Nursing Fundamental 1

Oximetry

determination of the oxygen saturation of arterial blood using a photoelectric device called an oximeter

S1

the first heart sound, heard when the atrioventricular (mitral and tricuspid) valves close

Mechanical, neural, and chemical factors regulate the strength of what?

ventricular contraction and its SV

Normal capnography (EtCO2)

35-45 mm Hg

Average temp range for an adult

36-38 C 96.8-100.4 F

Average axillary temp

36.5 C 97.7 F

rectal temp

37.5 C, 99.5 F

Which of these assessments of an older adult, who has a urinary tract infection, requires an immediate nursing intervention?

Confusion

Of the following patients, which one is the best candidate to have his temperature taken orally?

A 27-year-old postoperative patient with an elevated temperature

The best term for breath sounds created by air moving through large lung airways is

Bronchovesicular.

Dehiscence

Bursting open of a wound, especially a surgical abdominal wound

afferent nervous system conveys info to the

CNS; going to your brain

In what part of obtaining a medical history do you ask "What happened?"

Determining the chief complaint

One time order

Given one time

In assisting the patient to exercise, the nurse should

Stop the exercise if pain is experienced.

The nurse is caring for a patient with a nursing diagnosis of risk for infection. Aware of the need for Standard Precautions, the nurse is careful to

Wear eyewear when emptying a urinary drainage bag.

Kussmaul's respiration

abnormally deep, regular and increases in rate.

Hyperthermia

an elevated body temperature related to the inability of the body to promote heat loss or reduce heat production

Examples of beta-adrenergic blockers

antenolol (Tenormin), nadolol (Corgard), timolol maleate (Blocadren), metoprolo (Lopresor)

AP

apical pulse

PRN order

as needed order written when patient requires it

Poplitealo

behind knee in popliteal fossa

scale used for predicting pressure sore risk

braden scale

First hour

every 15 minutes

Tachycardia

fast HR

vitamin c and zinc

important in wound healing

Posterior tibial

inner side of ankle below medial malleolus

Hypoxemia

low levels of arterial O2

Angiotensin-II receptor blockers (ARBs)

lowers blood pressure by blocking the binding angiotensin II, which prevents vasoconstriction.

paraplegia

paralysis both legs

normal stoma

red and moist

active exercise

the patient independently moves joints through their full range of motion (isotonic exercise)

pyuria

pus in the urine; urine appears cloudy

Common pulse site used to assess character of pulse peripherally and status of circulation of hand?

radial

Radial

radial or thumb side of the forearm at wrist

What does tympanic temperature rely on?

radiation of body heat to an infrared sensor

acute illness

rapid onset of symptoms and lasts only a short time; examples: cold, diarrhea, pneumonia, appendicitis

To prevent illness

reduce risk for illness. promote good health habits, maintain optimal functioning

closed wound

results from a blow, force, or strain caused by trauma such as a fall, an assault, or motor vehicle crash

negative nitrogen balance

results in muscle wasting and decreased physical energy for movement and work; caused by diseases that are characterized by a larger breakdown of protein than that which is manufactured

oliguria

scanty or greatly diminished amount of urine voided in a given time; 24-hour urine output is less than 400mL

fowlers position

semi-sitting position; head of bed elevated 45 to 60 degrees; used to promote cardiac and respiratory functioning; provides max space in thoracic cavity; high fowlers the bed is elevated to 90 degrees

Why do heatstroke victims not sweat?

sever electrolyte loss and hypothalamic malfunction

A nurse is preparing a change-of-shift report for a patient who had chest pain. Which information is critical for the nurse to include

sharp pain of 8 on a scale of 1 to 10

Cast care

skin is cleansed and inspected for any wounds before applying protect the cast from uneven pressure during the drying period because the shape and position can be changed use palm and lat part of fingers when handling the drying cast should be elevated on pillows when edema has decreased, cast is secured with bandaging caution not to place foreign objects under the cast check pulses after applying

What is included **********essment of the integumentary system?

skin, hair, scalp, and nails

Bradycardia

slow HR

chronic illness

slow onset, characteristics: permanent change, caused by change in anatomy, requires special patient education, long period of care or support; examples: heart disease, diabetes, lung diseases, and arthritis

Bronchodilators does what to respiration's?

slows rate and causes airway dilation

Stroke volume

the amount of blood entering the aorta with each ventricular contraction

Systolic pressure

the amount of force exerted within the arteries while the heart is actively pumping or contracting; the maximum pressure exerted against the arterial walls

enema

the introduction of a solution into the large intestine, usually to remove feces

pain threshold

the level at which a person experiences pain

Cardiac output

the volume of blood pumped through by the heart during 1 minute; the product of HR and the SV of the ventricle

purulent drainage

thick, musty or foul odor, varies in color

Moderate/conscience sedation

uses a local anesthetic at the surgical site plus IV systemic analgesia used with any procedure using local anesthesia requires close monitoring of VS and oxygenation patient maintains airway and should be able to follow commands wisdom teeth

Second intention

wound with tissue loss edges of wound do not approximate, wound is left open and fills with scar tissue

jaundice causes

yellowish, itchy skin; bilirubin problem and liver not functioning properly

objective

you can see the object

Respiration assessment

•Rate •Depth •Rhythm

Palpate skin moisture

•Use palms of hands •Perspiration normal on face, hands, axilla, and skinfolds in response to activity, a warm environment, or anxiety

What benefits come from position changes and good alignment?

- Good respiratory function - Improves circulation - Prevents pressure ulcers - Prevents contractures - Promotes comfort

What are the basic guidlines for conducting the interview?

- Greet the patient by title and anme and introduce yourself - Identify the patient - Begin the interview with general question and make observations - Use proper questioning principles throughout the interview - Use appropriate behavior and communication techniques to conduct the interview

What conditions warrant an amputation?

- Inadequate tissue perfusion - Severe trauma - Malignant tumors - Congenital deformities

What factors influence hygiene practices?

- Social practices - Personal preferences - Body image - Socioeconomic status - Health belief and motivation - Cultural variables - Physical condition

What are some ambulation aids?

- Walkers (4-point walking aids) - Canes (provide balance and support) - Crutches

Troubleshooting an otoscope steps include:

- change the batteries - recharge the unit - change the light bulbs - tighten the connections - plug it in

Oxygen saturation documentation

- the patient's oxygen saturation - the site where you measured oxygen saturation - any signs or symptoms of abnormal oxygen saturation - type of oxygen therapy (nasal cannula, mask) and flow rate - oxygen saturation after a specific treatment (nebulizer therapy) - your nursing interventions - the patient's response to care

water

-accounts for between 50% and 60% of adults total weight -2/3 of body water is contained within the cells (ICF) -the remainder of body water is extracellular fluid, body fluids -acts as solvent, aids digestion

The Nursing Process

-one of major guidelines for nursing practice -helps nurses implement their roles -integrates art and science of nursing -allows nurses to use critical thinking and clinical reasoning -defines the areas of care that are within the domain of nursing

urinary incontinence

involuntary loss of urine

Airborne precautions

measles (rubella) varicella pulmonary tuberculosis room with negative air pressure place with another-patient infected with same microorganism N95 place surgical mask on patient if moving

meaning of healing

mending and getting better from disease

Which medications reduce shivering?

meperidine or butorphanol

Body mechanics

obtain help whenever possible ask for patient help if able bend or flex knees use greater number of muscles as possible use thigh, arm, or leg muscles whenever possible use a wide base of support keep work close to your body work at the same level or height pulling requires less action than pushing directly face keep trunk straight use arms as levers when pulling patients to you

hemostasis

occurs immediately after intial injury, blood vessels constrict and clotting begins, exudate(drainage) forms and causes swelling and pain, increased perfusion results in heat and redness, platelets stimulate other cells to migrate to injury to participate in phases of healing

Frostbite

occurs when the body is exposed to subnormal temperature

Third intention

occurs when there is delayed suturing wounds sutured after granulation tissue begins to form

Post op care

on receiving patient from PACU perform baseline assessment monitor vital signs assess drains, tubes, IV sites, LOC, surgical site do not assign to CNAs maintain open airway maintain tissue perfusion promote rest and comfort promote wound healing promote adjustment to lifestyle prevent complications

Maslows level 1: physiologic needs

oxygen, food, water, sex, rest, physical activity; physiologic needs are highest priority

chronic pain

pain that may be limited, intermittent, or persistent but that lasts beyond the normal healing period

hemiplegia

paralysis one half of the body

sims position

patient again lies on the side but the lower arm is behind the patient and the upper are is flexed at both the shoulder and the elbow

How much does the diaphragm move in order to get air into the lungs?

1 cm or 4/10 of an inch

How much of the probe should be lubricated?

1-1.5 inches for adults and 1 inch for an infant

How long does it take for a plaster cast to dry?

24-48 hours

3 Point Scale to Grade Force (strength) of Pulses

3+ = full, bounding 2+ = normal 1+ = weak 0 = absent

Average core temperature for the elderly population

35-36.1 C 95-97 F

Healthy young adults average oral temperature

37 C 98.6 F

tympanic temp

37.5 C, 99.5 F

Olfaction

Using the sense of smell during a physical examination

Febrile

feverish; pertaining to a fever

HIPAA

health insurance portability and accountability act regulations regarding patient privacy and electronic medical records protects patients

Antipyretics

medications that reduce fevers

when listening to bowel sounds

start lower right and go up, across and down

Respiratory rate infant (6 months)

30-50

BPM

Beats per minute

Diffusion

the movement of oxygen and carbon dioxide between the alveoli and the red blood cells

major classifications of hypertension

-primary (essential): characterized by an increase above normal in both systolic and diastolic pressures -secondary : caused by another disease condition like kidney disease, aorta disorders, or adrenal cortex disorders

heat production

-primary source is metabolism -hormones, muscle movements, exercise increase metabolism -thyroid hormone and shivering also increase heat production - energy production decreases and heat production increases

Mild hypothermia classification

34-36 C 93.2-96.8 F

Prehypertension in adults

120-139 over 80-89

The highest temperature of the day in healthy people

4 PM

Newborn normal BP

40 (mean)

Sphygmomanometer

A compression cuff with a pressure bulb containing a release valce that is used to obtain blood pressure. Comes in aneroid and mercury forms

Asking an adult what the statement "A stitch in time saves nine" means to him is a mental status examination technique used to assess

Abstract thinking.

Care plan

the patient is always involved results in greater success when involving the patient

Hygiene

Affects comfort, safety, and well being; includes cleaning and grooming; maintains personal body cleanliness and appearance; promotes healthy skin; helps prevent infection and disease

Inspect boney prominences

Any point on the body where the bone is immediately below the skin surface

Pulse sited used to auscultate for apical pulse?

Apical pulse

Appropriate pulse observations

Appropriate documentation of pulse includes rate, rhythm (regular, irregular), and volume (full, weak, thready, or bounding on a scale of 0 to 4), and if necessary, wall elasticity (hard, inflexible).

How long would you perform a back massage?

Approximately 3 min

Edema

Areas of skin become swollen or "edematous" from a build up of fluid in the interstitial space

The nurse is caring for a hospitalized young adult male who is uninsured even though he works as a dishwasher at a local restaurant. He states that he would like to get a better job, but he has no education. How can the nurse best assist this patient psychosocially?

By providing information and referrals

How do you assess the reflex response?

By tapping a tendon with a reflex hammer. The reflex responses are rated so no response, sluggish, normal, brisker than normal or hyperactive

Examples of ACE inhibitors

Captopril (Capoten), enalapril (Vasotec), lisinopril (Prinivil, Zestril), benazepril (Lostensin)

The nurse is providing oral care to an unconscious patient and notes that the patient has extremely bad breath. The term for "bad breath" is

Halitosis.

Cast

Hard structures of plaster, fiberglass, or plastic materials used to immobilize musculoskeletal tissues after injuries

The nurse is caring for a patient who has diabetes mellitus and circulatory insufficiency, with peripheral neuropathy and urinary incontinence. The nurse realizes that patients with these conditions

Have decreased pain sensation and increased risk of skin impairment.

The nurse is providing discharge teaching for an older adult woman who will need dressing changes at home. Her husband, who is also elderly, is her only source of care. The husband states that he will not be able to perform the dressing changes. What does the nurse need to arrange for?

Home care service referrals

With respect to the concept of caring, most nursing theories

Identify caring as highly relational involving patient and nurse.

The nurse is working in a drug rehabilitation clinic and is in the process of admitting a patient who says that she wants to be "detoxified." It is important for the nurse to

Identify the patient's stage of change.

A nurse has taught the staff about informatics. Which statement indicates that the staff needs more education?

If a nurse has computer competency, the nurse is competent in informatics.

When would you NOT use a safety razor?

If the patient is: - Receiving an anticoagulant - Undergoing chemotherapy - On high dose aspirin therapy

The complementary and alternative therapy that is known to alter immune function is which of the following?

Imagery

Stat order

Immediate admin Emergency single dose

Assess for Edema

Inspect Palpate (Non-pitting, pitting)

In developing a nursing care plan for increasing activity tolerance in a patient, the nurse should (Select all that apply.)

Involve the patient and the patient's family in designing an exercise plan. Consider the patient's ability to increase activity level. Consult with members of the health care team

When dealing with the concept of "touch," the nurse realizes what with regard to contact touch?

Involves only skin-to-skin contact

Unlike arthritis, joint degeneration

Involves overgrowth of bone at the articular ends.

Define "Planning" in the nursing process

Involves setting patient-centered goals and expected outcomes and plans nursing interventions

Dyspnea

Labored or difficult breathing

When assessing pain, what set of questions do you ask?

OPQRST

The patient is eager to begin his exercise program with a 2-mile jog. The nurse instructs the patient to warm up with stretching exercises. The patient states that he is ready and does not want to waste time with a "warm-up." The nurse explains that the warm-up

Prepares the body and decreases the potential for injury.

What must be identified during the nursing process?

Problems and special needs must be identified

The nurse is caring for a patient with a urinary catheter. After the nurse empties the collection bag and disposes of the urine, the next step is to

Remove gloves and dispose of in garbage.

Urinary assistance

Run warm water over perineal Coffee, fluids

Carotid artery pulse

S1 (AV valves closing) is synchronized with the _________________

What type of malignant tumors tend to affect primarily young people?

Sarcoma

Encouraging children to play a game of kickball would be best suited for which age group?

School-aged

A structural curvature of the spine associated with vertebral rotation is known as

Scoliosis.

A man is hospitalized after surgery that amputated both lower extremities owing to injuries sustained during military service. The nurse should recognize his need to grieve for what type of loss?

Situational loss

When assessing the activity tolerance of a patient, the nurse would evaluate which of the following? (Select all that apply.)

Skeletal abnormalities Emotional factors Age Pregnancy status

. After providing care, a nurse charts in the patient's record. Which entry should the nurse document?

Skin pale and cool

Which symptom is an expected cognitive change in the older adult patient?

Slower reaction time

Korotkoff Sound

Sounds heard, via stethoscope, over an artery distal to the blood pressure cuff

A basic foundational principle of chiropractic care is that

Structure and function coexist.

Two abnormalities in pulse rates?

Tachycardia and bradycardia

What is the primary goal for psychosocial measures?

The primary goal is to produce a feeling of well being in the confused and disoriented elderly patient

Hemodynamics

The science of the blood flow through the circulation

Define percussion

This skill involves striking one object against another and interpreting the sound that is made

Circumduction

To move a limb in a circular manner. Can be best performed at ball and socket joints

The patient experienced a surgical procedure, and Betadine was utilized as the surgical prep. Two days postoperatively, the nurse's assessment indicates that the incision is red and has a small amount of purulent drainage. The patient reports tenderness at the incision site. The patient's temperature is 100.5° F and the WBC is 10,500/mm3. Which nursing action should the nurse take?

Utilize SBAR to call and communicate the patient's needs to the physician.

The nurse is caring for a patient with an incision. Which of the following actions would best indicate an understanding of medical and surgical asepsis?

Utilizing clean gloves to remove the dressing and sterile supplies for the new dressing

Diet influence on bowel elimination

We know that regular intake of food helps maintain peristalsis. Fiber (soluble and insoluble) provides bulk for in fecal material to help remove waste products from the GI tract efficiently. Fiber rich food produce gas which distends the intestinal walls and increases colonic motility and initiates defecation reflex.

Caring is a universal phenomenon that involves

What matters to a person.

What should the nurse recognize when comparing the physical changes in young and middle adulthood?

Young adults are quite active but are at risk for illness in later years.

What is the sequence of obtaining orthostatic hypotension measurements

[patient supine, sitting and standing. Obtain BP readings within 3 mins after the patient changes position.

A nurse is teaching a community group of school-aged parents about safety. The most important item to prioritize and explain is how to check the proper fit of

a bicycle helmet.

sinus tract

a cavity or channel underneath the wound that has the potential for infection

evidence-based practice (EBP)

a problem-solving approach to making clinical decisions, using the best evidence available; blends both science and art of nursing so best outcomes are achieved; may consist of specific nursing interventions or use guidelines established for the care of patients

What is thermoregulation?

a process that allows your body to maintain its core internal temperature

Korotkoff sounds

a series of five sounds (four sounds followed by an absence of sound) heard during the auscultatory determination of blood pressure and produced by sudden distention of the artery because of the proximally placed pneumatic cuff

orthopnea

ability to breathe without difficulty only when in an upright position (sitting upright or standing)

Biot's respiration

abnormally shallow for 23 breaths followed by irregular period of apnea.

paralysis

absence of strength secondary to nervous impairment

Regional anesthesia

administering a nerve block such as a spinal, caudal, epidural, or peripheral block patient is awake but the area of surgery is anesthetized used for OB procedures or surgery on lower extremities

When to measure vital signs

admission to a healthcare facility, assessing a patient during home care visits, during a routine schedule in a hospital, before, during and after a surgical procedure or invasive diagnostic procedure. before, during and after a transfusion of blood. before, during, and after the administration of medication therapies that affect cardiovascular, respiratory, or temp functions. physical condition changes. before, during, and after nursing interventions influencing vital signs, when a patient reports a nonspecific symptom of physical distress.

tertiary health promotion

after an illness is diagnosed and treated; example: teaching a patient with diabetes how to recognize and prevent complications, refer woman to support group after removal of breast due to cancer

Factors affecting wound healing

age- children and adults heal aster than elderly peripheral vascular disease pvd- impaired blood flow decreased immune system function reduced liver function decreased lung function nutrition lifestyle meds (steroids, heparin, antiinflammatories) infection chronic ilnesses

BP - You place the lower edge of the cuff at least 1 inch above the antecubital space to

allow for proper placement of the stethoscope over the brachial artery.

ileostomy

allows liquid fecal content from the ileum of the small intestine to be eliminated through the stoma

Which part of the hypothalamus controls heat loss?

anterior hypothalamus

when does discharge planning start?

as soon as the patient comes in the door

If you palpate an abnormal rate with a peripheral pulse what is the next step?

assess the apical rate

Hypothermia

at risk are post op patients, newbrons, elderly wearing a hat, providing more clothing or blankets, give warm fluids, adjust room temp, eliminate drafts, increase muscle activity, submerge frostbitten areas in a warm bath

pulse is regulated by what?

autonomic nervous system through cardiac sinoatrial node

nonmaleficence

avoid causing harm

radiation

diffusion of heat by electromagnetic waves (such as an uncovered head)

pronation

face down; laying on your stomach

Crackles

fine or coarse nonmusical sounds indicates fluid in the lungs

Post op leg exercises

flex and extend right foot, repeat with left trace circles to the right 5 times then to the left bend right leg at the knee, sliding foot back toward buttocks as far as possible tighten buttock muscles for a count of 10 5-10 times per hour

secondary health promotion

focus on SCREENING for early detection of disease with prompt diagnosis and treatment of any found; example: assessing children for normal growth and development and encourage regular medical, dental and vision exams

A straight, erect posture promotes what time of respiration?

full chest expansion

Lying flat prevents:

full chest expansion

Example of diuretics

furosemide (Lasix), spironolactone (aldactone), metolazone, polythiazide, hydrochlorothiazide.

