Term
3 types of physical assessments |
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Definition
1. complete assesment 2. daily assessment 3. focused assesment of body part |
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Term
who completes a "complete assessment" |
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Definition
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Term
when ___________ the client, always explain the reason, when/where, what will happen, assist as needed, ask to empty bladder, collect sample if needed, continuously reassure, be specific about taking clothing off for gown |
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Definition
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Term
when ___________ the patient, take into account the patients age, physical condition, energy level, ROM limitations |
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Definition
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Term
most accessible positions |
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Definition
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Term
_______ assessment includes: head to toe assessment, healthh history, level of activity/functioning |
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Definition
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Term
__________ assessment usually not done by an lpn |
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Definition
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Term
_____ may be delegated tasks such as these: inventory of personal property, allergies, medication list, dietary habits, past medical history, fall risk assessment, info related to impairments and disability |
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Definition
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Term
conducted at the beginning and end of each shift; can be performed by rn; includes head to to systematic/efficient; energy level, fewest position changes, modified for different ages, general or specific |
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Definition
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Term
when you enter the room, _______ begins |
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Definition
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Term
important in ___________ assessment: LOC, alert, lethargic, sedated, or unconscious |
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Definition
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Term
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Definition
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Term
person, place, time, incident = |
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Definition
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Term
how to check _______ response: speech is clear, appropriate, slurred, incoherent, dysphagia, or aphasia (no speech) |
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Definition
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Term
how to check _________ response: squeeze both fingers; equal bilaterally, grips, flexion/extension |
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Definition
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Term
how to assess _________: description; sharp, dull, burning, non-existant, scale 0-10 |
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Definition
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Term
pupils are normally ___-___ mL in diameter |
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Definition
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Term
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Definition
Pupils are Equal, Round, React to Light and Accommodate |
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Term
when you hold a piece of paper up and you can see something written behind it but paper loses focus, and then look at paper and written thing loses focus |
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Definition
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Term
light makes the pupil ______ |
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Definition
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Term
darkness makes the pupil ________ |
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Definition
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Term
temperature, pulse, respirations, bloodpressure, and pulse oximetery (and pain) are all __________ ________ |
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Definition
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Term
always record _______ and ________ at the same time each day and use the same, appropriate equipment. |
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Definition
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Term
why might tattoos/piercings swell |
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Definition
hepatitis, infection, allergy |
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Term
pinching the skin to check for hydration |
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Definition
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Term
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Definition
60-100 beats/min (resting) |
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Term
what is a bilateral pulse |
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Definition
means that the pulse rate should be the same throughout the whole body |
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Term
pulse is usually taken ______ or _________ |
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Definition
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Term
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Definition
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Term
instrument used to listen to internal sounds in the body |
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Definition
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Term
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Definition
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Term
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Definition
0- absent 1- thready 2- weak 3- normal 4- bounding |
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Term
strong visible pulse that is difficult to stop with pressure |
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Definition
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Term
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Definition
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Term
edema is a sign that the ________ may be beginning to fail |
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Definition
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Term
how to display capillary refill |
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Definition
pushing the nail beds...white/pink |
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Term
way to test for capillary refill; frowned upon; may cause deep vein thrombosis |
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Definition
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Term
difference between thrombosis and embolus blood clots |
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Definition
thrombus is stationary embolus moves |
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Term
fast breathing; more than 24 breaths per minute |
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Definition
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Term
slow breathing; less than 10 breaths per min |
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Definition
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Term
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Definition
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Term
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Definition
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Term
measures oxygen saturation at the capillary level |
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Definition
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Term
pulse oximetry normal level |
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Definition
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Term
life threatening pulse oximetry |
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Definition
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Term
always ___________ before you ____________ the abdomen |
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Definition
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Term
when muscles in the abdomen cease to hold the intestines back and the abdomen is distende |
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Definition
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Term
what quadrant for appendicitis |
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Definition
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Term
___________ in old people can be a sign of constipation |
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Definition
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Term
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Definition
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Definition
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Definition
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Definition
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Term
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Definition
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Term
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Definition
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Term
newborns with increased pigmentation in sacral area |
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Definition
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Term
newborns with tiny whiteheads on the face and nose |
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Definition
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Term
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Definition
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Term
where to assess infant respirations |
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Definition
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Term
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Definition
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Term
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Definition
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Term
medical term for "hearing loss" |
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Definition
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Term
_________ fontanel closes at 8 weeks |
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Definition
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Term
____________ fontanel closes at 18 weeks |
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Definition
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Term
voluntary head control by ____ months |
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Definition
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Term
top of ears line with (BOTTOM/TOP) of eyes |
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Definition
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Term
__________ of feet up to age 2 1/2 years old |
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Definition
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Term
may be expressed after 1st trimester; milk |
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Definition
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Term
paralysis of the lower extremities |
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Definition
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Term
paralysis of half of the body (right or left side); stroke side effect |
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Definition
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Term
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Definition
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Term
ability to perceive environmental stimuli and body reactions |
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Definition
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Term
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Definition
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Term
burn from hot liquid or vapor |
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Definition
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Term
excessive exposure to thermal, chemical, electrical, or radioactive heat |
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
no feeling; damaged nerves |
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Term
usually occurs from electrical equipment malfunctions (in medical institutions) |
