling, redness, tenderness, loss of function

Affects entire body.
Symptoms: fever, increased leukocytosis, malaise, anorexia, N&V, lymph enlargement organ failure

Course of infection

the time the pathogen enters the body until the appearance of signs and symptoms

onset of nonspecific to more specific signs and symptoms; contagious

symptoms of infection apparent; when infection is considered severe

signs and symptoms begin to disappear

return to state of health

Degree of risk of causing someone to get sick. The higher the count the sicker you become

Chain of infection:

• ________: normal flora in the wrong location can cause infection

• ________

  • ______ or ______

• Portal of ____

• Mode of ________

  • ______ or _______

• Portal of ____

• _______ host

  • (more likely) _____, ____, and ____________

GOAL: “break” the chain and it will slow the spread of infectious disease.

Precaution categories

What precaution:

Applied to all patients.

• hand hygiene, gloves/PPE, room, sharps & equipment, respiratory/cough hygiene

Contact precautions

• _____ or _______

• _____ and ______ (minimum PPE)

• _______ ____ or ______

scabies, staph aureus, hepatitis, C. diff, MRSA, VRE, ESBLs, Herpes zoster or shingles, covid

Droplet precautions

• __-__ feet

• _____ and ____ impact spread (cold prevents)

• ____

  • ______ and ______ for transport

• ____ _____ or _____ (dependent on circumstance)

• _____ or ____ (room, 3 ft separation)

• influenza

• pertussis (whooping cough)

• mumps and measles

• adenovirus

• norovirus

• rhinovirus (common cold)

• mycoplasma pneumonia

• covid

Airborne precautions:

• travel ___ distance

• ___ particles stay for ____

• ______ air pressure (AIIR, hallway to room; 6-12 exchanges with HEPA filter)

• ____ for client to transport

• _______ room

• TB

• smallpox

• chickenpox (varicella)

• Measles (rubeola)

• disseminated herpes zoster

• covid (other droplet diseases become airborne with aerosolizing procedures)

Private room ONLY

Protective precautions

• _____ airflow (AIIR: room to hallway with 12 exchanges an hour with HEPA filter)

• _______ (e.g. stem cell, kidney)

• No ____

Putting on PPE sequence

Doffing PPE sequence

Hospital-associated infection (HAI) characteristics:

• often ________

• _____ LOS

• _____ expense

• Increases potential for _____

Most common HAIs

• CAUTI

• SSI

• CLABSI

• VAP

• MRSA

• VRE

• VRSA

• VISA

• ESBLs

• MDRSP

enhanced barrier precautions—long term care

Airborne is always ___ patient(s) to one room

Cleaning technique practices that reduce the presence of disease-causing microorganisms on surfaces.

e.g.) CHG baths, hand hygiene, cleaning your equipment (anything shared), etc.

Cleaning techniques that ensures the sterility of items that will come in contact with the client, through use of equipment such as sterile gloves, in order to prevent pathogen transfer to the client

100% no organisms

All microorganisms, including spores, are eradicated.

Processes: steam and then dry heat, ethylene oxide gas, chemicals

Cleans instruments so microorganisms are eradicated but does not remove spores. Otherwise use single use equipment.

• High-level: only a few spores remain

• Low-level: most bacteria destroyed but some spores, viruses, & fungi remain

Types of Immunity (3)

active immunity:

• Disease causes immune system to ______ ________

  • ____

  • ____-_____

• develops after ____

• ___-____

Passive immunity:

• _____ antibodies

  • ______ via ______

  • _____ ______

• protection is ________

• ___-____

Herd:

• _____ percentage of population is protected against a certain disease

• ______ amount of virus transmission

Vaccine Routes

Mild side effects of vaccine

What do you do with redness at injection site?

Maintain vaccine record:

• ____ of _______

• _______ and ____ _______

• ____

• ______

• _____ of ______ _______

• ____ and _____ of administration

Report adverse events how?

blood sample to document concentration of antibodies

Titer adequate levels meaning

Titer inadequate levels

Common titer tests

Anaphylactic reaction from:

• ______ vaccine

• Components in vaccine:

  • ___ allergy (or gelatin for live?)

  • _______ or _____

• Administer with caution to those with moderate or severe acute illness, with or without ______

Live virus not given to:

• Severely ______ _______ ______

• Severe _______ __ ______

• ______ women

Administer with caution: moderate or sever acute illness, with or without fever

Minimize vaccine reaction

Mild anaphylactic reaction

moderate to severe anaphylactic reaction:

• ______ _____

• ____

• _____ HOB

• Administer: _______, _____, _____ per orders

• Monitor _____ ____ and _____ _____

VAERS

• Established in 1990.

• Managed by CDC and FDA.

• Accept & analyze reports of adverse events after vaccination. Anyone can report.

• Healthcare personnel are required to report.

what age has decreased response to vaccinations?

main principles in nursing code of ethics

Part of abdomen that contains the:

liver, pancreas, gallbladder, ascending colon, some of the kidneys

Part of abdomen that contains the:

stomach, spleen, pancreas, transverse colon, intestines

Part of the abdomen that contains the:

small + large intestine and left reproductive organs

Part of the abdomen that contains the:

appendix, intestines, and right reproductive organs

Area of abdomen that contains the bladder and uterus

Bowel sounds that are more than 15-30 seconds to hear but at least one every 5 minutes.

Ecchymosis; bruising around umbilicus

sign of bleeding in the peritoneal cavity or parancitis

Ecchymosis in the flank

Sign of bleeding in the peritoneal cavity or parancitis

The shape of a pregnant woman’s abdomen