What do you take note of in the general survey?

gender, age, signs of distress, posture, body type, motor activity, gait, hygiene, grooming, dress, body odor, affect, mood, speech, sensory/perceptual mental status

Malignant hyperthermia

hereditary condition of uncontrolled heat production that occurs when susceptible people receive certain anesthetic drugs

What is the most important sign of heatstroke?

hot and dry skin

Respiration influenced by smoking

increased rate due to pulmonary airway changes

inductive reasoning

one builds from specific ideas or actions to conclusions about general ideas

Foods causing constipation

popcorn, Chinese vegetables, broccoli, raw fruits, pineapple, corn, celery, tomatoes, nuts, coconuts, fruits with seeds, tough meats, shrimp, lobster

Pulse site used to assess status of circulation to lower leg?

popliteal

What risk factors do The National Cancer Institute have on their list for cancer?

tabacco, exposure to radiation, alcohol, diet, chemicals and other substances

ostomy

surgical opening from the inside of an organ to the outside

intentional wound

the result of planned invasive therapy or treatment ex. surgery, intravenous procedure

S2

the second heart sound, heard when the semilunar (aortic and pulmonic) valves close

inversion

turning foot inward

How many heart sounds are there and what are they?

two; S1 and S2

Ulnar

ulnar or little finger side of forearm at wrist

Wheeze

whistling, musical, high pitch from air being forced though an obstruction

Nursing is recognized as profession based on what criteria

-well defined body specific and unique knowledge -strong service orientation -recognized authority by a professional group (ANA) -code of ethics -professional organization that sets standards -ongoing research -autonomy and self-regulation

Talking with a colleague or writing in a journal

...

Which types of patients can cause challenging communication situations? (Select all that apply.)

A female patient who is outgoing and flirty An older adult patient who is demanding A teenager frightened by the prospect of impending surgery A child who is developmentally delayed

If the pusle is irregular, how long do you count the rate?

A full 60 sec

What is used to ambulate and/or transfer a weak or unsteady patient?

A gait belt

A new nurse asks the preceptor why a change-of-shift report is important since care is documented in the chart. What is the preceptor's best response?

A hand-off report provides an opportunity to share essential information to ensure patient safety and continuity of care."

What are some nursing interventions you can do for diabetic patients?

- regulation of insulin - understand that the patient may express concerns over diet change - contact nutritional medicine to speak to the patient - daily inspections of skin surface - exercise as prescribed by the physician - monitor body weight - monitor blood glucose level - problems must be reported promptly - provide emotional support

Factors that decrease vital signs:

- rest - depression - depressant drugs - age (decrease P and RR)

Position influence on bowel elimination

A person who is mobile, squatting is the normal position during defection, lean forward, exert intraabdominal pressure, contract gluteal muscle. Trying to straighten the anorectal angle. A person who is immobile, raise head-of-bed with the goal of getting the person into a sitting position on the bedpan. Easier said than done!

The nurse is admitting a patient with uncontrolled diabetes mellitus. It is the fourth time the patient is being admitted in the last 6 months for high blood sugars. During the admission process, the nurse asks the patient about her employment status and displays a nonjudgmental attitude. Why does the nurse do this?

A person's compliance is affected by economic status.

Extension

A position that is made possible by the joint angle increasing; moving of the joint away from the body

Lithotomy

A position where the patient is lying supine with the knees and hips flexed

Reduction

A procedure used to reposition the ends of a broken bone

Admission

A process that occurs when a patient enters a health care agency for care and treatment

Arrhythmia

A pulse with irregular rhythm

Stress

A response or change in the body caused by an emotional, physical, social, or economic factor

Of the following interventions, which would be the most important for preventing skin impairment in a mobile patient with local nerve damage?

During a bath, assess for pain.

Arterial pulses

Each heart beat creates a pressure wave that makes arteries expand and then recoil; all have this pressure wave or pulse throughout their length; you can only palpate this wave at body sites where it lies close to the skin and over a bone

Chronic

Long or continued; of long durationg. Usually an unpredictable duration. - Emotional effects may be long-lasting and severe - Source maybe unknown or poorly understood - May be no cure for source - Causes patient insecurity of never knowing how one will feel from day to day

The patient is admitted with chronic back pain. The nurse who is caring for this patient should

Look at how pain influences the patient's ability to function.

antipyretic

a substance or procedure that reduces fever

Easily accessible pulse site used during psychological shock or cardiac arrest when other sites are not palpable?

carotid

Easily accessible pulse used to assess which population?

children

pale stoma

shows signs of anemia

What are "Problems" based on?

signs and symptoms

SBP

systolic blood pressure

stoma

the part of the ostomy that is attached to the skin

passive exercise

the patient is unable to move independently, the nurse moves each joint through its range of motion

5 vital signs

respirations, pulse rate, blood pressure, temperature, and pain

A patient cancels a scheduled appointment because she will be attending a Shiva for a family member. Recognizing the importance of this cultural ritual, the nurse's best comment would be which of the following?

"I'm so sorry for your loss."

A nurse discusses the risks of repeated sun exposure with a young adult patient. Which of these patient responses would be most expected from this patient?

"I've had this mole my whole life. So what if it changed color? My skin is fine."

After the anticipated demise of a chronically ill patient, the unit nurse is found crying in the staff lounge. The best response to her crying colleague would be

"It is normal to feel this way. Give yourself some time to mourn."

What are the classifications of malignant tumors?

- Carcinomas: arise from epithelial tissue. can occur in the coverings of body parts - Sarcomas: arise in connective tissue. can occur in bone, muscle, cartilage, and other types of connective tissue. they tend to affect primarily young people and metastasize rapidly

What does the examiner use the assessments for?

- Gather baseline data - Supplement, confirm, or refute previously gathered data - Confirm and identify diagnosis - Make clinical judgments about a patient's changing health status - Evaluate the physiological outcomes of care

Pain assessment, management and effectiveness of relief measures are recorded on what forms? (inpatient, outpatient and field or mass casualty)

- Inpatient: MAR and Nursing Notes SF 510 - Outpatient: Chronological Record of Medical Care SF 600 and Emergency Treatment Record SF 558 - Field or Mass Casualty: Field Medical Card DD 1380

What can you do to assist a visually impaired patient?

- Provide a safe environment - Assist the patient to walk - Provide emotional support - Identify yourself when entering and leaving - Do not shout at the patient - Promote independence - Provide entertainment

You can try to manage behavior in elderly patients in 3 ways. What are they?

- Psychosocial measures - Pharmocotherapy - Family Support

Pulse characteristics:

- Rate - Rhythm - Strength - Equality

What are the most common problems with inactivity?

- Respiratory complications - Constipation - Contractures - Atrophy - Pressure ulcers - Boredom

What problems may arise from uncontrolled diabetes?

- Retinal change leading to blindness - Kidney disease - Nerve damage - Circulatory disorders: stroke, heart attack, slow wound healing, hypertension

You have reviewed the patient's records to determine her baseline BP, but if that had not been possible it would be appropriate for you to

- measure her BP on one arm, remove the cuff, wait at least 2 minutes, measure it on the other arm, and average the two values. - inflate the cuff to 30 mm Hg above the point of the previously palpated systolic pressure.

Older adult skin

-Loss of elasticity -Epidermis thins and flattens -Dermis thins and flattens -Loss of elastin, collagen, and subcutaneous fat -Decrease in number of sweat and sebaceous glands -Vascularity of the skin decreases while vascular fragility increases

Apical pulse (skills stack)

-Places diaphragm of stethoscope at the apex of the heart (5th intercostal space, left midclavicular line) -Counts rate for 30 seconds; states regularity, rate/minute (if irregular, counts for full minute) -Hand hygiene

Palpation Blood Pressure Measurement

-Positions cuff 2.5 cm above palpated brachial artery with arrows centered over artery -Palpates radial artery while inflating cuff to 30 mmHg above point where pulse disappears -Slowly deflates cuff & notes pressure at which the radial artery pulse returns (verbalizes this is palpated systolic BP) -Removes cuff -Performs hand hygiene

color classification of open wounds

-R: red-protect -Y: yellow-cleanse -B: black-debride -mixed wound: contains components of RY&B wounds

Fluid output

-Usually occurs between four organs: skin (~600mL/day), lungs (~400mL/day), gastrointestinal (GI) tract (~200mL/day), and kidneys (~1500mL/day). -Examples: urine, diarrhea, emesis, gastric secretion, drainage from wounds and tubes

How far below the axilla should the axillary pad be?

1.5-2 inches

Moderate hypothermia classification

30-34 C 86.0-93.2 F

axillary temp

36.5 C, 97.7 F

If a persons HR is 70 bpm and the SV is 70 mL what is the cardiac output?

4900 mL/min

Apical

4th to 5th intercostal space at left midclavicular line

How long does it take for fiberglass and polyurethane casts to dry?

5-15 min. Some weight bearing casts require up to 72 hrs to dry

Tumor

A new growth of abnormal cells

Amputation

A total or partial removal of an extremity, which is considered a surgical reconstructive procedure.

Flat abdominal contour

Abdomen is straight with no distention or indention

A nurse is caring for an adult patient who has had a minor motor vehicle accident. The health history reveals that the patient is currently in the process of obtaining a divorce. Which of the following actions should the nurse take? (Select all that apply.)

Agree upon and make time for the patient to talk. Use active listening skills and therapeutic touch as appropriate. Teach stress reduction strategies. Inform patient that stressed individuals are more likely to have accidents.

Characterisitics of temporal thermometer:

An infrared sensor measures the temperature of the superficial temporal artery. Used by sweeping the sensor across the forehead and just behind the ear

1) A nurse makes an effort to have caring encounters with his or her patient because: A) a patient's dignity and self-worth is increased. B) it is required by the ANA Standards of Professional Performance. C) a patient is more likely to demonstrate improved health. D) it will improve the nurse's level of job satisfaction. 1) A nurse makes an effort to have caring encounters with his or her patient because: A) a patient's dignity and self-worth is increased. B) it is required by the ANA Standards of Professional Performance. C) a patient is more likely to demonstrate improved health. D) it will improve the nurse's level of job satisfaction.

Answer - A As per Berman text (page 450) - "When clients perceive the encounter to be caring, their sense of dignity and self-worth is increased and feeling of connectedness are expressed."

Q3) When a nurse tells the patient that she is going to get him a warm blankets. Client takes such promises seriously, so should the nurse, this is referred to as? a) Attitudes b) Autonomy c) Justice d) Fidelity

Answer: D: Fidelity refers to being faithful to agreements and promises. Attitudes are mental positions or feelings toward a person, object or idea. Autonomy refers to rights to make one's own decision. Justice is frequently referred to as fairness. (Berman, Page 85-86)

1. A nurse has passed medications to a client per the physician's orders. The client has experienced an adverse reaction to the administered drugs. What level of maleficence is this described as in Fundamentals of Nursing, chapter 5? a. placing negligent harm b. placing intentional harm c. placing unintentional harm d. placing malevolent harm e. placing client at risk of harm

Answer: e Rational: There is a known risk of harm when administering medications with the intention to be helpful as the possibility of adverse reactions is always present. Berman describes this as, "placing someone at risk of harm." (Berman text, p.86-87)

Which route for taking temperature is safer and less disturbing to infants and children?

Axillary

When listening to Korotkoff sounds, you would use your stethoscope's

Bell and diaphragm

Tympanic

Care with ear position

C

Centigrade

Ear wax

Cercumen

Characteristics of heat sensitive patch:

Chemical dot thermometers or tape changes color at different ranges. Most are for single use only. Least accurate method for taking temperature. Use in accordance with local policy.

Orthostatic hypotension is commonly seen in patients with...

Circulatory problems, dehydration, side effects to medication

Which of the following nursing actions would most increase a patient's risk for developing a health care-associated infection?

Clean technique for inserting a urinary catheter

Having misplaced his stethoscope, a nurse borrows a colleague's stethoscope. He next enters the patient's room and identifies himself, washes his hands with soap, and states the purpose of his visit. He performs proper identification of the patient before he auscultates her lungs. Which critical health assessment step was not performed?

Cleaning stethoscope with alcohol

When providing basic eye care, the nurse

Cleanses from inner canthus to outer canthus.

The nurse is admitting an elderly patient for failure to thrive and weight loss. A nasogastric tube is inserted for supplemental tube feedings. The nurse should become concerned when (Select all that apply.)

Clear, watery discharge is noted. Bleeding is noted where the tube comes in contact with the nares.

A school nurse recognizes a belt buckle-shaped ecchymosis on a 7-year-old student. When privately asked about how the injury occurred, the student described falling on the playground. Upon suspecting abuse, the school nurse's best next action is which of the following?

Contacting Social Services and reporting suspected abuse

Which of the following exercise activities would most likely provide the opportunity for mind-body awareness?

Cool-down activity

The nurse is planning playroom activities for a hospitalized 6-year-old patient. Which of the following age appropriate items that the nurse should ensure are available? (Select all that apply.)

Crayons and paper Children's books Building blocks

Many patients find it difficult to incorporate an exercise program into their daily lives because of time constraints. For these patients, it is beneficial to reinforce that many ADLs are used to accumulate the recommended 30 minutes or more per day of moderate-intensity physical activity. When instructing these patients, the nurse explains that

Daily chores should begin with gentle stretches.

The nurse is caring for a patient in Contact Precautions. The nurse includes hand hygiene as part of the plan of care to (Select all that apply).

Decrease the incidence of health care-associated infection. Protect the nurse from transmission of the microbes. Decrease the transmission of microbes to other patients. Prevent contamination of clean supplies.

A nurse has taught the patient how to use crutches. The patient went up and down the stairs using crutches with no difficulties. Which information will the nurse use for the "I" in PIE charting?

Demonstrated use of crutches

Nurses who make the best communicators

Develop critical thinking skills.

Oral thrush

Develops when the fungus Candida albicans grows out of control

Popliteal pulses

Difficult to localize; anchor your thumbs on the knee and curl your fingers around into the popliteal fossa; press your fingers hard to compress the artery against the bone

Hearing Loss

Difficulty hearing normal conversations. Losses range from milk to severe: deafness is the most severe and occurs in all age-groups. Common causes include age-related changes in the inner ear, exposure to noise and build up of cerumen (earwax)

The patient is a 50-year-old African American male who has come in for his routine annual physical. Which of the following preventive screenings does the nurse recommend?

Digital rectal examination of the prostate (DRE) annually

Your patient, Maggie, is showing signs of dysrhythmia upon taking your morning round of vitals. After you report to the doctor on staff, what would he most likely order?

ECG, holter monitor or a telemetry monitor.

How often should the patient's position change?

Every 2 hrs

A cancer patient asks the nurse what the criteria are for hospice care. What should the nurse answer?

Expected to live less than 6 to 12 more months

On admission, a patient weighs 250 pounds. The weight is recorded as 256 pounds on the second inpatient day. The nurse should evaluate the patient for

Fluid retention.

Why is a complete physical exam performed?

For routine screening, to promote wellness behaviors, for preventive health care measures, to determine eligibility for military service, and to determine the need for admission to a hospital or long-term care facility.

Why are neurological assessments often conducted simultaneously with the musculoskeletal system?

Frequently muscular disorders are the result of neurological disease

In providing perineal care to a female patient, the nurse should wash

From pubic area to rectum.

Older adult: nails

Growth rate decreases; lack luster; longitudinal ridges

The nurse is caring for a patient who recently had unprotected sex with a partner who has HIV. The nurse informs the patient

Highly active antiretroviral therapy has been shown effective in slowing the disease process."

A patient was admitted 2 days ago with pneumonia and a history of angina. The patient is now having chest pain with a pulse rate of 108. Using the SBAR, which piece of data will the nurse use for B

History of angina

A severely depressed patient cannot state any positive attributes to his or her life. The nurse patiently sits with this patient and assists the patient to identify several activities the patient is actually looking forward to in life. The nurse is helping the patient to demonstrate which spiritual concept?

Hope

For what patients are rectal thermometers contraindicated?

In patients with diarrhea, have had perineal/rectal surgery, with bleeding tendencies or cardiac patients

Which type of diabetes is most common in chiledren and young adults?

Insulin dependent/Type 1

When making rounds, the nurse finds a patient who is not able to sleep because of surgery in the morning. Which therapeutic response is most appropriate?

It must be difficult not to know what the surgeon will find. What can I do to help?"

The nurse is examining a patient who is admitted to the emergency department with severe elbow pain. Of the following situations, which would cause the nurse to suspect a ligament tear or joint fracture?

Joint motion is greater than normal.

Inference

Judgment or interpretation based off cues

Immediate intervention is needed when the newborn exhibits

Lack of reflexes.

MRI

MRI noninvasive way of differentiating normal from abnormal tissues in the body used for brain, knee joint, spin, and abdominal organs patients with implanted medal devices cannot undergo this procedure duration is long and noisy patient may become claustrophobic deep breathing, music, and relaxing techniques

The nurse is caring for a patient who is being discharged from the hospital after being treated for hypertension. The patient is instructed to take his blood pressure three times a day and to keep a record of the readings. The nurse recommends that the patient purchase a portable electronic blood pressure device. The nurse also instructs the patient that the

Machine requires frequent calibration to ensure accuracy.

A patient with gradual, progressive cognitive impairment (dementia) is admitted to the nursing unit after hip replacement surgery. Which of the following is a nursing care principle for care of cognitively impaired older adults?

Maintain physical health.

What are the 2 pharmacotherapy things?

Major and minor tranquilizers

When choosing an appropriate topic for a young adult health fair, the nurse ranks which topic as least relevant?

Menopause and climacteric factors

1200-1500 mL

Normal adult output averages __________ per day

To restore health

Nurse's responsibility to assess & teach levels of prevention

What are characteristics of the nursing process?

Nusing care is organized and has purpose, nursing team members have the same goals for the patient, patient feels safe and secure

Informed consent

Obtained awake and in right mind Well before procedure Surgeon has to give

Fluid intake

Occurs orally through drinking and eating; average daily intake is approx. 2300mL, but varies widely; other routes of fluid intake include IV, rectal, irrigation of body cavities that can absorb fluid

Orthostatic Hypotension (Postual Hypotension)

Occurs when a person rising upright from a lying or sitting position causes fainting, weakness, or lightheadedness and a significant drop in blood pressure

The patient is to have thoracentesis at the bedside but tells the nurse that he is afraid and would like to cancel. The nurse sits with the patient and asks him to describe his fears. She then explains the procedure and assures the patient that she will be with him during the procedure. The patient agrees to have the procedure, and during the procedure, the nurse stays with the patient, explaining each step and providing encouragement. How has the nurse helped this patient?

Providing a presence

A mother brings her 12-year-old daughter into a clinic and inquires about getting her an HPV vaccine that day. The nurse informs the mother that the HPV vaccine

Requires a three-injection series to be fully effective.

Which interventions utilized by the nurse would indicate the ability to recognize the inflammatory response?

Rest, ice, compression, and elevation

Internal rotation

Rotation towards the center of the body

The nurse is caring for a patient who has been sullen and quiet for the past three days. Suddenly, he says, "I'm really nervous about surgery tomorrow, but I'm more worried about how it will affect my family." What should the nurse do?