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Definition
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Term
pressurized water fire extinguisher; used for paper, cloth, wood (NEVER USED FOR GREASE FIRES) |
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Definition
CLASS A FIRE EXTINGUISHER |
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Term
carbon dioxide fire extinguisher; used for flammable liquids (i.e. gasoline, oil, paint grease, gases |
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Definition
CLASS B FIRE EXTINGUISHER |
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Term
dry chemical fire extinguisher; used for electrical fires (computer labs), burning liquids; Chemical is NONCONDUCTING |
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Definition
CLASS C FIRE EXTINGUISHER |
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Term
graphite-type chemical fire extinguisher; used for all types of fires; leaves a residue that can be irritating to skin/eyes |
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Definition
CLASS ABC FIRE EXTINGUISHER |
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Term
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Definition
Pull the pin Aim at the edge of fire Squeeze the handle to discharge Sweep from side to side |
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Term
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Definition
Rescue patients in immediate danger Alarm- Pull it! Contain the fire Extinguish or Escape the fire |
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Term
T or F: Everyone uses the stairs during evacuation plan. |
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Definition
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Term
practice evacuation plan at least ___ per year |
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Definition
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Term
poison control center phone number |
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Definition
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Term
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Definition
the "silent" killer; furnaces/heaters, CO detectors are low to the floor |
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Term
leading cause of injury among older adults |
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Definition
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Term
fall risk assessment is made on admission and with changes in condition (T or F) |
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Definition
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Term
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Definition
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Term
lack of oxygen caused by interuption in breathing |
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Definition
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Term
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Definition
foreign body airway obstruction |
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Term
all equipment must be properly grounded: this means they must have _____-________ plugs |
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Definition
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Term
overexposure to radioactive material used in diagnostic or therapeutic procedures |
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Definition
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Term
continuous radiation that involves a live video |
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Definition
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Term
protection for nurses during xray |
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Definition
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Term
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Definition
occupational safety and health administration |
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Term
ensures needless systems and assistive devices |
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Definition
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Term
OSHA's 2 standards for infectious waste: |
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Definition
bloodborne pathogens occupational exposure to tuberculosis (tb) |
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Term
T or F- It is "okay" to make a bed at the facility like we do at home, lying the sheets on the floor, and pressing them against us as we take them to the laundry basket. |
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Definition
false: handle linens as little as possible |
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Term
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Definition
material safety data sheets |
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Term
used for every hazardous chemical in institution; provides product name and chemical info, precautions for handling, instructions for safe use, procedures for spills, emergency first aid, and a 24-hr hotline phone number |
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Definition
Material safety data sheets |
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Term
3 types of disaster plans |
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Definition
external internal external/internal |
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Term
disaster plan that deals with events outside of the facility that cause a large amount of victims; ie plane/bus/train crash |
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Definition
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Term
disaster plan that deals with events within the facility that involves a large amount of victims; ie explosion, infection, fire |
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Definition
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Term
disaster plan that deals with events inside and outside of the facility that cause a large amount of deaths; ie, tornado/hurricane/flashflood/fire |
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Definition
internal/external disaster plan |
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Term
disaster plan should have atleast ____ days of food and water for each person |
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Definition
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Term
volunteer organization that ensures hometown security during local and national disasters; includes medical personnel, clergy, attorneys, etc. |
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Definition
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Term
method of prioritizing victims according to their need for care |
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Definition
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Term
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Definition
most severe; uncontrollable bleeding, major wounds, salvageable |
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Term
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Definition
significant; no ambulation- can wait |
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Term
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Definition
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Term
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Definition
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Term
when can you legally stop cpr? |
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Definition
when someone relieves you when you are physically exhausted |
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Term
where are reassignments made? |
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Definition
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Term
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Definition
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Term
protective devices used to limit the physical activity of a client or a part of the client's body |
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Definition
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Term
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Definition
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Term
t/f: restraints are applied as a last resort |
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Definition
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Term
physician's order for restraint must include: |
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Definition
type of restraint and how long it will be used |
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Term
safe efficient use of the body to move objects and carry out activities of daily living |
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Definition
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Term
widening base of support and lowering center of gravity means better _________ ________ |
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
most common injury in health care worker |
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Definition
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Term
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Definition
hold object close to body, wide base of support, bed at knees - not the waist |
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Term
more control occurs when you ______ an object DIRECTLY toward you than when you _________ an object away from you |
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Definition
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Term
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Definition
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Term
patients have the right to |
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Definition
participate in own care, accept/refuse medical/surgical treatment prepare advance directive information about provider of care |
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Term
two types of advanced directives |
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Definition
living will DPOA- durable power of attorney |
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Term
describes type of treatment desired by the patient as well as the undesired treatment |
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Definition
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Term
describes the medical treatment of life-sustaining treatments the person would want if seriously or terminally ill |
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Definition
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Term
t/f: attorney is required for living will |
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Definition
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Term
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Definition
durable power of attorney |
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Term
names a health care proxy (18+ yrs old) to make medical decisions in the event the patient is not able to decide for themselves |
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Definition
DPOA durable power of attorney |
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Term
t/f: living will considered more useful than DPOA |
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Definition
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Term
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Definition
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Term
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Definition
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Term
DNR must be written on yellow official form t/f |
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Definition
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Term
t/f: the physician must pronounce the patient deceased and document this status before the nurse can discontinue life support |
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Definition
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Term
physician provides means of death |
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Definition
physician assisted suicide |
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Term
t/f: in physician assisted suicide, the doctor administers lethal dose of medication |
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Definition
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Term
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Definition
comfort measures; end of life care |
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Term
person who delivers emergency care in good faith at the scene of an accident is immune from civil liability while providing care UNLESS |
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Definition
They abandon the scene, accept payment |
