Nurs 155 Exam 3 Questions And 100% Correct Answers
delirium
Reversible state of confusion-usually caused by a medical condition
depression
Mood disorder; sense of hopelessness and persistent unhappiness
dementia
a gradual and irreversible loss of intellectual function
hemiparesis
weakness of one side of the body, or part of it, due to an injury in the motor area of the
brain
Types of sensory deficits and examples
Tactile: touch; peripheral neuropathy
Smell: Olfactory; anosmia
Taste: Gustatory; decreased gustatory cells
Hearing: Auditory; conductive hearing loss, sensorineural hearing loss, and presbycusis
(age related hearing loss)
Equilibrium: motion sickness or Meniere's disease
Vision: Visual; myopia, presbyopia (far sightedness-age related), cataracts (lens of the
eye affected), glaucoma (pressure on optic nerve), diabetic retinopathy (blood vessels
of eye are damaged due to diabetes), and macular degeneration
scab
,Composed of clots and dead/dying tissue and serves to help hemostasis and prevent
contamination of wound by microorganisms.
granulation tissue
translucent red, fragile, bleeds easily. Has network of capillaries increasing the blood
supply
eschar
dried plasma proteins and dead cells
clean wound
No infection and the risk for the development of an infection is low
Pressure injuries
areas of compromised tissue integrity as a result of sustained pressure on a particular
area of the body *most common over bony prominences
Risk factors for pressure ulcers
aging skin
immobility
moisture/incontinence
obesity or lean body mass.
poor or inadequate nutrition (low protein intake)
Poor or ineffective hydration
Illness - fever and dehydration
anemia
Poor circulation/Vascular disease
edema
Impaired sensation
Decreased level of consciousness or sedation
friction/shear
Factors that influence wound healing
Oxygenation and tissue perfusion
, Diabetes
Nutrition
Age
Infection
unstageable pressure ulcer
The entire or part of the wound is covered with slough or eschar and depth is not
stageable.
Position for pressure relief for sacrum and greater trochanter
Lying on side at 30 degree
Scales that measure a person's risk factor for pressure ulcers
Norton Scale and Braden Scale
Nutritional needs for wound healing
Protein
Vitamin C, A, E
Copper
Zinc
Active range of motion
The client has full independent movement of all joints.
Also called isotonic exercise
Active assistive range of motion
The caregiver slightly assists the client or the client slightly assists himself or herself in
the movement of joints through a full motion.
Passive range of motion
The caregiver moves the patient's joints through a full motion. This exercise does not
maintain or improve strength but maintains flexibility and prevents contractures and
atrophy.
Underlying causing of clubbing
Chronic hypoxemia
Modifiable risk factors for cardiovascular disease
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