Stop what he/she is doing (if possible) and ask the patient to expand on his statement.

The nurse is caring for an adult patient in the clinic who has been evacuated and is a victim of flooding. The patient presents with signs and symptoms of a urinary tract infection. Along with needed education surrounding this diagnosis, the nurse teaches the patient about rest, exercise, eating properly, and how to utilize deep breathing and visualization. Which of these explanations would best support these nursing interventions?

Stress for long periods of time can lead to exhaustion and decreased resistance to infection.

Which is the best examination position for a complete geriatric physical examination on a weak patient with bilateral basilar pneumonia?

Supine position

When do you NOT use the blue probe?

Taking a rectal temperature

A preceptor is working with a new nurse on documentation. Which situation will cause the preceptor to intervene?

The new nurse charts consecutively on every other line.

A nurse is creating a plan to reduce data entry errors and maintain confidentiality. Which guidelines should the nurse include? (Select all that apply.)

Use a programmed speed-dial key when faxing. Implement an automatic sign-off. Impose disciplinary actions for inappropriate access. Shred papers containing personal health information (PHI).

A terminally ill patient is experiencing constipation secondary to pain medication. What is the best way for the nurse to improve the patient's constipation problem?

Use a stimulant laxative and increase fluid intake.

If the patient is a child, ask the patient if they are in pain. How do you get them to rate their pain?

Use the FACES system

A mother brings her child to the clinic for a 12-month well visit. The child weighed 6 pounds 2 ounces and was 21 inches long at birth. What finding indicates that the child needs further assessment?

Weight of 16 pounds

Is it normal for children's diastolic blood pressure to continue to zero?

Yes

dialysis

a mechanical way of filtering waste from the blood

Dorsalis pedis

along top of foot, between extension tendons of great and first toe

Tachypnea

an abnormally fast respiratory rate, usually more than 20 breaths per minutes in an adult

bradycardia

an abnormally slow pulse rate, usually fewer than 60 beats per minutes in an adult

Pulse deficit

an inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site

Dysrhythmia

an interval interrupted by an early or late beat or a missed beat

During a follow-up visit, a woman is describing new onset of marital discord with her terminally ill spouse. Using the Kübler-Ross behavioral theory, the nurse recognizes that the spouse is in which stage of dying?

anger

Which of the following is the best example of veracity? a) a nurse telling his/her patient the truth about the prognosis of his/her disease. b) a nurse respectfully addressing his/her patient by their last name. c) a doctor that brings his/her patient a glass of water when the patient is thirsty. d) a cleaning staff member quickly helping change sheets for a nurse.

answer: a. Veracity refers to telling the truth. This is important in order to maintain trust with a patient. The value of maintaining this trust can outway the immediate consequences of telling the truth. This is one of the moral principles. (Berman and Snyder text, p 86)

A nurse is taking care of a 32 year old Chinese female patient. Which of the following demonstrates culturally responsive care? a) The nurse trying to speak to the patient in Chinese upon first meeting her. b) The nurse believes she does not hold any biases about Chinese culture. c) The nurse is self aware of his/her own cultural beliefs and practices. d) The nurse tells the patient that Chinese herbs do not work as well as Western medicine.

answer: c. Culturally responsive care involves understanding ones own cultural, attitudes, and beliefs. It is not "b" because truthfully, people have biases toward different cultures, but the nurse should be able to recognize and be able to examine the bias that he/she holds. It is not "a" and because this is a generalization that the this nurse holds. He/she does not give the patient a chance to express their individuality. It is not "d" because this nurse isn't respecting the patients culture. (Berman and Snyder text, p 316)

What does your average basic metabolic rate depend on?

body surface area and thyroid hormones.

Pressure ulcer prevention

change position every 2 hours keep heels immobile avoid placing on trochanter minimize shearing and friction forces foam pad gently massage to restore circulation do not massage reddened skin provide adequate nutrition and fluid intake

psoriasis

common skin condition that speeds up the life cycle of skin cells, cells build up rapidly on surface of skin and extra skin cells form scales and red patches that are itchy and sometimes painful; chronic, comes and goes

indirect studies

commonly performed through radiography ex. abdominal ultrasound, MRI, abdominal CT scan, small bowel series, barium enema

Interrelated roles of nurses

communicator, teacher, counselor, leader, researcher, advocate, collaborator

Data gathered for the neurological assessment includes:

consciousness, orientation, coordination or movements, behavior, appearance and speech

ischemia

deficiency of blood in a particular area

desiccation

dehydration

Aging and digestion

dental carries, tooth loss, decreased gag reflex, decreased sense of taste, muscle tone of sphincters, gastric secretions, peristalsismore at risk for inadequate nutrition decrease calories if activity is decreased physical limitations arrange for companionship during meals limited incomes availability

How can surface temp vary?

depending on blood flow to the skin and the amount of heat lost to the external environment.

Fire safety

do not let patient bring appliances from home check for frayed wires no smoking especially around oxygen if there is a fire use the RACE technique

Tube Feeding

elevate HOB 30 to 90 degrees before feeding and leave it up 30 to 60 minutes after keep HOB 30 degrees at all times assess bowel every 8 hours assess abdomen for distention check residual by aspirating every 4 hours if residual is greater than 150mL then delay feeding 1 to 2 hours

Clara Barton

established red cross; volunteered to care for wounds and feed union soldiers during civil war; served as supervisor of nurses for the army of James

Recommended f/u for stage 1 hypertensive BP

evaluate therapy within 1 month

How often do you rinse the razor when shaving?

every 2 or 3 strokes

4 hours

every hours or until patient is totally recovered and vital signs have returned to normal

Internal hemorrhage

evidence of copious bleeding, decrease bp, elevated pulse, clammy skin, decreased urine output

Effects BP arm below heart

falsely lower PB

Clear liquid diet

grape, apple, and cranberry juice strained fruit juices vegetable broth carbonated water clear fruit flavored water sweetened gelatin and ice clear candies popsicles tea, coffee clear broth

Amphetamines and cocaine does what to respiration's?

increases rate and depth

Inflammatory response

induced by any mechanical, chemical, or infectious disease localized protective response vessels dilate, bringing more blood to the damaged area causing redness, warmth, edema. neutralizes and destroys harmful agents limit their spread to other tissues in the body prepares damaged tissues for repair histamine and serotonin are released during inflammation which cause capillary walls to become more permeable

Patient conditions not appropriate for electronic BP measurement

irregular HR, peripheral vascular obstruction, shivering, seizures, excessive tremors, inability to cooperate, BP less than 90 mm Hg systolic.

Safety at the hospital

orient patient to room, remote, call bell, and bed assess patients gait and risk for falling place high risk near the nurses station keep bed in low toilet patient on a regular schedule lock bed wheels on bed and chair night light nonskid slippers answer call lights quickly tell when you will check in next and be prompt grab bars next to toilet make sure patient is safe and all things are in reach stay with confused patient restrict fluids after 6 pm provide diversionary and social activities patients might enjoy perform change-of-shift safety checks

negative-pressure wound therapy

promotes wound healing and wound closure through the application of uniform negative pressure on wound bed, reduction in bacteria in the wound, and the removal of excess wound fluid, while providing a moist wound healing environment; results in mechanical tension on wound tissues, stimulating cell proliferation, blood flow to wounds, and the growth of new blood vessels

autonomy

respect rights of patients to make health care decisions

Cheyne-Stokes respiration

respiratory rate and depth are irregular, alternating periods of apnea and hyperventilation's. Slow shallow breaths that gradually increase to abnormal rate and depth. Then the pattern reverses

6 classes of nutrients

supply energy: carbs, proteins, lipids regulate body processes: vitamins, minerals, water

Patients at greatest risk for infection

surgical incisions artificial airways urinary catheters IV lines implanted prosthetic devices repeated injections or venipuncture immune compromise

The father has recently begun to attend his children's school functions since the death of his wife. This would best be described as which task in the Worden Grief Tasks Model?

task III

Third korotkoff sound

the Loudest beating

Which probe do you use when taking an axillary temperature?

the blue probe

The ability of a person to control body temperature depends:

the degree of temperature extreme, the persons ability to sense feeling comfortable or uncomfortable, thought process or emotions, and the persons mobility or ability to remove or add clothes

Body temperature

the difference between the amount of heat produced by the body processes and the amount lost to the external environment heat produced-heat lost = body temp

pulse deficit

the difference between the apical and the radial pulse rates. This condition may indicate a lack of peripheral perfusion for some of the heart contractions.

pain tolerance

the maximum level of pain that a person is able to tolerate

Capnography

the measurement of exhaled carbon dioxide through exhalation

pulse rate

the number of contractions over a peripheral artery in 1 minute

Pain assessment

the number scale or the facial scale fifth vital sign

dyspnea

the sensation of difficult or labored breathing

Fifth korotkoff sound

the sound disappears

beta-adrenergic blockers

to block sympathetic stimulation and decrease cardiac output

ACE inhibitors

to prevent vasoconstriction by angiotensin II and decrease circulatory fluid volume by reducing aldosterone production

A person is showing signs and symptoms of deficient fluid volume, what is the first aid protocol include?

transporting the person to a cooler environment and restoring fluid and electrolyte balance, removing excess body clothing, placing cool and wet towels over the skin, and using oscillating fans to increase convective heat loss.

Afebrile

without fever

Assessment of fluid balance

•Daily weights •Measuring and recording all liquid intake and output (I&O) during a 24 hour period •Intake and output should be approximately equal

Chronic pain

•Pain lasting longer than 6 months •Can be continuous or intermittent and may be as intense as acute - does not indicate tissue damage

Methods of heat transfer

•Radiation (Indirect contact) •Convection (Air current) •Evaporation (Moisture vapor) •Conduction (Direct contact)

sources of heat loss

•Skin (primary source) -Evaporation of sweat •Warming & humidifying inspired air •Eliminating urine & feces

The nurse is caring for a patient with pneumonia with a new nurse in orientation. Which of the following statements by the new nurse would indicate an understanding of the nature of this condition?

"An infectious disease like pneumonia may not pose a risk to others."

Ask during GI assessment

"Are you passing gas (flatus)?" "When was your last bowel movement?"

A nurse is caring for a 15-year-old who in the past 6 months has had multiple male and female sexual partners. The nurse knows that the therapeutic statement that would be most effective is

"I know you feel invincible, but STIs and unwanted pregnancy are a real risk. Let's discuss what you think is the best method for protecting yourself."

What are signs and symptoms of neglect?

- Lack of adult supervision - Malnourishment - Unsafe living environment - Untreated chronic illness

What can pooling of bloon in veins cause?

- Phlebitis: inlammation of the vein - Embolus: blood clot moving in the bloodstream - Thrombus: stationary blood clot - Thrombophlebitis: inflammatino of a vein associated with a thrombus

What are some nursing interventions you can do for a paralyzed patient?

- Promoting coping strategies - Helping family make adaptive changes - Maintaining skin integrity - Promoting bladder and bowel control

What are all the pulse locations?

- Radial - Brachial - Temporal - Carotid - Apical - Femoral - Popiteal - Dorsalis pedis - Posterior tibialis

What are some psychosocial measures?

- Reality orientation - Validation therapy - Reminiscence - Remotivation therapy - Resocialization

How do you escort a small, midly resistive patient?

- The tech will stand behind and to the left of the patient - Grasp the patient's left wrist with your left hand - Grasp the patient's left elbow with your right hand - Push on the elbow - Pull back on the wrist - Ambulate the patient

Older adult: skin

- Thinner, more easily injured and slower to heal - Dry skin - Decreased turgor

What are the specific gaits?

- Three-point gait - Four-point gait - Two-point gait - Swing-through gait - Swing-to gait

What are some common ear disorders?

- Tinnitus - Otitis Media - Meniere's Disease - Hearing Loss - Presbycusis

What can you do for unconscious patients?

- assess reponsiveness using Glasgow coma scale - maintain airway - reposition every 2 hours - attain and maintain fluid and electrolyte balances - maintain healthy oral mucous membrane - maintain skin integrity - maintain corneal integrity - fever management - promote urinary elimination - promote bowel function - stimulate them - provide adequate lighting

Comfort during bathing

-Provide privacy -Maintain safety -Maintain warmth -Promote independence

Factors influencing hygiene

-social practices -body image -health beliefs and motivation -developmental stage -personal preferences -socioeconomic status -cultural variables -physical condition

carbs

-sugars and starches -organic compounds composed of carbon, hydrogen, and oxygen -lactose is an animal source -most abundant and least expensive -classified as simple or complex sugars -converted to glucose for transport through blood -50-100g needed daily to prevent ketosis

sources of knowledge

-traditional ( passed down from generation to generation) -authoritative- comes from an expert, accepted as truth based on person's perceived expertise -scientific (obtained through the scientific method-research)

How far do you insert the rectal thermometer?

1-1.5 inches for adults or 3/4-1 inch for an infant. DO NOT force thermometer

Auscultation of the heart

1. Aortic Area 2nd right interspace close to the sternum. 2. Pulmonic Area 2nd left interspace. 3. ERB's Point 3rd left interspace. 4. Tricuspid Area 5th left interspace close to the sternum. 5. Mitral Area (Apical) 5th left interspace medial to the MCL

What are the 3 purposes of bathing?

1. Cleanse the skin by removing waste products secreted 2. Promote comfort 3. Stimulate circulation

List the BP equipment:

1. Stethoscope 2. Sphygmomanometer (cuff): 2 types, manual and electronic

How long would you wait before reassessing your patient's blood pressure on the same arm?

2 to 3 minutes

Respiratory rate toddler (2 years)

25-32

Normal pulse pressure

30 to 50 mm Hg

A newborn loses up to ___% of body heat through the head

30%

Inspection

A technique used in physical examination to carefully and critically examine the body using the sense of sight

Factors influencing urination

Age, pathophysiology, medications

Inspection of bowel movement

Aka stool, feces Color Size Characteristics

Explorer

An instrument, with a sharp pointed end, used for exploring the mouth

Question 1 In order for a facility to obtain magnet status, the professional work environment needs to meet which of the following components of the Magnet Recognition Program? a. Transformational leadership b. A low percentage of "failure to rescue" c. Collaboration with the other medical facilities d. State of the art biomedical devices e. New knowledge, innovation, and improvements

Answer, A and E. This is a knowledge question taken from ANA's Scope and Standards of practice, 2010 pg. 6

Choose the following health factors that contribute to the health disparities experienced by people living at or below the poverty line. A) Patient has inability to schedule appointments quickly, or during open hours. B) The provider has unconscious biases C) Interpreters are available for limited English-speaking patients D) Patient isn't able to read, or fully understand insurance forms.

Answer: A, B, C, D these are all factors that contribute to the health disparities experienced by people living at or below the poverty line. (Berman, pg. 318)

During a routine physical assessment, the nurse obtaining a health history notes that a 50-year-old female patient reports pain and redness in the right breast. What is the nurse's best action in response to this finding?

Assess the patient as thoroughly as possible.

Who clips the toenails of a diabetic or one with circulatory disease?

Care requires a doctor's order, and is performed by a nurse or a physician

The nurse is caring for a patient in labor and delivery. When near completing an assessment of the patient for dilatation and effacement, the electronic infusion device being used on the intravenous infusion alarms. Which of these actions is most appropriate for the nurse to take?

Complete the assessment, remove gloves, wash hands, and assess the intravenous infusion.

Physiological symptoms of a stress response include all of the following except

Constricted pupils.

The patient has been overweight for most of her life. She has tried dieting in the past and has lost weight, only to regain it when she stopped dieting. She is visiting the weight loss clinic/health club because she has decided to do it. She states that she will join right after the holidays, in 3 months. The nurse recognizes that the patient is in which stage of the change process?

Contemplation

Of the following mechanisms of heat loss by the body, identify the mechanism that transfers heat away by using air movement?

Convection

A correctional facility nurse is called to the scene of a deceased inmate. The correction officer wants to quickly move the body to the funeral home because he is not comfortable with death. The inmate's body will need to be transported where?

Coroner's office for an autopsy

To increase quality and years of healthy life, Healthy People 2020 focuses on four areas. One of those areas is

Creating social and physical environments that promote good health.

A nurse wants to integrate all pertinent patient information into one record, regardless of the number of times a patient enters the health care system. Which term should the nurse use to describe this system?

Electronic health record

Several theories on aging have been put forth, and the nurse should use these theories to

Guide nursing care.

NRS

Numerical Rating Scale

The nurse is working in a clinic that is designed to provide health education and immunizations. As such, this clinic is designed to provide

Primary prevention.

What can you do to prevent respiratory complications in inactive patients?

Range of motion exercises

When initiating the care of families, one factor that helps organize the family approach to the nursing process is that the nurse

Realizes that individuals have an impact on families.

During a relaxation therapy skills group, the instructor discusses the cognitive skill of learning to tolerate uncertain and unfamiliar experiences. This best describes the skill of

Receptivity.

R

Respirations

RR

Respiratory rate

When recording the patient's respiratory status, what must be recorded? (Select all that apply.)

Respiratory rate Character of respirations Amount of oxygen therapy

Pathological

Resulting from desease

stages-of-illness behaviors

Stage 1: experiencing symptoms Stage 2: assuming the sick role Stage 3: assuming a dependent role Stage 4: achieving recovery and rehabilitation

A male student comes to the college health clinic. He hesitantly describes that his testis has lumps. The nurse recognizes this as a potential sign of which of the following?

Testicular cancer

What is the general survey?

The assessment begins with a general survey of the patient when the corpsman/technician first meets the patient

In planning a physical activity program for a patient, the nurse must understand that

The best program includes a combination of exercises.

Orthopedics

The branch of medicine that is concerned with the correction or prevention of skeletal demormities

The nurse is caring for an elderly patient admitted with nausea, vomiting, and diarrhea. Upon completing the health history, which priority concern would require collaboration with social services to address the patient's health care needs?

The electricity was turned off 2 days ago.

A nurse is giving a hand-off report to the oncoming nurse. Which information is critical for the nurse to report

The patient has a new pain medication, Lortab

The patient is diagnosed with athlete's foot (tinea pedis). The patient says that she is relieved because it is only athlete's foot, and it can be treated easily. The nurse explains that athlete's foot is

The patient is diagnosed with athlete's foot (tinea pedis). The patient says that she is relieved because it is only athlete's foot, and it can be treated easily. The nurse explains that athlete's foot is

Diastolic Pressure

The pressure exerted on the arterial walls during ventricular relaxation at which point, the left ventricle is filled with blood. This is the last blood pressure sound you will heart and is the bottom number on a blood pressure reading

True or False: Transferring a patient into bed is just the reverse order used in getting the patient up.

True

A nurse is assessing a patient's hearing. Which of the following items does the nurse gather before conducting the assessment? (Select all that apply.)

Tuning fork Current list of medications

An elderly patient is wearing a hearing aid. Which technique should the nurse use to facilitate communication?

Turn off the television.

Of the following sites, which are used for obtaining a core temperature? (Select all that apply.)

Tympanic Pulmonary artery

The nurse is caring for a patient who becomes nauseated and vomits without warning. The nurse has contaminated hands. The nurse's best next step is to

Wash hands with an antimicrobial soap and water.

When might taking a blood pressure by palpation be necessary?

When a working stethoscope is unavailable or the background noise is too loud to hear the pulse

When caring for a middle-aged adult exhibiting maladaptive coping skills, the nurse is trying to determine the cause of the patient's behavior. From a growth and development perspective, what should the nurse recall?

When individuals experience repeated developmental failures, inadequacies sometimes result.

A home health nurse is performing a home assessment for safety. Which of the following comments by the patient would indicate a need for further education?