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Term
tiny liviing bodies visible only with a microscope present in the environment, body surfaces, mouth, and respiratory, intestinal, urinary, and vaginal tracts |
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Definition
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Term
microorganisms that perform essential functions of the body; first line of protection against infection |
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Definition
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Term
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Definition
bacteria, virus, fungi,parasite |
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Term
most common type of disease-causing microorganism |
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Definition
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Term
microorganism with NO NUCLEI |
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Definition
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Term
two specific types of bacteria |
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Definition
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Term
smallest of pathogens; invade the cell and change its dna and rna |
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Definition
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Term
microorganism that does not respond to antibiotics |
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Definition
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Term
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Definition
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Term
plant organism; yeast or mold; eat tissue on or near skin |
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Definition
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Term
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Definition
yeast infection, athletes foot |
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Term
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Definition
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Term
live on other organisms; totally dependent on host to survive |
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Definition
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Term
invasion of the body by a disease causing organism or an infectious agent |
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Definition
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Term
microorganism that causes disease |
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Definition
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Term
thrives when system is compromised; ie aids |
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Definition
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Term
microorganisms ability to live inside and outside of the body (aggressiveness) |
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Definition
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Term
disease that is spread directly or indirectly; it can spread |
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Definition
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Term
insect or item that can transmit disease |
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Definition
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Term
international organization that protects world populations from communicable disease |
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Definition
world health organization WHO |
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Term
agency charged with protecting usa from disease and spread of diseases; located in atlanta GA |
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Definition
centers for disease control and prevention CDC |
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Term
microorganism remains within a specific part of the body (type of infection) |
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Definition
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Term
type of infection that spreads to other parts of the body; everywhere! Blood! bacteremia! |
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Definition
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Term
spreads to all parts of the body (infection) |
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Definition
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Term
acute vs. chronic infection |
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Definition
sudden short acting vs. slow onset, long lasting, returning |
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Term
infection that was acquired within a healthcare setting |
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Definition
healthcare associated infection (nosocomial infection) |
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Term
infection directly caused by a healthcare provider |
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Definition
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Term
Links in chain of infection |
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Definition
1. Pathogenic Agent 2. Carrier 3. Resevoir 4. Portal of Exit 5. Transmission 6. Portal of entry |
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Term
source of infection; first link |
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Definition
parthogenic/etiologic agent |
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Term
carries and can spread infection to others |
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Definition
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Term
where microorganism lives before it infects |
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Definition
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Term
way by which microorganisms leave the resevoir |
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Definition
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Term
way microorganism is transmitted to the host |
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Definition
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Term
inanimate object; toy; cooking utensil; anything that is contaminated!!! |
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Definition
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Term
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Definition
direct contact indirect contact airborne droplet |
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Term
way microorganism gets into the body |
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Definition
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Term
person with compromised immune response |
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Definition
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Term
t/f: all six links in chain must connect for an infection to occur |
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Definition
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Term
t/f: failure to perform appropriate hand hygiene is the leading cause of healthcare associated infections and spread drug resistant organisms |
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Definition
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Term
hormone that regulates blood pressure, immune function, glucose metabolism |
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Definition
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Term
small increases of cortisol |
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Definition
increased energy levels, immunity, memory, lower sensitivity to pain |
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Term
prolonged elevation of cortisol |
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Definition
low energy, immunity, groggy memory, high sensitivity to pain |
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Term
t/f: nutrition is important for infection resistance |
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Definition
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Term
t/f: medical therapies may contribute to decreased immune system |
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Definition
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Term
resistance to infection by the body |
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Definition
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Term
body produces own antibodies |
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Definition
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Term
antibodies passed down from parents |
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Definition
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Term
local reaction of tissues when exposed to injury or infections |
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Definition
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Term
primary signs of inflammation |
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Definition
pain swelling redness heat weakened function |
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Term
3 stages of inflammatory response |
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Definition
vascular and cellular response exudate production reparative phase |
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Term
these are all examples of ____________ issues
in vitro fertilization, artificial insemination, surrogate motherhood, cloning, organ donation, stem cell research, abortion, and advance directives |
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Definition
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Term
a system of standards or moral principles that direct actions as being right or wrong |
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Definition
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Term
deal with right or wrong behavior (conduct) or character |
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Definition
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Term
the worth you assign to an idea or action; freely chosen and affected by age and maturity |
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Definition
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Term
the values and ethical principles governing nursing practice, conduct and relationships |
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Definition
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Term
defends choices in behavior and actions you take as a nurse, they are the laws that govern nursing practice |
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Definition
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Term
florida statutes are located on these two pages in the florida board of nursing practice act |
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Definition
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Term
you must always follow the ________; no matter what your personal beliefs may be. |
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Definition
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Term
always present statement of objection to employer ______ starting your employment |
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Definition
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Term
personal ethics and nursing ethics are (DIFFERENT/THESAME) |
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Definition
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Term
all patients must be cared for _______ |
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Definition
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Term
evolution of nursing ethics; the nurses purpose WAS: |
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Definition
to follow physician's orders; advocacy was more for physician than for patient |
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Term
evolution of nursing ethics; the nurses purpose NOW involves |
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Definition
critical thinking; patient advocacy; encouraging patients to become involved with their care and assisting them in doing so |
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Term
issues the ethics committee deals with |
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Definition
multidisciplinary, religious, and cultural issues |
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Term
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Definition
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Term
consent or refuse treatments; cannot speak for others |
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Definition
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Term
keeping the patient informed; support and teaching done by RN or physician; answer questions; support patient decisions |
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Definition