When it is cold outside in the winter, I can warm my car up in the garage."

health

a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity

Pyrogens

bacteria and viruses elevate body temperature

What population often has sinus dysrhythmia and how can you verify it is a normal finding

children; have the child hold their breath and the HR usually becomes regular

How would you measure a core temperature?

invasive measurement such as an artery catheter

shear

results when one layer of tissue slides over another layer

acute wound

usually heal within days to weeks

First intention

wound with little tissue loss edges of wound approximate and only a slight chance of infection

pressure ulcer

wound with localized area of injury to the skin and/or underlying tissue

The nurse is teaching a group of older adults at an assisted-living facility about age-related physiological changes. Which question would be the most important to ask this group?

"Are you able to hear the tornado sirens in your area?"

The nurse knows that the young adult patient understands the health risks that affect his/her age group when the patient states

"Controlling the amount of stress in my life may decrease the risk of illness."

The nurse is admitting a patient with an infectious disease process. What question would be appropriate for a nurse to ask this patient?

"Do you have a chronic disease, and how long have you had it?"

The nurse discussed threats to adult safety with a college group. Which of the following statements would indicate understanding of the topic?

"I guess smoking even at parties is not good for my body."

The patient is about to undergo a certain procedure and has voiced concern about outcomes and prognosis. The nurse caring for the patient underwent a similar procedure a few years earlier and stops to listen to the patient's concerns. Which of the following responses by the nurse may be most beneficial?

"I had a similar procedure last year and I can tell you what I went through."

Vitamins

-organic compounds needed by the body in small amounts -most are active in form of coenzymes -classified as water soluble or fat soluble -absorbed through intestinal wall (small intestine) directly into bloodstream -needed for metablolism

protein

-required for formation of all body structures -based on amino acid composition -animal proteins are complete, plant proteins are incomplete -RDA for adults is 0.8g/kg

What are the 3 nursing interventions for patients with abusive or self-abusive behavior?

1. provide emotional support for the patient and family, and encourage the patient to talk about their problems 2. Being a good listener 3. Do not be judgmental

How much do the ribs retract upward from the midline in order to get air into the lungs?

1.2-2.5 cm or 1/2-1 inch

Stage 2 hypertension (diastolic)

100 mmHg and above

How many patient identifiers does the Joint Commission require?

2

How far should the crutch tips be lateral and anterior to the toes of the forefoot?

2-4 inches lateral and 4-6 inches anterior to the toes of the forefoot

Instruct the patient not to remain in the tub longer than how many minutes?

20 min

Respiratory rate for child

20-30

forehead temp

34.4 C, 94.0 F

Electronic thermometers provide two modes of operation:

4-second predictive temperature and 3-minute standard temperature

Lowest temperature time of the day in healthy people

6 AM

1 month old normal BP

85/54

The paramedics transport an adult involved in a motor vehicle accident to the emergency department. On physical examination, the patient's level of consciousness is reported as opening eyes to pain and responding with inappropriate words and flexion withdrawal to painful stimuli. The nurse correctly identifies the patient's Glasgow Coma Scale score as

9.

A 70-year-old patient who suffers from worsening dementia is no longer able to live alone. When discussing health care services and possible long-term living arrangements with the patient's only son, what should the nurse suggest?

A nursing center because home care is no longer safe

Which of these approaches would be most appropriate for the nurse to use when teaching a 4-year-old patient about a scheduled surgery?

Allow the child to touch and hold medical equipment such as thermometers and syringes.

3:Which of the following is the least "best evidence" for evidence -based practice? A.Trial and error B.Clients values and preference C.Clinical experience D.The optional of experts

Answer:A Rationale:Trial and Error:is considered as the least evidence because it doesn't valid evidence and be harmful the the patients.(Berman text pg 28}

Why do the elderly have special nursing needs?

Because of physical, psychological, and social changes

Which artery is the most appropriate for assessing the pulse of a small child?

Brachial

Types of arterial pulses

Carotid Brachial Radial Femoral Popliteal Post Tibial Dorsalis Pedis

Define "Evaluation" in the nursing process

Crucial to determine whether the patient's condition or well-being has imporved after the application of the nursing process

Just as health and health behavior are affected by internal and external variables, so are illness and illness behavior. Which external variables can affect illness and behavior? (Select all that apply.)

Cultural background Social support Socioeconomic status

The patient has been in bed for several days and needs to be ambulated. Before ambulation, the nurse

Dangles the patient on the side of the bed.

The nurse is caring for a patient who refuses "AM care." When asked why, the patient tells the nurse that she always bathes in the evening. The nurse should

Defer the bath until evening and pass on the information to the next shift.

The family is a central institution in American society; however, the concept, structure, and functioning of the family unit continue to change over time. The uniqueness of each family is referred to as family

Diversity.

Vertigo

Dizziness in which a patient inappropriate experiences the perception of motion due to dysfunction of the vestibular system. Often associated with nausea and vomiting as well as a balance disorder, causing difficulties standing or walking

While assessing the skin of an 82-year-old male patient, a nurse discovers nonpainful ruby red papules on the patient's trunk. What is the nurse's next action?

Document cherry angiomas as a normal geriatric skin finding.

Whenever you are assisting a patient, what do you always do as your last step?

Document the procedure

The physician order reads "Lopressor (metoprolol) 50 mg PO daily. Do not give if blood pressure is less than 100 mm Hg systolic." The patient's blood pressure is 92/66. The nurse does not give the medication and

Documents that the medication was not given owing to low blood pressure.

The nurse is caring for a patient in hospice. As she observes the family dynamics, she notes that the patient is getting adequate care, but the wife is not sleeping well and needs rest. The nurse also assesses the need for better family nutrition and meals assistance. The nurse discusses these assessments with the patient and his family and formulates a plan of care with them to address these issues. The nurse is utilizing which approach to family nursing practice?

Family as system

Surgery (anesthesia) influence on bowel elimination

General anesthesia used during surgery temporarily stop peristalsis. Usually lasts 24 to 48 hours. Local or regional anesthetics may affect peristalsis minimally if at all.

Which type of diabetes develops during pregnancy?

Gestational diabetes

Role of nurse: hygiene

Healthy people can maintain their own hygiene Ill, physically or emotionally challenged people often require assistance with hygiene

A nurse is teaching the staff about health care reimbursement. Which information should the nurse include?

Home health, long-term care, and hospital nurses' documentation can affect reimbursement for health care.

The use of critical thinking attitudes is necessary to design a plan of care to meet the patient's hygiene needs. Which of the following are considered critical thinking attitudes? (Select all that apply.)

Humility Curiosity

Examples of vasodilators

Hydralazine hydrochloride (Apresoline) and minoxidil (Loniten)

The nurse is caring for a patient who has an elevated temperature. The nurse understands that

Hyperthermia occurs when the body cannot reduce heat production.

What do you do if clean linen touches the floor?

Immediately discard it

The nurse is caring for a patient who has a bloodborne pathogen. The nurse splashes blood above the glove to intact skin while discontinuing an intravenous infusion. The nurse's best next step is to

Immediately wash the site with soap and running water, and seek guidance from the manager.

A male patient with diabetes who is taking medication for erectile dysfunction is experiencing pain and discomfort related to the side effect of priapism. The nurse knows that this patient is at greatest risk for

Impaired circulation due to medication.

According to the World Health Organization, what is the best definition for "health"?

Involving the total person and environment

The nurse is caring for a patient who claims that he does not believe in God, nor does he believe in an "ultimate reality." The nurse realizes that this patient

Is an atheist/agnostic.

The nurse is caring for a group of medical-surgical patients. The patient most at risk for developing an infection is the patient who

Is recovering from a right total hip arthroplasty.

A nurse has provided care to a patient. Which entry should the nurse document in the patient's record?

Left abdominal incision 1 inch in length without redness, drainage, or edema

Vitiligo

Localized loss of skin pigmentation characterized by milk-white patches

An elderly patient presents to the hospital with a history of falls, confusion, and stroke. The nurse determines that the patient is at high risk for falls. Which of the following interventions is most appropriate for the nurse to take?

Lock beds and wheelchairs when transferring.

Which type of diabetes is Type 2?

Non-insulin dependent

Which type of diabetes is hereditary?

Non-insulin dependent (Type 2)

A 61-year-old obese patient is diagnosed with type 2 diabetes and high blood pressure. The patient states that he is upset about the diet restrictions imposed by the treatment regimen. What is the nurse's best approach?

Offer counseling on nutrition and exercise.

An 80-year-old male is brought to the emergency department with an exacerbation of chronic obstructive pulmonary disease (COPD). He states that he quit smoking 30 years ago, so it can't be COPD. He argues, "It's just these colds I've been getting. They're just getting worse and worse." The nurse understands that

Older adults do not have to alter physical activity because of physical changes.

Snellen chart

One of several charts used in testing visual acuity; letters, numbers, or symbols are arranged on the chart in decreasing size from top to bottom

Defamation

One person makes remarks against another that are untrue

The priority assessment immediately after birth is to

Open the airway.

The nurse needs to obtain a radial pulse from a patient. To obtain the correct measure, what must the nurse do?

Place the tips of the first two fingers over the groove along the thumb side of the patient's wrist.

A patient has been admitted and placed on fall precautions. The nurse explains to the patient that interventions for the precautions include

Placing a high risk for falls armband on the patient.

The nurse is caring for a patient who is immobile. The nurse is aware that the patient is at risk for Impaired skin integrity because

Pressure reduces circulation to affected tissue.

The nurse has received a report from the emergency department that a patient with tuberculosis will be coming to the unit. What items will the nurse need to care for this patient? (Select all that apply.)

Private room Negative-pressure airflow in room Communication signs for Airborne Precautions N95 respirator, gown, gloves, eyewear

A nurse prepared an audiotaped exchange with another nurse of information about a patient. Which action did the nurse complete? The nurse completed a

Report.

An elderly patient has been on high doses of antibiotics and is experiencing a sudden loss of hearing. The nurse should contact the health care provider and

Stop antibiotic use until the physician responds.

Drawbacks of complementary and alternative therapies would be all of the following except

Strong support by allopathic medical providers.

Adaptive behavior

The ability to cope with problems in ways considered appropriate by society

Respiration

The exchange of gases between the atmosphere, blood, and body cells

The nurse is caring for a hospitalized patient. Which of the following behaviors alerts the nurse to consider the need for restraint?

The patient continues to remove the nasogastric tube.

The nurse is discussing with a patient's physician the need for restraint. The nurse indicates that alternatives have been utilized. What behaviors would indicate that the alternatives are working?

The patient folds three washcloths over and over.

The coordinated efforts of the musculoskeletal and nervous system maintain balance, posture, and body alignment. Body alignment refers to

The relationship of one body part to another.

Prosthesis

The replacement of a missing body pat by an artificial substitute.

How do you record taking a blood pressure by palpation?

This blood pressure reading will only have 1 number, the systolic pressure, over the letter "P" for palpation

When does orthostatic hypotension occur?

This occurs when the blood pressure rapidly in relation to position changes from lying to sitting or standing.

The nurse is admitting a patient who will be having elective surgery. The nurse spends over an hour asking the patient questions as part of the admission process. What is the nurse's primary reason for doing this?

This will help the nurse provide better care for the patient.

A patient with an intravenous infusion requests a new gown after bathing. Which of the following actions is most appropriate?

Thread the intravenous bag and tubing through the sleeve of the old gown and through the sleeve of the new gown without disconnecting.

A head and neck physical examination is completed on a 50-year-old female patient. All physical findings are normal except for fine brittle hair. Based on the physical findings, which of the following laboratory tests would the nurse expect to be ordered?

Thyroid-stimulating hormone test

A couple is informed that their fetus' condition is incompatible with life after birth. Nurses can best help the couple with their end-of-life decision making by offering them which of the following?

Time and careful explanations

True or False: Diagnoses are prioritized to meet the patient's immediate needs

True

True or False: Diet therapy can be a factor in delaying the onset of full blown AIDS

True

True or False: Do not let the patient know that you are assessing respirations; a patient can alter the rate and depth of breathing

True

Defense Mechanisms

Unconscious reactions that block unpleasant or threatening feelings

The nurse knows that a priority reason for being knowledgeable about biophysical developmental theories is to

Understand how the physical body grows.

A nurse needs to begin discharge planning for a patient admitted with pneumonia and a congested cough. When is the best time the nurse should start discharge planning for this patient?

Upon admission

Examples of urine tests

Urinalysis, urine culture, 24 hour urine

Diaphragm

Use the _______________ of the stethoscope to listen for high pitch sounds, such as breath sounds, *normal heart sounds*, bowel sounds, press it firmly against the body part being auscultated

What are the advantages of taking a tympanic temperature?

Very rapid measurement, 2-5 sec, unaffected by smoking or oral intake of foods or fluids.

A febrile preschool-aged child presents to the after-hours clinic. Varicella is diagnosed on the basis of the illness history and the presence of small, circumscribed skin lesions filled with serous fluid. The nurse documents the varicellar lesions as which type of skin lesion?

Vesicle

Which of these manifestations, if identified in a school-aged child during a routine assessment, should a nurse associate with a possible developmental delay or problem?

Withdrawn demeanor and verbalizes that he has no friends

To ensure an accurate reading with the aneroid sphygmomanometer you are using, you position yourself

Within three feet of the gage eye level with the gage

A nursing student is providing education to a group of older adults who are in an independent living retirement village. Which of the following statements made by the nursing student requires the nursing professor to intervene?

You do not need to worry about getting a sexually transmitted infection at this point in your life."

wound

a break or disruption in the normal integrity of the skin and tissues

fistula

and abnormal passage from an internal organ or vessel to the outside of the body or from one internal organ or vessel to another

Which medications lower BP?

antihypertensive, diuretic, opioid analgesics, or other cardiac medications.

unintentional wound

are accidental; occur from unexpected trauma

Informed consent

before procedure patient needs to be in right mind all invasive tests requiring a contrast medium, sedation, premedication, and a scope require informed consent

proliferation phase

begins 2-3 days of injury and may last up to 2-3 weeks, new tissue is built to fill wound space through action of fibroblasts, capillaries grow across wound, thin layer of epithelial cells form across wound, granulation tissue forms a foundation for scar tissue to develop

beneficence

benefit the patient; balance benefits against risks and harms

orthopnea

changes in breathing when sitting or standing

overflow incontinence

chronic retention of urine, the involuntary loss of urine associated

Medical asepsis

cleanliness and protects items in the environment from contamination most all microorganisms are destroyed clean technique

HIPAA rights

consent notice access amendment accounting for disclosures restriction of disclosure

Vitamin K food sources

dark green leafy vegetables, cauliflower, soybean oil, green tea, synthesis of intestinal bacteria

necrosis

death of tissue

bradypnea

decreased respiratory rate; occurs in some pathologic conditions

parasympathetic stimulation on pulse

decreases heart rate

What can changes in blood pressure cause?

dizziness, lightheadedness, and fainting

Two types of thermometers?

electronic and disposable

when taking BP The reason for removing the outer sweater is to

ensure proper cuff application. prevent falsely high readings. allow for proper inflation of the cuff's bladder. eliminate any muffling of the Korotkoff sounds.

Heatstroke

heat suppresses the function of the hypothalamus due to prolonged exposure to the sun or a high environmental temperature overwhelms the heat loss mechanisms of the body

Reducing fevers

large fluid intake lower room temp increase circulating air remove covers or clothing control or reduce body activity tepid sponge bath, cooling blanket, high calorie diet, or meds

A saturation of less than what percentage is a clinical emergency?

less than 90%

Normal systolic BP

less than <120 mm Hg

Normal diastolic BP

less than <80 mm Hg

Apical rate

listening to heart sounds by using a stethoscope or palpating a peripheral pulse

Diastolic pressure

minimal pressure exerted against the arterial walls at all times

serosanguineous drainage

mix of serum and blood cells; light pink to blood tinged

Interview

more directed than therapeutic communication establish a rapport with the patient before beginning formal questioning active listening use closed end questions to find med history then open ended

Jackson Pratt

most common active suction negative pressure

pulmonary ventilation

movement of air in and out of lungs

Non-shivering thermogenesis occurs primarily in what types of people?

neonates

quadriplegia

paralysis of both arms and both legs

Hematocrit

percentage of red blood cells in the blood, determines blood viscosity.

Pulse site used to assess circulation to the foot?

posterior tibial and dorsalis pedis

glycosuria

presence of sugar in the urine

What does a sphygmomanometer include?

pressure manometer, and occlusive cuff and a pressure bulb with a release valve.

T

temperature

Battery

the action of harming another

Documenting BP includes the patients position and what else?

the extremity

Assault

the threat to harm another

body mechanics

the use of proper body positions to provide protection from the stress of movement and activity

eschar

thick, leathery scab or dry crust that is necrotic and must be removed before the stage can be determined accurately

hemiparesis

weakness of half of the body

Purpose of vital signs

•Baseline indicator of a patient's status •Detect undiagnosed medical problems •Monitor chronic illnesses/disease processes

Palpate skin texture

•Use palms of hands •Healthy skin texture feels smooth and firm, with an even surface

Which of the following statement about religion and spirituality is true?

Spirituality is unique to the individual.

Skin assessment techniques

Inspection, palpation

Normal physical findings in a healthy newborn include

Sporadic motor movements.

What would be required after exposure of a nurse to blood by a cut from a scalpel in the perioperative area?

Testing the patient and offering treatment to the nurse

Where are the Patient Valuables Envelopes sent?

To a place in the MTF wehre patients' valuables are kept locked.

The patient is being admitted to the emergency department with complaints of shortness of breath. The patient has had chronic lung disease for many years but still smokes. The nurse should

Use oxygen cautiously in this patient

Maslows level 2: safety and security needs

both physical and emotional components; being protected from potential or actual harm

A patient says, "You are the worst nurse I have ever had." Which response by the nurse is the most assertive?

"I feel uncomfortable hearing that statement."

In a cardiac dysrhythmia clinic, a patient inquires about using acupuncture to help alleviate stress. The nurse's best answer is which of the following?

"It is acceptable, but do not use electro-acupuncture."

A 68-year-old female asks the nurse if a contraceptive is still necessary. What is the best response by the nurse?

"Let's discuss this further, what is your current level of sexual activity?"

A mother brings her 4-year-old daughter to clinic. She states that she is upset because she has caught her child masturbating. Which response by the nurse is best for calming the mother?

"That is a natural part of development. Your child is exploring and becoming familiar with her body."

The nursing instructor will need to provide further instruction to the student who uses which of these statements when describing the differences between cognitive and psychosocial development in children?

"The school-aged child still requires total assistance in all activities for safety."

Which of these statements would be most appropriate for a nurse to state when assessing an adult patient for growth and developmental delays?

"Would you please describe your usual activities during the day?"

The nurse is teaching a class to pregnant women about common physiological changes during pregnancy. Which statement by the nurse accurately describes these changes?

"You and your partner may experience feelings of uncertainty about assuming the roles of parents."

How do you apply an escort hold?

- Stand next to the patient - Take hold of the patient's left arm abouve the elbow with your right hand - Rotate the patient's arm anteriorly and medially - Ambulate

What are some nursing interventions for a patient with an amputation?