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Term
the ___________ is accountable to: themselves, the patient, the Rn, the physician, the instructor, institution, nursing standards |
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Definition
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Term
reporting peers if they are displaying potentially harmful behaviors; ie impaired, theft, patient abuse, asking peers to cover mistakes |
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Definition
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Term
these are the _________________ ___ _______: nonmaleficence, beneficence, autonomy, fidelity, and justice |
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
rule of 6 for medications |
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Definition
Plz MR, DidnT Do (it) patient, medication, route, dose, time, documentation |
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Term
at the hospital the side rails must be (UP/DOWN) |
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Definition
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Term
at the LTC facility, the side rails must be (UP/DOWN) |
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Definition
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Term
difference between beneficence and nonmaleficence |
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Definition
beneficence is preventing harm, nonmaleficence is doing no harm. |
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Term
nursing duties: always put patient ______- |
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Definition
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Term
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Definition
patients can do or act as they want; patients can dictate how, when, or by whom care will be delivered; choose segments of plan of care to have and/or refuse |
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Term
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Definition
thinking through all the facts; deciding independently and voluntarily; acting based on their decision |
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Term
jehovahs witnesses cannot |
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Definition
accept other blood into their body |
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Term
in the middle east, the (MALE/FEMALE) makes all the decisions |
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Definition
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Term
quality vs. quantity of life |
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Definition
deciding to forgo recommended treatment for advanced stage of disease even if it will extend quantity of life |
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Term
acting in a patients best interest when they are no long able to do so on their own |
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Definition
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Term
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Definition
could cost you your job!!! do not discuss patient in public; patients name does NOT have to be mentioned if circumstances are known by others |
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Term
who can you speak with about patient |
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Definition
medical professionals directly involved in this patient's care; instructor |
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Term
disrespectful attitude towards the patient and patient's input regarding their own thoughts and beliefs related to their own care |
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Definition
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Term
it is advised to develop plan of care without the patients input (T/F) |
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Definition
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Term
steering the patients decisions in a different direction than what they may have chosen is not "okay" (T/F) |
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Definition
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Term
giving an opinion of what you believe would benefit the patient most without allowing them to consider all the options is never okay (t/f) |
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Definition
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Term
your legal guideline for as a long as you practice nursing in the state of florida |
|
Definition
florida nurse practice act |
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Term
(T/F) no person or agency can legally authorie you to do something in your capacity of a nurse that is not covered by the nurse practice act |
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Definition
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Term
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Definition
definitions of nursing, lpn, use of lpn title, scope of practice, elements of unprofessional conduct, and function of state board of nursing |
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Term
nursing care that can be safely performed by lpn, based on knowledge and skills gained during the educational program |
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Definition
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Term
patients medical condition is predictable; medical and nursing orders are not changing continuusly- require nly basic nursing care |
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Definition
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Term
the (RN/LPN) assesses if the situation is basic or complex |
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Definition
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Term
patients situation is not predictable; medical and nursing orders are changing continously- expectations of care beyond scope of LPN practice |
|
Definition
complex patient situation |
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Term
physicians order is given to an RN or LPN |
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Definition
delegate medical act (depends on facility's policy) |
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Term
states that the rn gives nursing orders to lpn |
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Definition
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Term
supervisor is continously present to coordinate, direct, or inspect nursing care; must be on the premises |
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Definition
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Term
supervisor has same supervision responsibilities but can be on premises or accessible by phone |
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Definition
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Term
funcitons of the board of nursing: |
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Definition
committees of councils decide whether specific activities are within scope of practice |
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Term
each (STATE/HOSPITAL) has their own board of nursing |
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Definition
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Term
practicees can differ from (HOSPITAL TO HOSPITAL/ STATE TO STATE) |
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Definition
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Term
where to call if you think there is abuse |
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Definition
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Term
|
Definition
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|
Term
8 categories (specific reasons to seek disciplinary action via nurse practice act) |
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Definition
fraud, negligence, discipline by another jurisdiction, unethical conduct, criminal activity, violation of nurse practice act, incompetence, alohol drug abuse |
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Term
written complaint that damages reputation |
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Definition
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Term
spoken complaint that damages reputation |
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Definition
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Term
Responsible for own actions includinh negligent behavior |
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Definition
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Term
Responsible fir actions of others |
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Definition
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Term
The nurse becomes temporarily employee of the physician. Physician controls nurses actions that may have lead to harm caused to the patient |
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Definition
Captain of the ship doctrine |
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Term
Legal document and subject to subpoena |
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Definition
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Term
Are all common causes of ________ ________ Lack of safety knowledge skill observation reporting |
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Definition
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Term
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Definition
The patient, yourself, and instructor |
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Term
_________ is your priority |
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Definition
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Term
Liability of student nurses and instructors |
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Definition
Responsible to read about patient Be aware of all patients medications Create your own plan of care Request assistance if /when needed |
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Term
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Definition
Make the patient /student assignments Reasonable supervision of students Provide ongoing support during clinical experience |
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Term
The right to be left alone and free from intrusion : choose care based on personal feelings attitudes and beliefs, accept /reject treatment, control how sensitive information is shared |
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Definition
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Term
The nondisclosure of information regarding patients |
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Definition
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Term
Information that must be revealed to health department |
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Definition
Communicable diseases Adverse reactions related to vaccines Criminal acts Equipment related injuries Clear and present danger to patient Abuse /neglect Incompetence /unprofessional acts |
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Term
Ethical document (not legal), includes high quality hospital care, clean /safe environment, involvement in own care, protection of your privacy, help when leaving the hospital, help with billing claims |
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Definition
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Term
Took effect in 2003, gives patient rights over their health information |
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Definition
Health insurance portability and accountability act (hipaa) |
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Term
Three basic parts of Hippaa law |
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Definition
Protection of privacy-Protected health information Administrative simplification- Reduction of paperwork for reimbursement Security standards- security standards for protection of information (password protected) |
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Term
Must be available to all patients employees and health related companies with whom the provider of care does business with, patient reads and signs, NOT THE SAME as signing consent for treatment |
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Definition
Notice of privacy practices HIPPA |
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Term
Gives access ti medical records, ammendments to medical records, restriction on use of health information, access to accounting, confidential communications (identity), complaints about hippa violations |
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Definition
Hipaa notice of privacy practices |
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Term
How much information can be released |
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Definition
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Term
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Definition
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Term
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Definition
..18 years pregnant or married female Self supporting minor (emancipated) Competent in eyes of the law |
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Term
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Definition
Indentify the problem for which they are seeing a physician for, Understand options of care (pros /cons) Make decisions related to care Support reasons for their choice |
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Term
Obtained on admission, may be revoked verbally or in writing |
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Definition
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Term
What does "CBC" stand for? |
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Definition
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Term
(NEUTROPHILS/LYMPHOCYTES) increase with bacterial infections |
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Definition
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Term
(NEUTROPHILS/LYMPHOCYTES) increase with viral infections |
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Definition
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Term
|
Definition
Erythrocyte sedimentation rate |
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Term
Why are some organisms drug-resistant? |
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Definition
1. misuse/overuse of antibiotics 2. not completing antibiotics 3. over prescribing new antibiotics |
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Term
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Definition
methicillin resistant staph aureus |
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|
Term
where does MRSA colonize? |
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Definition
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|
Term
|
Definition
hand-to-hand, hand-to-nose |
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Term
_______ usually appears as a small lesion, first believed to be an insect bite, that if untreated, grows and fills with exudate |
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Definition
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|
Term
|
Definition
1. draining and packing 2. antibiotic therapy 3. close monitoring of the wound |
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Term
factors that cause a disease, what led to the disease appearing; where disease came from |
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Definition
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Term
disease that affects many people across different regions, continents, and/or world-wide; ie AIDS |
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Definition
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|
Term
when cause of disease is unknown |
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Definition
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|
Term
disease that affects a particular part or region of the world; ie SARS |
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Definition
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|
Term
refers to a disease that occurs in many different individuals at the same time; ie the Flu |
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Definition
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|
Term
|
Definition
severe acute respirator syndrome |
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|
Term
when and where was SARS an endemic? |
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Definition
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|
Term
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Definition
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|
Term
t/f: 331 people died in 121 countries in 2009 because of the epidemic of H1N1 |
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Definition
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|
Term
|
Definition
person to person contact droplet (cough/sneeze) surface blood and bodily fluids |
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Term
if hands are visibly soiled, use (SOAP AND WATER/HAND SANITIZER) |
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Definition
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|
Term
if hands are not visibly soiled, use (SOAP AND WATER/HAND SANITIZER) |
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Definition
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|
Term
hand sanitizer must have over ____% alcohol to be effective |
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Definition
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|
Term
when should hands be washed? |
|
Definition
often, and before and after each procedure |
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Term
agents that inhibit growth of "some" microorganisms |
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Definition
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|
Term
agent that destroys pathogens other than spores |
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Definition
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|
Term
microorganism with a helmet; ie mold |
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Definition
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Term
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Definition
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|
Term
inhibits the growth of bacteria |
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Definition
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Term
t/f: bacteria cannot survive in warm, dark areas. |
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Definition
false; bacteria cannot survive in cool, well lit areas. |
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Term
absense of disease causing microorganisms |
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Definition
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|
Term
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Definition
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|
Term
prevents spread of pathogens from one person to another |
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Definition
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|
Term
practices used to confine a specific microorganism to specific area; or limit growth and spread |
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Definition
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|
Term
sterile technique; completely free of microorganisms and spore |
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Definition
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|
Term
guidelines for special care to be used with all bodily fluids |
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Definition
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|
Term
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Definition
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|
Term
|
Definition
transmission-based precaution |
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|
Term
systematic, lorgical method of providing nursing care |
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Definition
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|
Term
what is the purpose of the nursing process? |
|
Definition
to identify a client's health status identify actual or potential healthcare problems or needs establish a care plan deliver specific nursing care to meet needs |
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Term
5 steps of the nursing process |
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Definition
1. assessing 2. diagnosing 3. planning 4. implementing 5. evaluating
A Delicious PIE |
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Term
systematic collection, organization, validation, and documentation of data |
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Definition
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|
Term
when is the initial assessment completed and by whom? |
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Definition
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|
Term
these are all components of the ____________; medical history, physical assessment, lab results, diagnostic test results, and information controlled by other health personnel. |
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Definition
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|
Term
difference between subjective and objective symptoms |
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Definition
the nurse cannot measure subjective symptoms |
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Term
complaints or conditions that cannot be measured; ie itching, pain, hunger, weakness, sadness |
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Definition
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|
Term
detectable or measurable complaints or conditions; ie blood pressure, fever, sweating |
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Definition
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|
Term
medical term for sweating |
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Definition
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|
Term
the __________ is the primary source of data |
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Definition
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|
Term
observation includes using the ______ to collect data |
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Definition
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|
Term
___________ involves inspection, auscultation, palpation, and percussion to collect data |
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Definition
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|
Term
what are the components of nursing diagnosis? |
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Definition
problem, defining characteristics, and etiology |
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Term
process of designing nursing activities required to prevent, reduce, or eliminate a patient's health problems |
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Definition
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|
Term
record of planning activities |
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Definition
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|
Term
planning that takes place during patient's stay at facility |
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Definition
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|
Term
planning that takes place in regards to the client's needs after release from hospital |
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Definition
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|
Term
care plan where the nurse mentally plans care that will be administered |
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Definition
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|
Term
written guide that organizes information about client's care |
|
Definition
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|
Term
nursing care that is normally provided to groups of patients with same needs |
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Definition
standardized plan of care |
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|
Term
specific plan of care to your patient's needs; very detailed, no generic statements |
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Definition
individualized plan of care |
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|
Term
information and instructions readily available on all patients; one per patient; may be written in pencil so it can be updated as needed |
|
Definition
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|
Term
|
Definition
SUBJECTIVE? OBJECTIVE? PLAN!!! |
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Term
t/f: plans of care should be prioritized in order from most to least important |
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Definition
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|
Term
concept of Maslow's Hierarchy of Needs |
|
Definition
the most important needs are at the bottom of the pyramid, as you work your way up to the peak, they decrease in importance |
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|
Term
t/f: every nursing diagnoses must have at least one expected outcome |
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Definition
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|
Term
phase in which interventions and activities occur |
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Definition
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|
Term