- discuss phantom limb pin before surgery - discuss effects of amputation on body image - Allow and encourage the patient to express his feelings - discuss skin care - ensure physical and occupational therapy

BP documentation

- the blood pressure reading - the site where you measured the blood pressure - any signs or symptoms of blood-pressure alterations - your nursing interventions - the patient's response to care

DO NOT TAKE TEMP

- within 20 minutes of smoking or drinking -Within an hour of exercising vigorously or taking a hot bath

Report vital signs

-Abnormal findings!!!!! -Assessed causes -Associated symptoms like pain, shortness of breath, diaphoresis or bleeding

Capillary refill

-An index of peripheral perfusion and cardiac output -Depress and blanch the nail bed** -Release and note time color returns -Usually vessel refills within a fraction of a second or less than 2 seconds

Palpate for Edema

-Firmly depress skin over tibia (called assessing for pretibial edema) or medial malleolus for 5 seconds -Indentation left behind means "pitting edema" is present

1. A nurse discovers a client lying on the floor. He/she helps him back to bed. What should the nurse do FIRST? 1. File an incident report 2. Restrain the client 3. Notify another nurse 4. Ask a CNA to check on the client 5. Put a bed alarm on the client

1. Correct answer is E. Putting a bed alarm on the client promotes immediate safety of the client. An incident report should be filed second. Berman & Snyder page 75

What are the 5 basic skills invovled in a physical examination?

1. Inspection 2. Palpation 3. Percussion 4. Auscultation 5. Smell

What are the different types of diabetes?

1. Insulin dependent 2. Non-insulin dependent 3. Gestational diabetes

NAVMED 6010/8

A Patient Valuables Envelope

How far away do you position the patient from the Snellen chart?

20 ft

anuria

24-hour urine output is less than 50mL; complete kidney shut down or renal failure

Normal systolic pressure in adults:

90-140mmHg

Mouth mirror

A small round mirror with detachable handle that is used to view the oral cavity

Low Fowler's Position

A supine patient with the head of the bed raised at to 30 degrees

The patient has been bedridden for several months owing to severe congestive heart disease. In determining a plan of care for this patient that will address his activity level, the nurse formulates which of the following nursing diagnoses?

Activity intolerance related to physical deconditioning

Which patient is most in need of a nurse's referral to adoption services?

An infertile couple religiously opposed to artificial insemination

Characteristics of tympanic thermometers:

An infrared sensor measures the temperature fo the tympanic membrane. The tympanic thermometer is frequently used for critically ill patients, infants, and children because it can be used without rousing the patient.

Hypotension

Abnormally low blood pressure; may cause insufficient perfusion of internal organs; systolic vlood pressure reading of 90mmHg or lower

A therapeutic touch practitioner scans the patient's body to identify what?

Accumulated tension

The nurse is presenting an educational session on safety for parents of adolescents. The nurse should include which of the following teaching points?

Adolescents need information about the effects of beer on the liver.

A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for the nurse to understand before she assesses the patient's blood pressure?

Caffeine and smoking can cause false BP elevations.

(1) A registered nurse wishing to practice in a state other than where they are licensed should: 1) Rent a house there to establish residency 2) Contract the other state's Board of Nursing 3) Retake the N-CLEX exam in that other state 4) Open a bank account to establish residency

Answer: 2 - If the states have an interstate compact the nurse will be able to practice in both states. Berman p 56

What are the disadvantages of taking a tympanic temperature?

Cerumen impaction will distort readings and it is contraindicated in patients who have had surgery of the ear or tympanic membrane

Which medication could cause an abnormal drug interaction in a patient taking an antidepressant medication?

Chamomile

(2) A female minor enters a clinic seeking treatment for an STD. The nurse should: 1) Contact the minor's mother for consent 2) Contact the minor's father for consent 3) Obtain consent directly from the minor 4) Tell the minor help isn't available for her

Answer: 3 - Minors can provide consent for themselves in certain situations. Berman p 60

A teen female patient reports intermittent abdominal pain for 12 hours. No dysuria is present. When performing an abdominal assessment, the nurse should

Ask the patient about the color of her stools.

A 15-year-old patient is concerned because her mother wants her to receive the HPV vaccination, but the patient is unsure if she wants it. Which response by the nurse is most therapeutic?

Ask the patient what concerns she may have about the vaccination

When the nurse views the family as context, the primary focus is on the health and development of an individual member existing within a specific environment (i.e., the patient's family). Although the focus is on the individual's health status, the nurse should

Assess how much the family provides the patient's basic needs

Pulse equality

Assess strength bilaterally

The concept of "knowing" the patient comprises both the nurse's understanding of a specific patient and the nurse's subsequent selection of interventions. To know a patient means that the nurse (Select all that apply.)

Avoids assumptions. Focuses on the patient. Engages in a caring relationship.

The patient is being admitted for elective knee surgery. While the nurse is admitting the patient, she will

Begin to develop a discharge plan.

Of the following hearing aids, which interferes the most with wearing eyeglasses and using a phone?

Behind-the-ear hearing aid

B/P

Blood pressure

Where can the blood pressure be taken by auscultation?

Blood pressure can be taken above the antecubital space on the arm or over the mid-thigh on the leg.

Auscultation of abdomen

Bowel sounds originate from the movement of air and fluid through the stomach and large and small intestine "Normal" bowel sounds are high-pitched, gurgling, cascading sounds occurring irregularly from 5-30 times a minute (don't count) Use the diaphragm of stethoscope Auscultation RLQ versus all 4 quadrants

The nurse is caring for an infant and is obtaining the patient's vital signs. The best site for the nurse to obtain the infant's pulse would be the _____ artery.

Brachial

Even when a patient has restraints, what needs to be within reach?

Call bell

A nurse wants to reduce data entry errors on the computer system. Which behavior should the nurse implement?

Chart on the computer immediately after care is provided

The parents of a 14-year-old boy express concern over their child's rebellious behavior. The nurse should plan to respond to the parents' concern by informing them that their

Child's behavior is normal because the adolescent is trying to adjust to his emerging identity.

The nurse is making her first set of rounds in the morning. In doing so, she meets a patient whom she has never worked with before. She introduces herself and explains the plan of the day. She also asks the patient how he normally takes his morning medications, such as before breakfast, after breakfast, or during breakfast. She does this because most of the morning medications in that institution are scheduled by pharmacy for 0900. Getting to know her patient will allow her to

Choose the most appropriate time to give the medication.

Meniere's Disease

Chronic disease of the fluid balance in the inner ear. It has 3 typical symptoms: severe vertigo, tinnitus, and a sensorneural hearing loss. Nausea and vomiting from dizziness can last a few minutes to many hours. It can eventually lead to total hearing loss.

The nurse is caring for a group of medical-surgical patients. The unit has been notified of a fire on an adjacent wing of the hospital. The nurse quickly formulates a plan to keep the patients safe. Which of the following should the nurse implement? (Select all that apply.)

Close all doors. Note evacuation routes. Note oxygen shut-offs. Await direction from the fire department.

Providing "presence" involves "being there" and "being with." What does this involve?

Closeness and a sense of caring

Urine inspection

Color, clarity, odor

Unconsciousness

Condition in which there is a depression of cerebral function ranging from stupor to coma. Stupor-person can be aroused only briefly and only by vigorous external stimulation. Coma-eyes do not open upon stimulation, absence of comprehensible speech,, and failure to obey commands

A patient who has had several sexual partners in the past month expresses a desire to use a contraceptive. Which contraceptive method should the nurse recommend?

Condom

Inspection of abdomen

Contour, symmetry

Scaling of the scalp accompanied by itching is known as

Dandruff.

The patient applies sequential compression devices after going to the bathroom. The nurse checks the patient's application of the devices and finds that they have been put on upside down. Which of the following nursing diagnoses will the nurse add to the patient's plan of care?

Deficient knowledge

The emergency department has been notified of a potential bioterrorist attack. The nurse assigned to the department realizes that the most important task for safety in this situation is to

Determine the biologic agent and manage all patients using Standard Precautions.

Whenever you are working with moving a patient in something with wheels, what should you always do?

Lock the wheels while transferring and unlock them when the patient is already in the wheelchair

A teen patient is tearful and reports locating lumps in her breasts. Other history obtained is that she is currently menstruating. Physical examination reveals soft and movable cysts in both breasts that are painful to palpation. The nurse also notes that the patient's nipples are erect, but the areolae are wrinkled. The next nursing step is which of the following?

Discuss fibrocystic disease as the likely cause.

The nurse is caring for a school-aged child who has injured his leg after a bicycle accident. To determine whether the child is experiencing a localized inflammatory response, the nurse should assess for which of these signs and symptoms?

Edema, redness, tenderness, and loss of function

Pyrexia (Fever)

Elevated body temperature

An argument for passing "universal health care" legislation is that it would help fulfill the Healthy People 2020 goal of

Eliminating health disparities in America.

In caring for the patient's spiritual needs, the nurse understands that

Establishing presence is part of the art of nursing.

What do you do when you suspect a vision problem in a patient?

Evaluate the vision with the Snellen chart

The nurse is preparing to assess the blood pressure of a 3-year-old. How should the nurse proceed?

Explain to the child what the procedure will be

An older adult patient in no acute distress reports being less able to taste and smell. What is the nurse's best response to this information?

Explain to the patient that diminished senses are normal findings.

Personal habits influence on bowel elimination

Fear of using public restrooms, etc.

Heart assessment

Heart sounds: S1, S2 Rhythm: regular or irregular

The nurse is changing linens for a postoperative patient and feels a stick in her hand. A nonactivated safe needle is noted in the linens. This scenario would indicate that the nurse may be at risk for

Hepatitis B.

What can you do to prevent constipation in inactive patients?

High fiber diet, increase fluid intake, privacy when eliminating, encourage a regular time for elimination, nurse or coprsman/tech may need to remove fecal impaction.

A nurse is standing beside the patient's bed. Nurse: How are you doing? Patient: I don't feel good. In this situation, which element is the feedback?

I don't feel good.

Which of these patient statements is the most reliable indicator that an older adult has the correct understanding of health promotion activities?

I still keep my dentist appointments even though I have partials now."

Presbyopia

Impaired near vision in middle-age and older adults, caused by loss of elasticity of the lens and associated with the aging process

A patient has trouble speaking words, and the patient's speech is garbled. Which nursing diagnosis is most appropriate for this patient?

Impaired verbal communication

Who must you apply an escort hold to?

Impulsive patients

When is abuse most commonly seen?

In children and the elderly, but abuse can occur at any age

B. 30

In the healthy adult, urine output should be ______ mL or more per hour. A. 40 B. 30 C. 20 D. 10

Teeth

Indication of the person's general health

What is the physical exam made up of?

Individual assessments for each body system

Who are Geriatric charis used by?

Individuals with mobility disabilities

The nurse is caring for a patient who has cultured positive for Clostridium difficile. Which of the following nursing actions would be appropriate given this organism?

Instruct assistive personnel to use soap and water rather than sanitizer to clean hands.

How does the tympanic thermometer provide an accurate reading?

It provides an accurate core temperature reading because eardrum is close to the hypothalamus

The patient has quit smoking and has been smoke free for the past 2 years. Of the following stages, which best fits her current stage of change?

Maintenance

Radial pulses

Medial to the radius at the wrist

Palpate Skin Mobility and Turgor

Mobility is the ease of the skin to rise; turgor is its ability to return to place promptly when released

When focusing on temperature regulation of newborns and infants, the nurse understands that

Newborns need to wear a cap to prevent heat loss.

A number of factors influence a patient's personal preferences for hygiene. Because of this, it is important for the nurse to realize that

No two individuals perform hygiene in the same manner.

The nurse asks a patient where the pain is, and the patient responds by pointing to the area of pain. Which form of communication did the patient use?

Nonverbal

OLD CARTS

Onset Location Duration Characteristics Aggravating and Alleviating Factors Related Symptoms Treatment Severity

Paraplegia

Paralysis characterized by motor or sensory loss in the lower limbs and trunk

Hemiplegia

Paralysis of one side of the body

Quadriplegia

Paralysis of the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord

An active lifestyle is important for maintaining and promoting health. In developing an exercise program, the nurse understands that

Physical activity enhances functioning of all body systems.

The patient is restless with a temperature of 102.2° F (39° C). One of the first things the nurse should do is

Place the patient on oxygen.

If the patient is supine, how should you position their arm?

Place the patient's forearm straight alongside the body or across lower chest or upper abdomen

The nurse is caring for a patient who is terminally ill with very little time left to live. The patient states, "I always believed that there was life after death. Now, I'm not so sure. Do you think there is?" The nurse states, "I believe there is." The nurse has attempted to

Provide hope.

P

Pulse

Closed Reduction

Realigning a broken bone by manual manipulation without incisions

The patient is confused, is trying to get out of bed, and is pulling at the intravenous infusion tubing. These data would help to support a nursing diagnosis of

Risk for injury.

A confused patient is restless and continues to try to remove his oxygen and urinary catheter. What is the priority nursing diagnosis and intervention to implement for this patient?

Risk for injury: Prevent harm to patient, use restraints if alternatives fail.

External rotation

Rotation away from the center of the body

When comparing physical growth patterns between school-aged children and adolescents, the nurse notes that

Secondary sex characteristics usually develop during the adolescent years.

After comparing appropriate play activities for infants and preschool children, the nurse should appropriately offer which of the following activities to an infant?

Set of plastic stacking rings

The nurse is observing his 2-year-old hospitalized patient in the playroom. The nurse is most likely to observe the child

Sitting beside another child while playing with blocks.

The nurse is providing an education session to an adult community group about the effects of smoking. Which of the following is the most important point to be included in the educational session?

Smoking affects the cilia lining the upper airways in the lungs.

Psychological stress influence on bowel elimination

Stress increases peristalsis (diarrhea and distention), some diseases of the GI tract are exacerbated (made worse by) stress (i.e. irritable bowel syndrome) depression slows it down, constipation.

During an annual gynecological examination, a college student discusses her upcoming college break at a tropical location. After the student receives an oral contraceptive prescription, the nurse identifies the importance of skin cancer prevention education by discussing which evidence-based prevention health topic?

Taking extra precautions in the sun secondary to the prescription

The nurse has had three patients die during the past 2 days. Which approach is most appropriate to manage the nurse's sadness?

Talking with a colleague or writing in a journal

Axillary precautions

Used on newborns not core accurate

Ophthalmoscope

Used to check pupillary reaction to light and to inspect the inner eye. It may be portable or wall mounted

What organizations have developed strict regulations regarding the use of restraints and documentation?

The Joint Commission (TJC) Centers for Medicare and Medicaid Service (CMS)

What is used to record the skin temp of distal fingers or toes presence and quality of distal pulse, movement, sensation in fingers and toes, and color of fingers and toes?

The Neurological Circulation Check Sheet

A nurse in a long-term care setting that is funded by Medicare and Medicaid is completing standardized protocols for assessment and care planning and for meeting quality improvement within and across facilities. Which task did the nurse just complete?

The Resident Assessment Instrument/Minimum Data Set

What does the procedure used to transfer a paitent to a wheelchair depend on?

The patient's ability to assist

150-200 mL

There is a desire to urinate with _______________ urine in bladder

True or False: Sitting on a bedpan is extremely uncomfortable

True

30 mL

Urine output less than _______________ per hour indicates possible circulatory, blood volume, or renal alterations

A patient is aphasic, and the nurse notices that the patient's hands shake intermittently. Which nursing action is most appropriate to facilitate communication?

Use a picture board.

When would you usually give a patient a back massage?

Usually following the patient's bath

The nurse is teaching a patient about contact lens care. The patient has plastic lenses, so the nurse instructs the patient to

Wash and rinse lens storage case daily.

The patient had a colostomy placed 1 week ago. When approached by the nurse, the patient and his wife refuse to talk about it and refuse to be taught about how to care for it. The nurse realizes that the patient and his wife are in which stage of adjustment?

Withdrawal

According to some developmental theorists, intellectual development and moral development differ between men and women. What did Gilligan propose?

Women struggle with issues of care and responsibility.

bradypnea

an abnormally slow respiratory rate, usually fewer than 12 breaths per minutes in an adult

wellness

an active state of being healthy by living a lifestyle promoting good physical, mental, and emotional health

ABCs

airway breathing circulation

Femoral

below inguinal ligament, midway between symph and ASIS

Nutrition and wound healing

constant supply of protein is needed to meet the body's need to build and replace tissue and cells

efferent

creates effect and goes to body part from brain

Stridor

croaking or crowing sound heard when partial obstruction of the upper passages

Temporal artery measurements detect the temperature of which blood flow?

cutaneous blood flow

chronic wound

do not progress through stages of healing; healing impeded

Computer charting

do not share pass codes never walk away from without logging off first

laxatives

drugs that induce emptying of the intestinal tract

nurse practice acts

each state has its own; protects public with legal scope of nursing practice

Areas particularly susceptible to frostbite?

earlobes, tip of the nose, fingers and toes.

diaphoresis

excessive sweating

supination

face up; laying on your back (spine)

Effects BP arm above heart

falsely lower BP

What part of the body controls body temperature?

hypothalamus

physiological measures that indicate pain

increased blood pressure and pulse

frequency

increased incidence of voiding

Respiration influenced by exercise

increases

Why would hypothermia be intentional?

induced during surgical or emergency procedures to reduce metabolic demand and the need of the body for oxygen

Injury to the brain stem does what to respiratory rate?

inhibits respiratory rate and rhythm

When taking temp rectally

insert the probe about an inch and a half into the patient's anus.

The direct/invasive arterial BP method

insertion of a thin catheter into an artery

At a normal slow heart rate, what are the classic characteristics of S1 that you will hear through your stethoscope upon listening via the apical site?

low pitched and dull "lub"

Angiotensin-converting enzyme (ACE) inhibitors

lower blood pressure by blocking the conversion of angiotensin I and angiotensin !!, preventing vasoconstriction; reduced aldosterone production and fluid retention, lowering circulating fluid volume.

Diuretics

lowers blood pressure by reducing resorption of sodium and water by kidney, lowering circulating volume.

Oxygen safety

no smoking check electrical devices for frayed wires avoid flannel do not use oils, chapstick, alcohol, vaseline securely strapped oxygen cylinders monitor for skin irritation from cannula assess for dry mucous membranes indicating a need for humidification to prevent tissue breakdown 2 to 3L/min

Is there an advantage over antipyretic medications vs therapies?

no; antipyretic medication is the best method

Temporal

over temporal bone of the head, above and lateral to eye

dysuria

painful or difficult urination

maslow hierarchy of needs

provides a framework for nursing assessment and for understanding the needs of patients at all levels; many nursing interventions are aimed at meeting patients' basic human needs

What two mechanisms can affect thermoregulation?

psychological and behavior mechanisms

ICU uses which sites for core temperatures?

pulmonary artery, esophagus, and urinary bladder.

What classifications should be documented for pulse and what is their rating?

pulse strength (4) full or strong (3) normal and expected (2) diminished or barely palpable (1) absent (0)

Patients at high risk for heat stroke

those with cardiovascular disease, hyperthyroidism, diabetes, or alcoholism.

diuretics

used to increase urinary output

What three things does respiration involve?

ventilation, diffusion and perfusion.

A stooped or slumped position impairs:

ventilatory movement

BP controlled by 5 factors

•Cardiac Output •Peripheral vascular resistance •Volume of circulating blood •Viscosity of blood •Elasticity of vessel walls

Evaluate after medication

•Chart med given •Any difficulties •Patient response •Re-check pain in 1 hour •Chart effectiveness •May need additional med or change

Factors affecting body temp

•Circadian rhythms •Age and gender •Environmental temperatures •Thermoregulatory center in hypothalamus

Elements of a skin assessment

•Color and Tone •Temperature •Moisture •Texture •Thickness •Integrity •Boney Prominences •Mobility & Turgor

Inspect skin integrity

•Epidermis and/or dermis is intact

Acute pain

•Intense and of short duration •Usually lasts less than 6 months - tissue damage

Types of Pain

•Mild or severe •Chronic or acute •Intermittent or intractable •Burning, dull, or sharp •Precisely or poorly localized •Referred •Visceral •Somatic •Cancer?