actions initiated by nurses to achieve patient goals; reducing or eliminating the cause of nursing diagnosis |
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Definition
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|
Term
things NEVER to do in nursing documentation |
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Definition
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|
Term
intervention performed through interaction with the patient; ie R.O.M. exercise |
|
Definition
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|
Term
intervention performed away from, but on behalf of the patient; ie making followup appointments |
|
Definition
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|
Term
nurse initiated intervention that nurse is licensed to do based on training and education |
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Definition
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|
Term
physician initiated intervention carried out as direct results of physicians order |
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Definition
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|
Term
combination of independent and dependent intervention |
|
Definition
collaborative (interdisciplinary) intervention |
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|
Term
problem-solving, decision making, and critical and creative thinking are all ____________ skills |
|
Definition
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|
Term
verbal, non-verbal communication, conveying knowledge, attitudes, feelings, interest, and apprecation of patient's culture and values are all ___________ skills |
|
Definition
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|
Term
hands-on skills, using equipment, giving injections, moving/lifting/repositioning patients are all examples of __________ skills |
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Definition
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|
Term
one of the things that sets LPNs apart from CNAs |
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Definition
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|
Term
The organic, inorganic, and energy producing substances found in foods required for body functioning |
|
Definition
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|
Term
the result of the interaction between nutrients and the human body |
|
Definition
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|
Term
3 major functions of nutrients |
|
Definition
1. provide energy for body process and movement 2. structural material for body tissues, 3. regulate body processes |
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Term
|
Definition
1. water 2. macronutrients 3. micronutrients |
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Term
the body's most basic nutrient need |
|
Definition
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|
Term
water's functions (nutrition) |
|
Definition
1. metabolism 2.transporter 3.lubricant 4.insulator 5.shock absorber 6. temperature |
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|
Term
provide fuel that converts to energy; found in carbohydrates, proteins and fats |
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Definition
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|
Term
two basic kinds of carbohydrates |
|
Definition
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|
Term
simple carbohydrates consist of |
|
Definition
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|
Term
complex carbohydrates consist of |
|
Definition
|
|
Term
3 Kinds of simple carbohydrates |
|
Definition
1. monosaccharides 2. disaccharides 3. polysaccharides |
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|
Term
_________ simplest form of all carbohydrates |
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Definition
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|
Term
________ are water soluble |
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Definition
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|
Term
|
Definition
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|
Term
|
Definition
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|
Term
_________ means "does not dissolve in water" |
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Definition
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|
Term
_________ means "dissolves in water" |
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Definition
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|
Term
________ cannot be digested |
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Definition
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|
Term
supplies roughage, or bulk, to the diet, helping the digestive track eliminate waste |
|
Definition
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|
Term
_______ helps weight control, treats constipation, lowers blood cholesterol, stabilizes blood glucose |
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Definition
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|
Term
daily recommended fiber intake per day |
|
Definition
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|
Term
altering of food from natural state |
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Definition
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|
Term
often referred to as empty calories |
|
Definition
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|
Term
the end products of carbohydrate digestion are _____________ |
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Definition
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|
Term
body uses ________ to produce energy |
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Definition
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|
Term
digested carbohydrate is absorbed by the _______ ____________ |
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Definition
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|
Term
hormone secreted by pancreas needed for glucose to be transported into the cells |
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Definition
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|
Term
medical condition where the pancreas fails to produce adequate amounts of insulin in the bloodstream to lower/control blood glucose level, or facilitate glucose entering cells |
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Definition
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|
Term
digested carbohydrates are maintained in the body either as _________ or _________ |
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Definition
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|
Term
glycogen formation process |
|
Definition
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|
Term
process of glycogen being converted back into glucose when needed to maintain blood levels or provide energy |
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Definition
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|
Term
organic substances composed of amino acids |
|
Definition
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|
Term
the building blocks of proteins |
|
Definition
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|
Term
amino acids are categorized as either _________ or __________ |
|
Definition
essential or nonessential |
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|
Term
_______ amino acids are those that cannot be manufactured in the body and must be supplied by ingesting protein |
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Definition
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|
Term
________ amino acids are those that the body can manufacture |
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Definition
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|
Term
amino acids that in certain conditions cannot be produced in sufficient quantities from other amino acids |
|
Definition
conditionally essential amino acids |
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|
Term
there are ____ essential amino acids |
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Definition
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|
Term
there are ____ nonessential amino acids |
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Definition
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|
Term
proteins may be _____ or ______ |
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Definition
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|
Term
__________ proteins contain all nine essential amino acids plus many nonessential ones |
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Definition
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|
Term
__________ proteins lack one or more essential amino acids and are usually derived from vegetables |
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Definition
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|
Term
only plant source of complete proteins |
|
Definition
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|
Term
when foods containing some essential amino acids are combined with others so that together they contain all nine essential amino acids, the foods are called: |
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Definition
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|
Term
__________ proteins are plant based, less expensive, and contain less fat |
|
Definition
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|
Term
most protein is digested in the _____ ________ where enymes break it down into the end products of protein digestion |
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Definition
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|
Term
end products of protein digestion |
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Definition
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|
Term
_______ are transported to the liver, where some are used to synthesize specific proteins such as albumin, globulin, and fibrinogen |
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Definition
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|
Term
|
Definition
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|
Term
body cannot store excess _____ ______ for future use |
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Definition
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|
Term
protein metabolism includes 3 activities |
|
Definition
1. anabolism 2. catabolism 3. nitrogen balance |
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Term
|
Definition
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|
Term
|
Definition
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|
Term
a measure of the intake and loss of nitrogen |
|
Definition
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|
Term
organic substances that are greasy and insoluble in water but soluble in alcohol |
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Definition
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|
Term
_____ are lipids that are solid at room temperature |
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Definition
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|
Term
______ are lipids that are liquid at room temperature |
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Definition
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|
Term
the basic structural units of most lipids (made of carbon chains and hydrogen) |
|
Definition
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|
Term
simple lipids (most common) |
|
Definition
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|
Term
account for over 90% of the lipids in food and in the body; contain 3 fatty acids |
|
Definition
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|
Term
triglycerides may be ________ or __________ |
|
Definition
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|
Term
found in animal products, such as butter, and are usually solid at room temperature (harder means more fat); contribute to elevated blood cholesterol; considered unhealthy |
|
Definition
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|
Term
usually liquid at room temperature and are found in plant products; lower blood cholesterol; healthier |
|
Definition
unsaturated triglycerides |
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|
Term
fat like substance that is both produced by the body and found in foods of animal origin; most of it is synthesized in the liver |
|
Definition
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|
Term
needed by the body to form bile acids and to synthesize steroid hormones; primary lipid connected to heart disease |
|
Definition
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|
Term
normal "total cholesterol" |
|
Definition
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|
Term
triglycerides normal level |
|
Definition
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|
Term
|
Definition
|
|
Term
|
Definition