Pulse Assessment

•Rate (Count beats) •Amplitude (Strength) •Rhythm (Regular/Irregular)

The nursing student correctly explains health promotion teaching points for parents of toddlers when she states

"Setting consistent, firm limits will help the child cope with the frustration of learning self-control."

Nurse Practice Acts

-define legal scope of nursing practice -create state board of nursing to make and enforce rules and regulation -define important terms and activities in nursing, including legal requirements and titles for RNs and LPNs - established criteria for the education and licensure of nurses

phases of wound healing

-hemostasis-vessels constrict and clotting begins -inflammatory-white blood cells move to wound -proliferation-granulation tissue is formed -maturation-collagen is remodeled, forms scar

goals of nursing research

-improve care in clinical setting -study ppl and nurse process: education, policy development, ethics, nursing history -develop greater autonomy and strength as a profession -provide evidence-based nursing practice

wound complications

-infection -hemorrhage -dehiscence(wound separates) and evisceration(protrusion) -fistula formation

minerals

-inorganic elements found in all body fluids and tissues -some function to provide structure in the body, others help regulate body processes -contained in ash that remains after digestion -macrominerals include calcium, phosphorus, magnesium -microminerals include iron, zinc, manganese, and iodine

fats

-insoluble in water and blood -composed of carbon, hydrogen, and oxygen - 95% of lipids in diet are triglycerides -most animal fats are saturated -most vegetable fats are unsaturated -digestion occurs largely in small intestine -most concentrated source of energy in diet -RDA not established, 20-35% total calorie intake

nursing process for bowels

-inspection -auscultation -percussion -palpation (deep palpation is performed by advanced medical personal)

assessing blood pressure

-listening for korotkoff sounds w/ stethoscope -first sound is systolic -change or cessation of sound occurs: diastolic pressure - brachial artery and popliteal artery are commonly used

For each hour of exercise in hot conditions __ to __ of body fluid can be lost in sweat

1/2-2 mL

During a normal relaxed breath, a person inhales how much air?

500 mL

How much blood in an adult does a heart normally pump per minute

5000 mL

Hyperglycemia

A clinical syndrome of diverse causes with high levels of serum glucose (e.g., high sugar in the blood)

Comfort

A condition of ease or well-being

A dying patient with liver and renal failure requires pain medication. The nurse anticipates that the medication dose will be

A decreased dose from milligrams per kilogram levels.

Mental Illness

A distrubance in the ability to cope or adjust to stress; behavior and function are impaired

Diabetes

A distrubance of the metabolism of carbohydrates and the use of glucose by the body

Fluid balance

A dynamic interplay of three processes: fluid intake and absorption, fluid distribution, fluid output; important because it maintains the health and functions of all body systems

Tissues

A fine, very thin fabric, such as gauze, that is used during a physical exam to wipe off instruments; may also be used by patients to remove excess lubricant from membranes after the examination

Plaster

A pasty composition that hardnes on drying, which is used in strips for casting

What is a patient's medical history used for?

A patient medical history is used to: - establish patient contact and rapport - provide a focal point for the physical assessment - aid in ordering appropriate tests - institute appropriate treatment

Which of the following concepts are important to utilize when evaluating orders for restraints? (Select all that apply.)

A physician's order is required for restraint and includes a face-to-face evaluation. Orders are time limited. Restraints are not ordered prn (as needed). It should be specified that restraints are to be removed periodically. Restraint orders are time dated and signed by the physician.

Sim's Position

A position in which a patient is in a side-lying position on either side, with the top leg glexed up toward the abdomen; used to assess the rectum and vagina

Lateral Recumbent Position (Sims')

A position in which the patient is lying on the side in which one leg is straight and the top leg is flexed at the hip and knee, resting against a surface

Trendelenburg Position (shock position)

A position in which the patient's feet and legs are higher than the head

Flexion

A position that is made possible by the joint angle decreasing; moving of the joint toward the body

The nurse suspects the possibility of a bioterrorist attack. Which of the following factors is most likely related to this possibility? (Select all that apply.)

A rapid increase in patients presenting with fever or respiratory or gastrointestinal symptoms Lower rates of symptoms among patients who spend time primarily indoors Large number of rapidly fatal cases of patients with presenting symptoms Patients with symptoms all coming from one location in the area

Percussion/Reflex hammer

A rubber hammer ued to assess reflexes, which are automatic responses to a given stimulus

The home health nurse is teaching a patient and family about hand hygiene in the home. The nurse is sure to emphasize washing hands before

And after treatments.

Pressure Point

Areas on the skin where the cast has been indented or pushed in what may cause sores and skin breakdown

The nurse is caring for a patient who suddenly becomes confused and tries to remove an intravenous infusion. The nurse begins to develop a plan to care for the patient. Which nursing intervention should take priority?

Assess the patient.

The nurse is caring for a patient who has been diagnosed with a terminal illness. The patient states, "I just don't feel like going to work. I have no energy, and I can't eat or sleep." The patient shows no interest in taking part in his care. The nurse should

Assess the potential for suicide and make appropriate referrals.

The patient requires temperatures to be taken every two hours. Which of the following cannot be delegated to nursing assistive personnel?

Assessing changes in body temperature

During a routine physical examination of a 70-year-old patient, a blowing sound is auscultated over the carotid artery. The nurse notifies the medical provider of the unexpected physical finding known as

Bruit.

A hospital is using a computer system that allows all health care providers to use a protocol system to document the care they provide. Which type of system/design will the nurse be using?

Critical pathway design

To promote parent-child attachment with a healthy newborn, what should the nurse do?

Encourage close physical contact as soon as possible after birth.

Of the following developmental changes, which are most commonly associated with the elderly? (Select all that apply.)

Fungal nail infections Less resilient skin and bruising Dry, itchy skin

The patient presents to the clinic with a family member. The family member states that the patient has been wandering around the house and mumbling. What is the first assessment the nurse should do?

Introduce self and ask the patient her name.

The nurse is providing care to a patient who is bedridden. To prevent fatigue, the nurse raises the height of the bed. The nurse understands that balance is maintained by raising the bed to

Prevent a shift in the nurse's base of support.

The nurse is caring for a patient who has just delivered a neonate. The nurse is checking the patient for excessive vaginal drainage. It is important for the nurse to utilize _____ Precautions.

Standard

To promote health

State of optimal functioning or wellbeing. not just absence of disease

The nurse is completing discharge education for the patient regarding home medications. Which patient behavior is an indication that the patient understands the directions regarding the antibiotic medication?

The patient states, "I will finish the antibiotic in ten days."

What is Hygiene?

The practice of cleanliness and affects a patient's comfort, safety and well-being.

A nurse preceptor is working with a student nurse. Which behavior by the student nurse will require the nurse preceptor to intervene?

The student nurse shares patient information with a friend.

Scale

Used to obtain a patient's weight, and must be calibrated to zero before use for accuracy

1. The process by which an individual slowly develops a new cultural identity by resembling the members of the prevailing group is known as: a. assimilation b. acculturation c. mingling d. socializing

answer: a rationale: Assimilation is to become like the members of the dominant culture. (b) Acculturation occurs when people integrate traits from other cultures. (b & c) Neither of these answers fit the description. (Berman text, p. 319)

When a patient takes medication that affects the HR, which pulse is the most accurate for pulse assessment?

apical

Maladaptive behavior

behavior used to cope with feelings and situations that are considered inappropriate to society. Patients exhibiting maladaptive behavior may be a danger to themselves or others. This includes abuse and self abuse which are a negative action carried out on one's self or others. These types of behaviors include child abuse, spousal abuse, suicide, and alcohol or drug abuse.

What time of day is your BP highest?

between 10 AM and 6 PM

What are common tendon reflex spots?

biceps, triceps, patellar, and Achilles

occult blood in stool

blood that is hidden in the specimen or cannot be seen on gross examination

cleaning a pressure ulcer

clean w/ each dressing change, gentle motions (patting), use 0.9% normal saline solution to irrigate and clean, report any drainage or necrotic tissue

serous drainage

clear and watery

Rhonchi

coarse, low pitched, rattling sound caused by secretions in the larger air passages

Kegal exercises

concentrate on stopping flow when voiding by tightening pelvic muscles hold for a count of 10 seconds relax for 10 seconds 3x a day with 15 repetitions try to work up to 25 repetitions will take at least 2 weeks to notice a difference

Opioid, analgesics, general anesthetics, and sedative hypnotics does what to the respiration rate?

depresses it

Why are older adults sensitive to temperature extremes?

deterioration, poor vasomotor control, reduced amounts of subcutaneous tissues, reduced sweat gland activity, and reduced metabolism.

constipation

dry, hard stool; persistently difficult passage of stool; incomplete passage of stool

reflex incontinence

experience emptying of the bladder w/o sensation of the need to void

Pulse site used to assess character of pulse during psychological shock or cardiac arrest when other pulses are not palpable; used to assess status of circulation to the leg

femoral

Intermittent fever

fever spikes interspersed with usual temperature levels

friction

occurs when two surfaces rub against each other

open drainage system

penrose drain; promotes drainage passively

Maslow's Hierarchy of Needs

physiologic, safety and security, love and belonging, self-esttem, and self actualization

Disposal of sharps

placed directly into biohazard container immediately replace when container is two thirds full

Steps to prevent med orders

plan ahead and do not rush prepare in a distraction free environment follow the 6 rights do not administer if drug is not clearly labeled check any unfamiliar drug order determine wether patient is receiving more than one drug with the same action ask another nurse to double check review MAR check order 3 times always identify patient before admin. with wristband, MAR, and ask of allergies check each drug at bedside with patients MAR document only after med has been given do not leave med. at bedside unattended familiarize the patient with the shape, color of drug obtain a complete drug history if a med error occurs, always report it insulin is always double checked

proteinurea

protein in the urine; indication of kidney disease

Pulses are assumed to be taken where unless otherwise indicated?

radial

Ostomy care

wash skin, skin barrier paste solution instilled into colon via stoma

The nurse is instructing the student nurse regarding discharge teaching and medications. Which response by the student would indicate that learning has occurred?

"I need to be precise when teaching a patient about Zyprexa (olanzapine) and Zyrtec (cetirizine)."

The nurse knows that the mother of a newborn understands associated health risks to her baby when she states

"I need to remind anyone who wants to hold the baby to wash their hands."

The nurse who is teaching a parent about developmental needs of the infant knows that the parent has verbalized understanding of a infant's developmental needs when he states

"My child will probably enjoy playing peek-a-boo."

A nurse is a preceptor for a nurse who just graduated from nursing school. When caring for a patient, the new graduate nurse begins to explain to the patient the purpose of completing a physical assessment. Which of the following statements made by the new graduate nurse requires the preceptor to intervene?

"Nursing assessment data are used only to provide information about the effectiveness of your medical care."

Converting F to C

(F-32) x 5/9

Average oral/tympanic temp

37 C 98.6 F

oral temperature for healthy adult

37.0 C, 98.6 F

Average rectal temp

37.5 C 99.5 F

How much of an increase in body temperature does shivering create?

4-5 times greater than normal.

WBC

4.5 to 11.0 million

Hypertension is higher in which ethnic population?

African americans

The staff is having a hard time getting an older adult patient to communicate. Which technique should the nurse suggest the staff use?

Allow the patient to reminisce.

The nurse is providing a complete bed bath to a patient using a commercial bath cleansing pack (bag bath). In doing so, the nurse should

Allow the skin to air dry.

The patient has contracted a urinary tract infection while in the hospital. Which of these actions would most likely increase the risk of a patient contracting a urinary tract infection (UTI)?

Allowing the drainage bag port to touch the graduated receptacle

Medical History:

An account of the events of a patient's life concerning their mental, emotional, and physical health

The home health nurse is caring for a patient in the home who is using an electrical infusion device. While visiting the patient, the nurse smells smoke and notices an electrical fire started by this device. The nurse uses the fire extinguisher and fights the fire when (Select all that apply.)

An exit route is available. The correct extinguisher is available. All occupants have left the home. Fire department has been called.

Cataracts

An increased opacity of the lens, which blocks lights rays from entering the eye. Starts to develop slowly after age 35 and is one of the most common eye disorders in older adults age 65 and above

Otitis Media

An infection of the middle ear. Symptoms may include earache or ear fullness, hearing loss, or fever. Chronic otitis media can damage the tympanic membrane or the ossicles and permanent hearing loss can occur. With acute otitis media, fluid builds up in the ear causing pain and hearing loss

Pain

An unpleasent sensation, occuring in varying degrees of severity as a consequence of injury, disease, or emotional disorder

Bounding Pulse

An unusually strong pulse

A student nurse in their clinical makes a mistake and it was later found that the act was negligent. Who may be held responsible? Select all that apply. 1. The student 2. The hospital or agency 3. The educational institution 4. The nurse that the student was following

Answer 1, 2, 3. The nursing student is responsible for their actions and is not practicing under another nurse's license. The hospital or agency and the educational institution will also be held potentially responsible. Berman pg. 75

A nurse is charting on a patient's record. Which action is most accurate legally?

Charts legibly

A patient admits that he knew for several months that he had an STI but did not report it. The nurse knows that this is because many people with STIs

Are hesitant to admit they contracted an STI.

3) The nurse has been asked by the head nurse to work a third double shift during one week. The head nurse begs the exhausted nurse to stay until midnight. What should she respond: a) Say yes, otherwise leaving would be considered abandonment. b) Say no and tell her to find someone else who is less tired to work. c) Say no, but tell her that you can stay until the next nursing shift begins. d) Say yes, but ask for the weekend off to compensate the overtime work.

Correct Answer: C Rationale: It is vital that nurses attend to their own needs, because caring for self is central to caring for others. Self-care is important for professional nurses. (Berman, 8th ed, Ch 25, p. 452)

F

Fahrenheit

True or False: A newly applied cast will be dry.

False: A newly applied cast will be WET

True or False: A physical examination or assessment should be performed the same for each patient.

False: A physical examination or assessment should be designed for the patient's needs

True or False: Although most vital sign values will fall within these norms and ranges, the patients overall condition must be considered so, not all values outside these ranges must be reported.

False: ALL values outside these ranges must be reported

True of False: Inactivity, whether minimal or prolonged, can affect the normal funciton of some body systems.

False: Inactivity, whether minimal or prolonged, can affect the normal function of EVERY body system.

True or False: When using a Snellen chart, instruct the patient to read the chart to the largest line in print possible

False: Instruct the patient to read the chart to the SMALLEST line in print possible

True or False: Measuring for crutches can only be done while the patient is standing

False: Measuring for crutches can be done with the patient SUPINE or STANDING

What measurement represent the overall crutch length? (laying down)

From the anterior fold (crease of armpit) to a pint approximately 6-8 inches lateral to the patient's heel

The nurse is preparing a smoking cessation class and is amazed at how many people still smoke even with the information on lung cancer so readily available. She believes that her class will convert many smokers to nonsmokers once they get all the latest information. The nurse is a believer in which of the following health care models?

Health Belief Model

The patient is admitted with shortness of breath and chest discomfort. Which of the following laboratory values could account for the patient's symptoms?

Hemoglobin level of 8.0

A patient asks about the new clinic in town that is staffed by allopathic and complementary practitioners. The nurse recognizes that the patient is most likely asking about which clinic?

Integrative medical clinic

According to Piaget's theory of cognitive development, the nurse should allow a hospitalized 4-year-old patient to safely play with

The blood pressure cuff.

Which of these manifestations, if identified in a 6-year-old patient, should the nurse associate with a possible developmental delay based on Piaget's theory?

The child continues to suck his thumb

Bell

Use the _____________ of the stethoscope to listen to low pitched sounds such as *abnormal heart sounds*, hold it lightly on the body part being auscultated

The nurse is providing an educational session for a group of preschool workers. The nurse reminds the group that the most important thing to do to prevent the spread of infection is to

Wash their hands between each interaction with children.

The nurse is preparing to provide a complete bed bath to an unconscious patient. The nurse decides to use a bag bath. She does this for which of the following reasons?

Washbasins can harbor gram-negative organisms.

Sim's position

a side-lying position with the lowermost arm behind the body and the uppermost leg flexed

In what part of obtaining a medical history do you ask, "How do you cope with stress?"?

Obtaining a psychosocial history

In what part of obtaining a medial history do you ask, "Do you live alone?"?

Obtaining an environmental history

Routine admission

Occurs when an illness or a health problem is not an immediate threat to the patient's life. The patient, or a family member when the patient is a minor or unable to communicate, is interviewed to obtain demographic information

To promote physical well-being and socialization in an older adult, what should the nurse realize?

Older adults may have a functional purpose in social arenas

The patient presents to the clinic with dysuria and hematuria. How does the nurse proceed to assess for kidney inflammation?

Percusses posteriorly the costovertebral angle at the scapular line

What can you do to prevent contractures and atrophy in inactive patients?

Range of motion exercises, isometric exercises, weight bearing exercises, and activities of daily living.

The nurse is caring for a male patient newly diagnosed with type 1 diabetes mellitus. The patient is not adjusting well to the diagnosis and is refusing to learn how to self-inject insulin. The patient's wife is critical of the patient's refusal to learn; a small argument ensues, and the wife leaves, stating, "I'll be back later when I cool off." What should the nurse do?

Realize that the wife will be an important part of therapy.

The nursing assistive person is taking vital signs and reports that a patient's blood pressure is abnormally low. The nurse should

Retake the blood pressure herself and assess the patient's condition.

The nurse is providing perineal care to an uncircumcised male patient. When providing such care, the nurse should

Retract the foreskin and return it to its natural position when done.

Urinary elimination

Rids body of urinary wastes; if it doesn't happen, all organ systems are affected eventually

Four Quadrants of the abdomen

Right upper, left upper, right lower, left lower

The patient is admitted to the emergency department of the local hospital from home with reports of chest discomfort and shortness of breath. She is placed on oxygen, has labs and blood gases drawn, and is given an electrocardiogram and breathing treatments. What level of preventive care is this patient receiving?

Secondary prevention

Which critical thinking standards should the nurse use to ensure sound effective communication with patients? (Select all that apply.)

Self-confidence Humility Independent attitude

The nurse using critical thinking to enhance communication with patients is one who

Self-examines personal communication skills.

Semi-Fowler's Position

Semi-upright sittin gposition with the head of the bed raised to 45 degrees

The female nurse is caring for a male patient who is uncircumcised but not ambulatory, although he has full function of arms and hands. The nurse is providing the patient with a partial bed bath. Perineal care for this patient

Should be done by the patient.

A parent calls the school nurse with questions regarding the recent school vision screening. Snellen chart examination revealed 20/60 for both eyes. Considering the visual acuity results, the nurse informs the parent that the child

Should have an optometric examination

The nurse should instruct the parents of an adolescent about which of the following health concerns? (Select all that apply.)

Signs of substance abuse Suicide prevention Safe sex practices Pregnancy

What are physical and psychological aspects of pain (signs and symptoms)?

Signs: elevated P, BP, and RR. Dilated pupils, perspiration, muscle tension, nonverbal communication. Symptoms: verbal complaint, constant focus on pain, agitation or depression, refusal of treatment that may cause pain, change in normal activity.

What position should the patient be in when taking a rectal temperature?

Sim's position with upper leg flexed

Factors that affect blood pressure

Smoking in the last 15-30 mins Drinking in the last half hour Anxiety/stress Ask the patient what their usual blood pressure is

How long should you soak the nails of a patient during foot and nail care?