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|
Term
|
Definition
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|
Term
test for lipoproteins and triglycerides |
|
Definition
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|
Term
it is desirable to have a higher _____ level and a lower ______ evel because the risk of heart disease is greater when _____ is elevated |
|
Definition
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|
Term
an organic compound that cannot be manufactured by the body and is needed in small quantities to catalyze (trigger) metabolic processes |
|
Definition
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|
Term
when _______ are lacking in the diet, _______ deficits result. |
|
Definition
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|
Term
generally classified as fat soluble or water soluble |
|
Definition
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|
Term
water-soluble vitamins include: |
|
Definition
vitamins c, B-complex, B1, B2, B3, B6, B9, B12, pantothenic acid, and biotin. |
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|
Term
the body ________ store water-soluble vitamins |
|
Definition
|
|
Term
fat soluble vitamins include |
|
Definition
|
|
Term
The body _____ store fat soluble vitamins |
|
Definition
|
|
Term
Two categories of minerals |
|
Definition
1.macrominerals 2.microminerals |
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|
Term
minerals that people require daily in amounts over 100mg; including calcium, phosphorus, sodium, potassium, magnesium, chloride, and sulfur |
|
Definition
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|
Term
minerals that people require daily in amounts less than 100 mg; including iron, zinc, manganese, iodine, fluoride, copper, cobalt, chromium, and selenium |
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Definition
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|
Term
Micro/Macrominerals are both found in vegetables, fruits, meats, and most essentially, ____ _____ |
|
Definition
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|
Term
the relationship between the energy obtained from food and the energy used by the body |
|
Definition
|
|
Term
|
Definition
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|
Term
body gets ______ from calories, carbohydrates, protein, fat, and alcohol |
|
Definition
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|
Term
the term for all the biochemical and physiological processes by which the body grows and maintains itself |
|
Definition
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|
Term
rate at which the body metabolizes food to maintain the energy requirements of a person who is awake and at rest |
|
Definition
basal metabolic rate (bmr) |
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|
Term
lean people have _______ bmr's than overweight people |
|
Definition
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|
Term
changes in __________ and ___________ occur in older adults and can affect food intake |
|
Definition
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|
Term
clients should be reminded of the dangers of high _________ intake |
|
Definition
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|
Term
_______ increase through food, supplements, or both is important for older adults |
|
Definition
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|
Term
Clients who do not have special needs eat the _______ diet; a balanced diet that supplies the metabolic requirements of a sedentary person |
|
Definition
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|
Term
diet where food and fluid are prohibited |
|
Definition
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|
Term
Diet limited to water, tea, coffee, clear broths, ginger ale, and other carbonated beverages, strained and clear juices, and plain gelatin; must be able to see thru |
|
Definition
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|
Term
diet contains only liquids or foods that turn to liquid: I.e. melted icecream, blended pb&j |
|
Definition
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|
Term
nutritional concerns with this diet because of the amount of milk offered |
|
Definition
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|
Term
diet that is easily chewed and digested |
|
Definition
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|
Term
diet that is ordered when the client's appetite, ability to eat, and the tolerance for certain foods change; allows for choice and evaluation of progress |
|
Definition
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|
Term
diet consist of plant foods only |
|
Definition
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|
Term
diet consists of plant foods along with dairy products |
|
Definition
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|
Term
diet consists of plant foods, dairy products, and eggs |
|
Definition
ovo-lacto vegetarian diet |
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|
Term
the first priority in nursing care when performing a nutritional assessment is to obtain the client's |
|
Definition
|
|
Term
the nurse must know how to obtain the client's weight and height accurately, meaning: |
|
Definition
the nurse must use the appropriate equipment |
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|
Term
weight recommended for optimal health |
|
Definition
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|
Term
A person is said to be __________ when the body weight exceeds IBW by up to 20% |
|
Definition
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|
Term
a person is said to be __________ when the body weight exceeds the IBW by more than 20% |
|
Definition
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|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
means that nutrient intake is insufficient to meet daily energy requirements; it can occur because the person does not eat enough food or because he or she cannot digest or absorb food |
|
Definition
|
|
Term
|
Definition
|
|
Term
excess body weight causes _______ on body organs and contributes to chronic health problems such as ________ and __________ ___________ |
|
Definition
stress, hypertension, diabetes mellitus |
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|
Term
obesity that interferes with mobility or breathing |
|
Definition
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|
Term
associated mostly with the starving children of developing countries, and as a significant problem of clients with cancer and chronic disease; characteristics include weight loss and visible muscle and fat wasting |
|
Definition
protein-calorie malnutrition PCM |
|
|
Term
The 3 most frequent nursing diagnoses related to nutrition are |
|
Definition
1. Imbalanced Nutrition: More than body Requirements 2.Imbalanced Nutritioin: Less than Body Requirements 3. Risk for Imbalanced Nutrition |
|
|
Term
Nursing care of clients with imbalanced nutrition includes assisting with |
|
Definition
changes in diet, monitoring blood glucose, stimulating appetite, assisting with meals, and providing enteral nutrition |
|
|
Term
clients who have _________ may need to monitor random blood glucose levels throughout the day |
|
Definition
|
|
Term
physical illness, unfamiliar or unpalatable food, environmental and psychological factors, and physical discomfort or pain may _______ a client's appetite |
|
Definition
|
|
Term
decreased food intake is often accompanied by a ________ in fluid intake, which may cause __________ |
|
Definition
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|
Term
Never _______ the feeding process! |
|
Definition
|
|
Term
the nurse ________ decide if an adaptive feeding aid should be used on a client |
|
Definition
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|
Term
two types of alternative feeding methods are |
|
Definition
1. enteral nutrition 2. parenteral nutrition |
|
|
Term
nutrition through the gastrointestinal system |
|
Definition
|
|
Term
|
Definition
|
|
Term
enteral access is achieved by _______, ________, ____________, and __________ |
|
Definition
1. nasogastric tubes 2. nasointestinal tubes 3. gastrostomy tubes 4. jejunostomy tubes |
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|
Term
inserted through one of the nostrils, down to the nasopharynx, and into the stomach; usually firm; |
|
Definition
nasogastric tube (NG Tube) |
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|
Term
_________ tubes are used for clients who have INTACT gag reflexes, who have adequate gastric emptying, and who require short-term feedings |
|
Definition
|
|
Term
nasogastric tubes may also be required for other reason than feeing; including |
|
Definition
1. prevention of nausea and vomiting 2. to remove stomach contents (i.e. overdose) 3. to wash the stomach of poisons |
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|
Term
|
Definition
|
|
Term
____________ tube is longer than the _____________ tube |
|
Definition
|
|
Term
tube that is inserted into one nostril, through the pharynx, esophagus, and stomach, and into the upper small intestine |
|
Definition
|
|
Term
insertion of the _______ tube may require special training; used when risk of aspiration is high |
|
Definition
|
|
Term
clients are at risk for aspiration if presenting these 5 conditions |
|
Definition
1. Decreased LOC 2. poor cough or gag reflex 3. endotracheal intubation or recent extubation 4. inability to cooperate with the procedure 5. restlessness or agitation |
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|
Term
_________ and ___________ devices are used for long term nutritional support, generally for more than 6 to 8 weeks. |
|
Definition
|
|
Term
tube placed surgically or by laparoscopy through the abdominal wall into the stomach |
|
Definition
|
|
Term
tube placed surgically or by laparoscopy through the abdominal wall into the intestine |
|
Definition
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|
Term
before feedings are introduced, tube placement is confirmed by _________ |
|
Definition
|
|
Term
the administration of 300 to 500 mL of enteral formula several times per day; usually administered thru the tube into the stomach over at least 30 mins. |
|
Definition
|
|
Term
generally administered over a 24 hour period using an infusion pump that guarantees a constant flow |
|
Definition
|
|
Term
continuous feedings that are administered in less than 24 hours; often administered at night and referred to as "nocturnal feedings", allows the client to eat regular meals throught the day |
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Definition
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Term
any formula that has passed the expiration date or solution that has been opened at room temperature for more than ______ hours must be discarded |
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Definition
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Term
a feeding tube used intermittently can become clogged. this can be prevented by |
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Definition
flushing the tube with clear water after bolus feedings or administration of medication; always follow facility approved method; prevention is the best way to ensure that the client will be able to receive nutrition via the tube |
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Term
feedings must be given through _________ when a client is unable to tolerate foods or formula through the gastrointestinal tract |
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Definition
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Term
there are 2 forms of parenteral nutrition |
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Definition
1. peripheral vein infusions 2. central vein infusions |
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Term
limited vein infusions that are done in peripheral veins |
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Definition
peripheral vein infusions |
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Term
when nutritional needs are great, the use of a large central vein is desirable; TPN is infused throuh a catheter that is surgically inserted into a central vein such as the _________ or the _________ vein; added risk of infection and must be closely monitored. |
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Definition
central vein infusions; subclavian or femoral vein |
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Term
two main veins used for central vein infusions |
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Definition
1. subclavian vein 2. femoral vein |
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Term
loss related to specific occurence (job loss/transfer) |
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Definition
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Term
loss of endurance; increase dependence (aging) |
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Definition