Soak the nails 10-20 min in warm, soapy water

Medication influence on bowel elimination

Some slow peristalsis (opiods) resulting in constipation, antibiotics decrease intestinal flora often resulting in diarrhea, Some medications are used to purposefully promote defecation (laxatives or cathartics) or slow it i.e. with diarrhea (antidiarrheal agents).

A nurse uses SBAR during hand-offs. The purpose of SBAR is to

Standardize communication.

steps in implementing EBP

Step 1: ask a question about a clinical area of interest or an intervention Step 2: collect the most relevant and best evidence Step 3: Critically appraise the evidence Step 4: integrate the evidence w/ clinical expertise, patient preferences, and values in making a decision to change Step 5: evaluate the practice decision or change

The circulating nurse in the perioperative area is observing the surgical technologist while applying a sterile gown and gloves to care for a patient having an appendectomy. Which of the following behaviors indicate to the nurse that the procedure has been done correctly? (Select all that apply.)

Surgical technologist touches only inside of gown. Surgical technologist slips arms into arm holes simultaneously. Surgical technologist uses hands covered by sleeves to open gloves. Fingers are extended fully into both gloves.

maturation phase

final stage of healing, begins 3 weeks to 6 months after injury, collagen remodeled, new collagen tissue is deposited, scar becomes thin white line

origination of the word "nurse"

from the latin word "nutrix" meaning to nourish

Signs and sx of heat stroke

giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances, and even incontinence

Stage 2 hypertension in adults

greater than or equal to 160 over greater than or equal to 90

Normal Sp02

greater than or equal to 95%

Brachial

groove between biceps and tricep muscles at antecubital fossa

tachypnea

increased respiratory rate; may occur in response to increased metabolic rate

Abnormal blood cell function does what to the respiratory rate?

increases

Decreased hemoglobin does what to the respiratory rate?

increases

Increased altitude does what to respiratory rate?

increases

When hematocrit rises and blood flow slows what happens to arterial BP?

increases

Respiration influenced by anxiety

increases as a result of sympathetic stimulation

sympathetic stimulation on pulse

increases heart rate

Cardiac cath

introduction of a catheter into the heart chambers to confirm a diagnosis or to evaluate the extent of disease determines function of heart, valves, coronary circulation, oxygen concentration at different sites, pressure, and cardiac output. consent form and must have a physical assessment and history before exam NPO for 6 hours surgical procedure observed by fluoroscopy and monitored by EKG post cath, bed rest for 2 to 12 hours may use leg approach

Shivering

involuntary body response to temperature differences in the body.

isokinetic exercise

muscle contraction with resistance

isometric exercise

muscle contraction without shortening

isotonic exercises

muscle shortening and active movement

Maslows level 4: self-esteem needs

need for a person to feel good about oneself, to feel pride and a sense of accomplishment, and to believe that others also respect and appreciate those accomplishments; positive self-esteem facilitates the person's confidence and independence

The mother of a recently murdered child keeps the child's room intact. Family members are encouraging her to redecorate and move forward in life. The visiting nurse recognizes this behavior as _____ grief.

normal

eupnea

normal, unlabored breathing, one respiration to four heartbeats

OSHA

occupational safety and health administration improve the work environment in areas that affect workers health and safety protects nurses regulations for PPE, fire, handling infectious materials, isolation procedures

Fever or pyrexia

occurs because heat loss mechanisms are unable to keep pace with excessive heat production, resulting in abnormal rise in body temperature

open wound

occurs from intentional and unintentional trauma; skin surface is broken, providing a portal of entry for microorganisms

Maslows level 3: love and belonging needs

often called higher-level needs; understanding and acceptance of others in both giving and receiving love; feeling of belonging; unmet needs produce loneliness and isolation

When would you give a certain cardiac drug?

only within a range of a pulse or BP values

prone position

person lies on the abdomen with the head turned to the side; the body is straight in the prone position because shoulders, head, and neck are in erect position, arms are easily placed in correct alignment w/ the shoulder girdle, hips, knees can be prevented from flexing or hyperextending

trauma

physical injury

human dimensions that compose the whole person

physical, intellectual, environmental, spiritual, sociocultural, and emotional

Transfer

physician and family must be notified before transferring, recorded in nursing notes, a ISBAR report should be given to the receiving nurse, all patients equipment should be initialed with a piece of tape to avoid loss of patients belonging

Suctioning

propose is to maintain a patent airway by removing secretions infants, unconscious patients, gravely debilitated, or those with a ineffective cough suction pressure is set at 80 to 120 mm Hg

Easiest pulse to palpate?

radial artery

acute pain

rapid in onset, varies in intensity and duration, protective in nature

suppression

stoppage of urine production; normally, the adult kidneys produce urine continuously at the rate of 60 to 120 mL/h

What are the types of treatment for cancer?

surgery, radiation, and chemotherapy

Ventialtion

the movement of gases in and out of the lungs

eversion

turning foot outward

How often should ROM exercises be done?

twice a day AM and PM or according to the doctor's orders

Pulse site used to assess status of circulation to hand and also used to perform on Allen's test?

ulnar

polyuria

excessive output of urine (diuresis)

Interventions after abnormal vitals

-What interventions to relieve vital sign changes •Bathing to decrease temp, cool compresses, medications or other procedures such as pressure to stop bleeding

While assessing an 18-month-old toddler, the nurse distinguishes normal from abnormal findings by remembering that Gesell's theory of development states

"Environmental influence does not affect the sequence of development."

measurement of pressure ulcer

-size of wound -depth of wound -presence of undermining, tunneling, or sinus tract(all on wound bed)

Respiratory rate for adolescent

16-20

Platelet

150,000 to 400,000

The nurse considers several new female patients to receive additional health education on the need for more frequent Pap smears and gynecological examinations. Which of the following assessment findings reveals the patient at highest risk for cervical cancer and thus having the greatest need for patient education?

22 years old, smokes 1 pack of cigarettes per day, has multiple sexual partners

Respiratory rate newborn

30-60

Macular Degeneration

Blurred central vision often occurring suddenly. It is caused by a progressive degeneration of the center of the retina. It is the most common cause of blindness in adults over age 50. There is no cure

pulse rate for healthy adult

60-100 (80 average)

Normal pulse range

60-100 BPM strong and regular

How much blood enters the aorta with each ventricular contraction?

60-70 mL

Adolescent heart rate

60-90

Normal diastolic pressure

60-90 mmHg

How many mL of heat is lost by evaporates fro the skin and lungs daily?

600-900 mL

Preschooler heart rate

80-110

Duration

A period of time in which something exists or lasts

The nurse is preparing to position an immobile patient. Before doing so, the nurse must understand that

Body mechanics alone are not sufficient to prevent injuries.

Factors influencing bowel elimination

Age Diet Fluid intake Physical Activity Psychological Personal Habits Pain Surgery and Anesthesia Position during defecation

The patient weighs 450 lbs (204.5 kg) and complains of shortness of breath with any exertion. His health care provider has recommended that he begin an exercise program. He states that he can hardly get out of bed and just cannot do anything around the house. To focus on the cause of the patient's complaints, the nurse devises which of the following nursing diagnoses?

Activity intolerance related to excessive weight

The therapy that is more effective in treating physical ailments than in preventing disease or managing chronic illness is _____ medicine.

Allopathic

Which person is the best referral for a patient who speaks a foreign language?

An interpreter

Phantom (phantom limb syndrome)

An often painful sensation in a limb, even though the limb has been amputated

During a sexually transmitted illness presentation to high school students, the nurse recommends the HPV vaccine series to prevent

Cervical cancer.

The nurse has been called to a hospital room where a patient is using a hair dryer from home. The patient has received an electrical shock from the dryer. The patient is unconscious and is not breathing. What is the best next step?

Check for a pulse.

1. A patient immediately experiences sharp, shooting pain in his left arm in response to the IV the nurse is inserting. The nurse is experienced and quickly removes the IV upon witnessing the patient's reaction, however, it is later determined that the patient suffered nerve damage as a result of the procedure. A tort is filed on the patient's behave citing an act of _________ on the nurses part. a. commission b. omission c. unprofessional conduct d. gross negligence

Correct Answer: a. While inserting the IV the nurse hit a nerve causing the patient pain. The nurse was assigned fault based on incorrectly inserting the IV, which is an example of an act of commission. Incorrect Answer: b. An act of omission would assume the nurse did not do something that should have been done. In this case the nurse immediately withdrew the IV upon seeing the patient's response, which is exactly what should have been done. c. Unprofessional conduct refers more to how a nurse behaves around with patient. In this case the nurse makes a mistake inserting the IV, but there is no evidence of poor professional behavior. d. Gross negligence would imply that it was the nurse's "extreme lack of knowledge, skill, or decision making" that caused the problem. On the contrary the nurse used correct decision-making skills when she acted quickly to remove the IV. Furthermore, since the nurse is "experienced" it is unlikely that a knowledge/skill deficit caused the incident. Berman pg. 68

The thickness or viscosity of the blood affects the ease with which blood flows through small vessels. The nurse examines what value, which might help determine the amount of blood viscosity?

Hematocrit

2. A patient shares with the nurse that is s/he entered a persistent vegetative state, s/he does not believe his/her family will not be able to resolve her medical condition effectively to her standards. What would be the most appropriate statement the nurse should state? a. "Tell your most trusted cousin how you want your medical condition to be handled." b. "Have a sit down with your family about how you want things specific things handled." c. "You should look into getting an advance directive to ensure your wishes are met." d. "Don't worry about that, your family will set do the right thing and fulfill your wishes."

Correct Answer: c Rationale: An advance directive, in the form of a living will, will ensure that the patient's specific instructions will be met about whichever medical treatment s/he wants or not want when s/he is not able to communicate that information. (Berman text, p. 65)

Fracture pan

Designated for patients with lower extremity fractures. Has a shallow upper end about 1/2 inch deep

Example of calcium channel blockers

Diltiazem (Cardizem, Dilacor XR), verapamil hydrochlorides (Calan SR), nifedipine (Procardia), Nicardipine (Cardene)

The nurse preceptor recognizes the new nurse's ability to determine patient safety risks when which behavior is observed?

Disposing of used needles in a red needle container

The nurse is preparing a patient for surgery. The nurse explains that the reason for writing in indelible ink on the surgical site the word "correct" is to

Distinguish the correct surgical site.

Stethoscope labeled

Ear pieces, binaurals, tubing, bell chest piece and diaphraqgm chest piece.

When assessing a patient's feet, the nurse notices that the toenails are thick and separated from the nail bed. The nurse is aware that this condition is caused by

Fungi.

A nurse is using the source record and wants to find the daily weights. Where should the nurse look?

Graphic sheet and flow sheet

The nurse knows that children in late infancy and toddlerhood are at risk for injury owing to

Growing ability to explore and oral activity.

The nurse is caring for a patient who has head lice (pediculosis capitis). The nurse knows that in treating this condition, one must understand that

Head lice may spread to furniture and other people.

Vital Signs

Health status measurements of life that are used to evaluate a patient's condition (e.g., temperature, respiratory rate, pulse, blood pressure). Pain, a subjective symptom, is also a vital sign because of the effect it has on other vital signs

An elderly patient is being seen for a chronic entropion. The nurse realizes that entropion places the patient at risk for which of the following?

Infection

A woman who has been in a monogamous relationship for the past 6 months presents to clinic with herpes on her labia. The patient is distraught because her partner must have cheated on her. Which response by the nurse is most effective in establishing an open rapport with a patient?

Inform the patient that all encounters are confidential.

Cue

Information that you obtain through use of the senses (e.g., patient crying implies pain or sadness)

The patient has been forcefully blowing his nose and now has a nosebleed. The nurse is concerned about the patient's condition and assesses the patient for which possible negative issues? (Select all that apply.)

Injury to the tympanic membrane (eardrum) Damage to nasal mucosa Eye injury

The unconscious patient is resisting attempts by the nurse to provide oral hygiene. To provide the needed care, the nurse may

Insert an oral airway upside down.

Glaucoma

Intracular structural damage resulting from elevated intraocular pressure caused by an aqueous humor outlfow obstruction. If left untreated, will lead to blindness

The nurse is developing an exercise plan for someone diagnosed with congestive heart failure and exercise intolerance. In doing so, the nurse should

Perform 6-minute walks at the patient's pace at least 2 times a day.

The nurse is caring for a patient who complains of feeling light-headed and "woozy." The nurse checks the patient's pulse and finds that it is irregular. The patient's blood pressure is 100/72. It was 113/80 an hour earlier. What should the nurse do?

Perform an apical/radial pulse assessment

Arteriosclerosis

Peripheral blood vessels tend to grow more rigid with age, resulting in a condition called _____________________ which restricts blood flow; the dorsalis pedis and posterior tibia pulses may become more difficult to palpate

How do you measure for the hand piece height? (laying down)

With the patient's arm close to their side, measure from the anterior axillary fold to the trochanter or ulnar wrist crease. Subtract 1.5 to 2 inches from this value and position the hand piece that distance from the center of the axillary

sanguineous drainage

blood cells present; looks like blood

subjective

coming from that subject

Converting C to F

F (9/5 x C) + 32

The nurse is working with the patient in developing an exercise plan. The patient tells the nurse that she just will not participate in a formal exercise program. The nurse then suggests that exercise activities can be incorporated into activities of daily living. The patient seems to be agreeable to that concept. Of the following activities, which would be considered a moderate-intensity activity?

Folding clothes

The nurse is providing education about the importance of proper foot care to a patient who has diabetes mellitus. The nurses understands that this is important for the patient because

Foot ulcers are the most common precursor to amputation.

When does heat production occur?

during rest, voluntary movement, involuntary shivering and non-shivering thermogensis.

What stimulates cardiac contraction?

electrical impulses originate from the sinoatrial (SA) node and they travel through the heart muscle

Infusion of IV fluids will do what to BP?

elevate BP

Recommended f/u for stage 2 hypertensive BP

evaluate therapy within 1 months, for those with higher pressure they need to be evaluated and treated immediately or within 1 week.

deductive reasoning

examines a general idea and then considers specific actions or ideas

perfusion

exchange of oxygen and carbon dioxide between circulating blood and tissue cells

diffusion

exchange of oxygen and carbon dioxide between the alveoli of lungs and circulating blood

Factors influencing character of respirations

exercise, acute pain, anxiety, smoking, body position, medications, neurological injury, hemoglobin functions.

Remittent fever

fever spikes and falls without a return to acceptable temperature levels

inflammatory phase

follows hemostasis and lasts 4-6 days, white blood cells move to wound, macrophages enter wound and remain extended time, they ingest debris and release growth factors, pt has generalized body repsonse

Contact precautions

gastro, resp, skin, or wound infections C diff E coli, hep A, shigella, rotavirus infection, skin infections, conjunctivitis, ebola, lassa, marburg place in private room or with someone equally infected wear gloves change gloves after contact with infectious material remove before leaving room cleanse hands immediately after removing wear a gown when entering room remove gown in room make sure clothing does not contact possible contaminated surfaces limit of patient movement outside of room dedicate specific equipment to that patient

direct studies

going inside the body ex. colonoscopy, sigmoidoscopy

Stage 1 hypertension in adults

greater than or equal to 14o over greater than or equal to 90

The absence of thyroid hormones reduces the BMR by how much?

half causing a decrease in heat production

When assessing the patients respirations

have the head of the bed elevated 45 to 60°. Appear to be taking pulse

At a normal slow heart rate, what are the classic characteristics of S2 that you will hear through your stethoscope upon listening via the apical site?

higher pitched and shorter "dub"

Patient with chronic lung disease have what ongoing condition?

hypercarbia

National patient safety goals

identify patients correctly improve staff communication use medicine safely prevent infection identify safety risk prevent mistakes in surgery

STAT

immediately

paresis

impaired muscle strength or weakness

What happens when the nerve cells of the hypothalamus becomes heated beyond the set point?

impulses are sent out to reduce body temperature

hypoxia

inadequate amount of oxygen available to cells

Colposcopy

inspection of the large intestine for polyps, inflammation, and malignant lesions fiberoptic scope is inserted anally and advanced to the large intestines patient will need laxatives or enemas until clear should not be done sooner than 10 to 14 days after barium GI studies clear liquid diet 24 to 48 hours before procedure bowel cleansing 24 hours before bowel fluid must be clear before procedure can be done any iron med, aspirin, and anti-inflammatory drug must be withheld for 3 days

Aims of Nursing

1. To promote health 2. To prevent illness 3. To restore health 4. To facilitate coping with disability or death

One benefit of using a stationary automatic blood pressure device is that the cuff

Fits over clothing.

A key component in all ROM exercises is...?

Flex or extend

Recommended f/u for pre-hypertensive BP

recheck in 1 year

You record temperatures with "T" followed by an R for....? A for .....? and T for .....?

rectal. axillary. tympanic.

eczema

red, itchy inflammation of the skin; usually develops in early childhood, more common in people w/ family history; treatment involves avoiding soap and other irritants and applying creams or ointments if prescribed

Wound infection

redness, swelling, pain, warmth, drainage, fever, increased leukocytes, rapid pulse and respirations

Calcium channel blockers

reduces peripheral vascular resistance by systemic vasodilation

debridement

removal of devitalized tissue and foreign material

Emergency response to hypothermia

removing wet clothes, replacing them with dry ones, and wrapping patients in blankets.

Hyperpnea

respiration's are labored, increase depth, and respiration greater than 20.

Apnea

respiration's cease for several seconds and persistent cessation results in respiratory arrest.

Hypoventilation

respiratory rate is abnormally low and depth of ventilation is depressed

Vital signs of a heatstroke

reveal a body temperature sometimes as high as 45 C and 113 F, increasing HR, and lowering of BP.

Patient placement to avoid

rim of ear, trochanter, heel, elbow, sacrum, ilium, shoulder blade, posterior knee, and side of head

Your patient, Emily, has a respiratory rate of 27 breaths per minute. What makes this respiratory rate a risk factor for Emily's health?

risk factor for cardiac arrest

sources of heat loss

skin (primary source), evaporation of sweat, warming and humidifying inspired air, eliminating urine and feces

What alters cardiac output?

slow, rapid or irregular pulse.

Stertor

snoring sound produced by inability to cough up secretions from the trachea or bronchi

the efferent system conveys via

somatic nervous system

Urinalysis normals

specific gravity is 1.010 to 1.030 straw or amber color transparent smells faintly like ammonia 30cc per hour 5.5 to 7.0 ph

Dehiscence

spontaneous opening of an incision sign of impending dehiscence is increased flow of Serosanguineous drainage

Axillary measurements have been shown to be as reliable as rectal in which types of patients?

stable infants

The Indirect/noninvasive arterial BP method

stethoscope and sphygmomanometer

urgency

strong desire to void

Skeletal traction

surgical placement of pins, tongs, screws, or wires that are anchored to or through the bone and therefore pierce the skin as much as 30lb or traction force counter traction is provided by patients weight and the position of the bed skin care around the openings for the pins using sterile technique circulation checks every hour for the first 24 hours then every 4 hours

4 patterns of a fever

sustained, intermittent, remittent, relapsing.

Mechanisms of heat loss

sweating, vasodialation (widening) of blood vessels, and inhibition of heat production.

edema

swelling caused by excess fluid trapped in your body's tissues

Core temperature

temp of the deep tissues

sustained or continuous fever

temp remains above normal with minimal variations

relapsing or recurrent fever

temp returns to normal for one or more days with one or more episodes of fever, each as long as several days

remittent fever

temperature does not return to normal and fluctuates a few degrees up and down

intermittent fever

temperature returns to normal at least once every 24 hours

places you can record a pulse

temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis

auscultatory gap

temporary disappearance of sounds usually heard over the brachial artery, occurring when the cuff pressure is high and is gradually reduced, with the sounds again heard at a lower level of pressure (usually occurring in patients who have hypertension)

apnea

temporary or transient cessation of breathing

Palpation

the application of the fingers with light pressure to the surface of the body to determine the condition of the underlying parts

Which probe do you use when taking an oral temperature?

the blue probe

If the patient is sitting, how should you position their arm?