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Term
loss of a body part due to accident or illness |
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Definition
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Term
feelings/loss/behaviors related to loss including overwhelming stress and sorrow |
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Definition
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Term
grieving period experienced by surviving loved ones |
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Definition
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Term
process and rituals through which grief is resolved |
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Definition
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Term
grieving in acceptance of loss |
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Definition
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Term
period of denial, depression, physiological symptoms, or suicidal thoughts |
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Definition
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Term
when mourner is judged by those not understanding the loss |
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Definition
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Term
t/f: childhood loss can threaten child's ability to develop normally |
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Definition
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Term
older adults dealing with successive losses |
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Definition
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Term
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Definition
dabda
denial anger bargaining depression acceptance |
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Term
Patient self determination act |
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Definition
the right to advance directives |
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Term
t/f the bodies of all patients, including the deceased, are to be handled with dignity and respect |
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Definition
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Term
national organ transplant act |
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Definition
governs organ and tissue donation in the USA |
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Term
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Definition
cessation of apical pulse, respirations, and blood pressure |
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Term
apical pulse found where? |
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Definition
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Term
an illness from which there is no reasonable expectation of survival |
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Definition
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Term
care that involves providing relief from suffering; comfort measures |
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Definition
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Term
for patients determined to have prognosis of 6 months or less survival time |
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Definition
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Term
the study of persons age 65 or older |
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Definition
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Term
gradual loss of muscle mass |
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Definition
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Term
recommended protein intake |
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Definition
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Term
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Definition
as you're getting up, your blood pressure drops and you get light headed and may pass out |
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Term
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Definition
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Term
hearing loss in the elderly |
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Definition
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|
Term
benign prostatic hyperplasia |
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Definition
enlargement of prostate gland that may lead to frequent urination |
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Term
t/f enter date and time with each entry |
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Definition
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Term
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Definition
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Term
t/f always document your opinion |
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Definition
FALSE: factual info only! |
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Term
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Definition
subjective objective assess plan intervention evaluation revision |
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Term
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Definition
problem intervention evaluation |
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Term
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Definition
only exceptions to norms are documented |
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Term
purpose of computerised documentation |
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Definition
large volumes of information error reduction accessibility |
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Term
physical change and increase in size; includes height, weight, bone size and dentition (teeth) |
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Definition
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Term
increase in complexity of function and skill progression; capacity to adapt to an environment |
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Definition
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Term
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Definition
birth to day 28; follows objects, closes hands (reflex) |
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Term
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Definition
one month to 1 year; sits, crawls, stands |
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Term
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Definition
1-3 years; skill with utensils, has daytime bowel/bladder control |
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Term
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Definition
3-6 years; climbs, learns letters/numbers, 1000 word vocabulary |
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Term
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Definition
6-12 years; participates in group activities, accomplishes tasks |
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Term
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Definition
12-20 years; puberty, peers and independence are important, take risks |
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Term
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Definition
20-40 years; finds life path, establishes long-term relationships |
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Term
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Definition
40-65 years; establishes career, commitment to family |
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Term
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Definition
"young old" 65-74 years; retirement or semi retirement, new activities |
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Term
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Definition
75-84 years; adapts to physical and sensory changes |
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Term
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Definition
85 years and older; assistive devices may be needed, may need help with ADLs |
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Term
two most common responses to hospital admission |
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Definition
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Term
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Definition
surrender of belongings, privacy, and independence |
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Term
t/f always address patient by last name unless they say you can call them something else and it has been documented |
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Definition
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Term
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Definition
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT |
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Term
|
Definition
patient request condition change |
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Term
official procedure by which the patient leaves the health care facility for home or other setting |
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Definition
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Term
patient leaving medical facility without permission of primary care provider |
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Definition
AMA against medical advice |
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Term
the exchange of information or thoughts between two or more people |
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Definition
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|
Term
feedback that both parties understand the message in the same manner |
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Definition
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Term
distance people prefer in interactions with others |
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Definition
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|
Term
study of spatial distances between individuals in different cultures and situations |
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Definition
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|
Term
space or things patients consider theirs |
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Definition
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|
Term
exchange of ideas using spoken or writtenword to include electronic communication |
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Definition
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|
Term
gestures, facial expression, and touch |
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Definition
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|
Term
__-__% of communication is nonverbal |
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Definition
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Term
patient centered, goal-directed, time-limited communication; used to determine patients' concerns, problems, feelings, or progress |
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Definition
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|
Term
loss of ability to speak or understand written or verbal language |
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Definition
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Term
difficulty articulation words, often a result of stroke |
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Definition
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Term
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Definition
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Term
seeking to gain specific information in an interview; closed ended questions |
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Definition
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Term
interview where the patient controls the conversation; open ended statements/questions |
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Definition
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|
Term
3 theories of human learning |
|
Definition
behaviorism cognitivism humanism |
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Term
learning where environment influences behavior |
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Definition
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|
Term
learning as a complex thinking process |
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Definition
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|
Term
learning focused on self-development |
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Definition
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|
Term
inhibiting factors of patient learning |
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Definition
emotions, learning plateau, physiological event, terminology |
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