Bend the patient's elbow 90 degrees, and support lower arm on chair or on the nurse's arm

Blood pressure

the force exerted on the walls of an artery by the pulsing of blood under pressure from the heart.

diastolic pressure

the force exerted when the heart is at rest in between each beat; the lowest pressure exerted against the arterial walls at all times

Fourth korotkoff sound

the sounds become muffled

Ausculatory gap

the temporary disappearance of sound

Convection

the transfer of heat away by air movement

Evaporation

the transfer of heat energy when a liquid is changed to a gas

Conduction

the transfer of heat from one object to another with direct contact

Radiation

the transfer of heat from the surface of one object to the surface of another without direct contact between the two.

illness

the unique response of a person to a disease; an abnormal process involving changed level of functioning

Single use/reusable dot thermometers

thin strips of plastic with a temperature sensor at one end

Caring is a universal phenomenon that influences the ways in which people (Select all that apply.)

think feel behave

proprioceptor or kinesthetic sense

this informs the brain of the location of a limb or body part as a result of joint movements stimulating special nerve endings in muscles, tendons, and fascia

How does the skin regulate temperature?

through insulation of the body, vasoconstriction, and temperature sensation.

vasodilators and calcium channel blockers

to relax smooth muscles of arterioles and decrease peripheral vascular resistance

Social groups influence hygiene preferences and practices, including the type of hygienic products used and the nature and frequency of personal care. Which of the following developmental stages is most likely to be influenced by family customs?

toddler

You're assessing a patient that has a possible heat stroke. You know that permanent neurological damage occurs in heatstroke patients unless cooling measure are rapidly started. What symptoms will you be looking for so the patient does not suffer neurological damage?

unconscious with fixed, non reactive pupils.

functional incontinence

urine loss caused by the inability to reach the toilet because of environmental barriers, physical limitations, loss of memory, or disorientation

standards

used as guidelines for peer review (ANA)

Local anesthesia

used for minor procedures tissue biopsies, vasectomies, pacemaker insertion, removal of superficial cyst, insertion of vascular access devices patient does not require care in post anesthesia recovery unit

Pulse oximetry

used for patients at risk for hypoxia monitors changes in the arterial oxygen saturation determines the amount of hemoglobin that is bound with oxygen 95 to 100%

Surgical asepsis

uses a sterile technique sterilization of all instruments and inanimate objects

Fluid intake influence on bowel elimination

varies from person to person. 3L per day, men and 2.2 liters for women. We get fluid from drinking them and from food such as fruits and vegetables. Inadequate fluid intake or fluid loss from vomiting affects the character of a person's feces, reduced fluid intake causes constipation (condition characterized by difficulty passing stool or an infrequent passage of hard stool i.e. less than 3 per week).

General guidelines for charting

verify name on chart before charting place date at the beginning of each chart black ink if error, initial and date and write error

Diaphoresis

visible perspiration primarily occurring on the forehead and the upper thorax.

visual or optic reflexes

visual impressions contribute to posture by alerting the person to spatial relationships with the environment

VS

vital signs

extensor or stretch reflexes

when extensor muscles are stretched beyond a certain point, their stimulation causes a reflex contraction that aids a person to reestablish erect posture

Which of these statements, if made by a parent, would require further instruction?

"I should cover for my school-aged child when he makes a mistake until he learns the ropes."

How often do you check a patient's cast if there is drainage or bleeding?

Check for an enlargement of the bleeding area at least every 1-3 hours

Physical activity influence on bowel elimination

Promotes peristalsis, immobilization decreases it. Get your patients moving

When would you administer antipyretics?

when the temperature is elevated outside of the acceptable range for your patient

What gender generally experience great fluctuations in body temperature?

women

What are some signs and symptoms of illness in infants?

- Jaundice - Redness or draining around the cord stump or circumsision - High temperature - Limp body, slow to respond - Eating poorly - Hard or watery stools

The nurse is teaching the patient about flossing and oral hygiene. The nurse teaches the patient that

Flossing removes plaque and tartar from the teeth.

When providing hygiene for an elderly patient, it is important for the nurse to closely assess the skin. This is because as the patient ages

Less frequent bathing may be required.

The nursing instructor will need to provide further instruction to the student who states

"An individual's biological processes determine physical characteristics and do not affect growth and development."

An 18-year-old male patient informs the nurse that he isn't sure if he is homosexual because he is attracted to both genders. The nurse establishes a trusting relationship patient by saying

"At your age, it is normal to be curious about both genders."

What are some safety measures for infants?

- Keep infants warm by wrapping them snuggly - Use both hands - Do not place pillows, quilts, or soft toys in the crib - Lay babies on their backs to sleep - An infant should always be restrained in a car seat - Small object should be kept out of reach

The older patient presents to the emergency department after stepping in front of a car at a crosswalk. After the patient has been triaged, the nurse interviews the patient. Which of the following comments would require follow-up by the nurse?

"I was so surprised; I didn't see or hear the car coming."

How can pain be managed?

- Medications - Mild exercise - Diversion techniques - Hot or cold compress - Physical therapy techniques - Reassurance

A 12-year-old female patient complains that her periods are making her fat. Which response by the nurse is most therapeutic?

"Does the weight fluctuate throughout the month, getting worse around the time of your period?"

An Orthodox Jewish Rabbi has been pronounced dead. The nursing assistant respectfully asks family members to leave the room and go home as postmortem care is provided. Which of the following statements from the supervising nurse reflects correct knowledge of Jewish culture?

"Family members stay with the body until burial the next day."

A mother expresses concern because her 5-year-old child frequently talks about friends who don't exist. What is the nurse's best response to this mother's concern?

"It's very normal for a 5-year-old child to have imaginary playmates."

What is the Corpmans/Technicians key role in assessment?

- Observing - Take notes on the observations and report them to the nurse

Name pain characteristics:

- Onset and duration - Location - Intensity - Quality - Pattern - Individual relief measures - Contributing symptoms

What are the types of paralysis?

- Paraplegia - Quadriplegia - Hemiplegia

What things are considered when developing a nursing diagnosis for a patient?

- Physical needs - Emotional needs - Social needs - Spiritual needs

An outcome for an older adult patient living alone is to be free from falls. Which of these statements by a patient indicates that teaching on safety concerns has been effective?

"I'll take my time getting up from the bed or chair."

The nurse is providing information regarding safety and accidental poisoning to a grandmother who will be taking custody of a 1-year-old grandchild. Which of the following comments would indicate that the grandmother needs further instruction?

"If my grandchild eats a plant, I should provide syrup of ipecac."

Pain is complex, involving multiple factors. What are these factors?

- Physiological factors - Social factors - Spiritual factors - Psychological factors - Cultural factors

What are common impairments in vision?

- Presbyopia - Cataracts - Glaucoma - Macular Degeneration - Vertigo

The nurse is leading a seminar about menopause and age-related changes. The nurse knows that a patient does not fully understand the changes of aging when the patient says

"Orgasms are no longer achievable after menopause."

Which statement by the nurse best explains the importance of play during the toddler stage of development?

"Play can enhance cognitive and psychosocial development."

A patient expresses concern that her partner no longer finds her attractive and is considering having a three-way to spice up the relationship. Which response is the best option for the nurse in this situation?

"Please help me understand how you are feeling about your relationship right now."

The nursing student is preparing a teaching project for parents of school-aged children. Which statement correctly identifies health risks in this age group?

"Poor nutrition and lack of immunizations continue to be health concerns for children of the poor."

How are "Special needs" taken care of?

- Guided by the hierarchy of needs adapted from Maslow - Physiologic needs for basic survival take precedence

How do you determine orthostatic hypotension?

- Have the patient lie supine for 1-3min before taking the 1st BP - Have the patient sit upright for 1-3min before taking the 2nd BP - Have the patient stand for 1-3min before taking the 3rd BP - Compare the readings - It is usually detected within 1min of standing

A female adult patient presents to the clinic with reports of a white discharge and itching in the vaginal area. During the health history, which of these questions should the nurse prioritize?

"What medications are you currently taking?"

The patient and the nurse are discussing Rickettsia rickettsii—Rocky Mountain spotted fever. Which patient statement to the nurse indicates understanding regarding the mode of transmission of this disease?

"When I go camping, I will be sure to wear insect repellent."

What are some causes of mental health disorders?

- Inability to cope or adjust to stress - Chemical imbalances - Genetics - Drug or substance abuse - Social and cultural factors

A nursing student is asked to compare major life events of young adult, middle adult, and childbearing families. Which statement by the student demonstrates understanding?

"When married people both work, income is increased, but so is stress."

The nurse is assessing a new patient admitted to home health. To decrease the risk of infection, which of these questions would be most appropriate to ask? (Select all that apply.)

"Will you demonstrate how to wash your hands?" "Do you have a working refrigerator?" "Can you explain the risk for infection in your home?" "What are the signs and symptoms of infection?"

The nurse is caring for an elderly woman and notices that she is not using her cane properly. Which of the following statements by the nurse would most likely elicit a positive response from the patient?

"You use the cane the way I did before I was shown a way to keep from tripping over it; do you mind if I show you?"

What are the responsibilities of a Corpsman/Technisian when admitting a patient to the ward?

(there are a ton so I hit the big ones or ones that aren't common sense) - Introduce yourself - Check & attach ID band - Assess patient's general appearance, vitals, fall risk - Issue clothes and necessities - Obtain a medical history - Explain visiting hours and their purpose - Demonstrate use of equipment - Explain hours for mealtime - Document

What are the responsibilities and procedures for discharging a patient?

(there are alot so I just named the big ones or the not-so-obvious ones) - verify the doctors discharge order - educate the patient - give appointment card - discuss symptoms that require immediate follow-up - complete discharge Nursing Notes SF 510 - send the completed clinical record to Patient Affairs - clean the unit

An inventory of all valuables and personal effects is conducted by who?

- 2 commissioned officers if the patient is a commissions officer or a civilian - 1 commissioned officer and one enlisted staff member if the patient is enlisted

What are common congnitive disorders in the elderly?

- Alzheimer's disease - Confusion - Delirium - Dementia - Depression

What are proper questioning principles for an interview?

- Ask direct questions. Do not use yes or no questions - Keep the interview focused on the patient's medical problems and needs - Use language that is understandable and appropriate

How can pain assessment be accomplished?

- Asking about pain - Believe the patient - Choose appropriate management - Give intervention

What are the different type of Protective Devices?

- Belt: sitting in wheelchair - Vest: sitting in chair or bed - Extremity Immobilizer: wrist and ankles - Mitten: hands

What are some characteristics of tumors?

- Benign: do not usually cause death. grows slowly and within a localized area. may resemble normal tissue. can cause problems if it loses blood supply and becomes necrotic - Malignant: cancerous and death can occur if not treated or controlled. may spread rapidly. may arise from a benign tumor that is chronically irritated or aggrivated. many types

How can errors be made in the pain assessment?

- Bias - Vague or unclear questioning - Patient not providing accurate pain information

Nursing assessment includes 2 steps. Define and describe them:

- Collection and verification of data from primary and secondary sources by using subjective and objective data - Analysis of all data as a basis for developing nursing diagnoses, identifying collaborative problems and developing a plan of individualized care

How can you protect the contour of the cast?

- Ensure the mattress does not sag - Never place a damp cast on a hard surface - Support the full length of the cast - Ensure that the case is not covered - Use the palms of the hands to lift the case

What are alternatives to protective devices?

- Frequent patient observation - Have family members help by sitting with them or bringing photos - Ensure patient comfort

What can you do to assist a hearing impaired patient?

- Gain the patient's attention without startling him - Face the patient - Ensure adequate lighting - Speak clearly and slowly - Do not eat or chew gum - State the topic of conversation first - Have pen and paper available to write down important names or words - Keep conversations short - Repeat statements as needed - Keep background noise to a minimum

What are the components of a physical examination?

- General survey - Vital signs - Integumentary system - Head and neck - Respiratory - Cardiovascular - Gastrointestinal - Genitourinary - Musculoskeletal - Neurological

Characteristics of respiration:

- Rate - Rhythm - Depth - Sound by auscultation

Restraint Guidlines

- Review local MTF policy on use of restraints - Requires continuous observation - Requires a doctor's order - Use the least amount of restraint possible - Always explain the purpose of the restraint - Documentation of restraints must be conducted every 15min

What are some causes of paralysis?

- Trauma - Spinal cord lesions - Multiple sclerosis - Infections and abscesses of the spinal cord - Congenital defects

Troubleshooting a sphygmomanometer steps include:

- check for holes in the bladder - check for holes in the tubing - ensure the guase is at zero - return inoperative equipment to the repair division

Troubleshooting an electronic thermometer steps include:

- check that it registers 90 before beginning - check that the probe connection is firmly seated in the unit - ensure the unit is returned to the charger after each use

Troubleshooting a stethoscope steps include:

- check tubing for cracks or holes - check the ear pieces - check the diaphragms - replace parts as needed

What are the types of baths?

- complete bed bath - partial bed bath - sponge bath at the sink - tub bath - shower - bag bath/travel bath - Therapeutic bathing

Factors that increase vital signs:

- exercise - eating - anger - hormone levels - stress - stimulant drugs - pain - age (increase blood pressure)

What are some causes for unconsciousness?

- head injury - drug overdose - coma related to a disease process

What are some complications of unconsciousness?

- infectious complications - pressure ulcers - gastrointestinal bleeding

What nursing interventions can you do for a cancer patient?

- pain management - coordinate activites to provide for undisturbed periods of rest and sleep to increase energy level - encourage the patient in own care to tolerance - monitor intake and output balance - explain need to avoid persons with infections

What are some nursing interventions for immunodeficiency patients?

- practice standard precautions - provide fluids as ordered - have patient perform coughing and deep breathing exercises to prevent pneumonia - encourage regular exercise and rest as tolerated - be a good listener and provide emotional support - avoid false reassurances but encourage hope

How can you stimulate urine flow?

- run water in a nearby sink - pour warm water over the perineum - have the patient visualize a bubbling brook - have female patients blow through a straw - have male patients stand by the bedside - use Crede's Maneuver

Factors of staging of tumors-process used to describe the extent of disease are...?

- size of tumor - presence or absence of a capsule - evidence of metastasis

Safety considerations for children include:

- stairway safety - covering electrical outlets - keeping household cleaners out of reach - using flame retardant sleepwear

Pain documentation

- the location, intensity, quality, duration, and pattern of the pain - any signs or symptoms of pain - the patient's vital signs - your nursing interventions - the patient's response to care

Respiration documetation

- the rate, rhythm, and depth of respirations - any signs or symptoms of respiratory alterations - abnormal respiratory sounds - the type of oxygen therapy (nasal cannula, mask) and flow rate - respiratory status after a specific treatment (nebulizer therapy) - any specimens and cultures obtained and sent to the lab - your nursing interventions - the patient's response to care

Pulse documentation

- the rate, rhythm, and strength of the pulse - the site you used to palpate the pulse - any signs or symptoms of pulse alterations - the pulse deficit (if applicable) - your nursing interventions - the patient's response to care

Temperature documentation

- the temperature reading - the route you used to measure the temperature - any signs or symptoms of temperature alterations - your nursing interventions ("antipyretic given") - the patient's response to care

What do you include when documenting ROM?

- type of exercise - the body part(s) exercised - leng of time, reps, or sets - patient's tolerance of the procedure

closed drainage system

-Jackson-pratt drain -hemovac drain may be connected to an electrical suction or built-in reservoir

Oral cavity in older adults

-Soft tissues atrophy & epithelium thins, especially in cheeks and tongue results in loss of taste buds -Decreased salivary secretion -Atrophic tissues ulcerate easily, which increases risk for infections such as oral candidiasis -Dental Changes

Nursing interventions for pain control

-Tighten wrinkled bed linens. -Reposition drainage tubes or other objects on which patient is lying. -Place warm blankets for coldness. -Loosen constricting bandages. -Change moist dressings. -Check tape to prevent pulling on skin. -Position patient in anatomic alignment. -Check temperature of hot or cold applications, including bath water.

Palpate skin temperature

-Use backs (dorsa) of your own hands -Palpate bilaterally -Normal range of findings: Warm, temperature equal bilaterally. Hands and feet may be slightly cool in cool environment

factors affecting body temp

-circadian rhythms -age and gender -physical activity -state of health -environmental temperature

establishing an effective nurse-patient relationship

-reduce anxiety through therapeutic communication, teaching, and acceptance -remember that the patient has concerns and needs other medical ones -communicate with the patient as an individual -take time to learn about the patient being admitted -provide for the family participation in all aspects of care

types of knowledge

-science (observing, identifying, describing, investigating, and explaining events and occurences that are perceived in world) -philosophy (the study of wisdom, fundamental knowledge, and the processes used to develop and construct on perception on life) -process (a series of actions, changes, or functions intended to bring about a desired result)

stages of pressure ulcers

-stage1: nonblanchable erythema of intact skin -stage2: partial-thickness skin loss -stage3: full-thickness skin loss; not involving underlying fascia( epidermis and dermis) -stage4: full-thickness skin loss with extensive destruction (epidermis, dermis, and subcutaneous) -unstageable: base of ulcer covered by slough and/or eschar in wound bed

Which entry will require follow-up by the nurse manager? 0800 Patient states, "Fell out of bed." Patient found lying by bed on the floor. Legs equal in length bilaterally with no distortion, pedal pulses strong, leg strength equal and strong, no bruising or bleeding. Neuro checks within normal limits. States, "Did not pass out." Assisted back to bed. Call bell within reach. Bed monitor on. -------------------Jane More, RN 0810 Notified primary care provider of patient's status. New orders received. -------------------Jane More, RN 0815 Portable x-ray of L hip taken in room. States, "I feel fine." -------------------Jane More, RN 0830 Incident report completed and placed on chart. -------------------Jane More, RN

0830

The patient is found to be unresponsive and not breathing. To determine the presence of central blood circulation and circulation of blood to the brain, the nurse checks the patient's _____ pulse.

Carotid

Lithotomy Position

Lying supine with the hips and knees flexed and the thighs abducted and rotated externally; used to assess the female genitalia and genital tract

Acquired immunodeficiency syndrome (AIDS)

Caused by a virus, called the human immunodeficiency virus, or HIV, that attacks the immune system. Without immune system, even a minor illness can become fatal

The posterior hypothalamus helps control temperature by

Causing vasoconstriction.

What are the 5 steps of the nursing process?

1. Assessment 2. Nursing diagnosis 3. Planning 4. Implementation 5. Evaluation

What are the different types of thermometers?

1. Glass thermometers 2. Electronic thermometers 3. Tympanic thermometers 4. Temporal thermometer 5. Heat sensitive patch, chemical dot thermometers or tape changes color at different ranges

What are the basic guidlines for obtaining a medical history?

1. Maintain patient confidentiality 2. Prepare the environment 3. Conduct the interview

Steps to assess vital signs:

1. Medical aspepsis 2. Properly identify the patient 3. Assess for patient safety, privacy, allergies, comfort and education 4. Ensure the patient has had nothing hot or cold to eat or drink for 15min 5. Ensure the patient has not smoked for at least 15min 6. Ensure the patient has not been physically active for at least 15min

Exam gloves

Used when palpating the buccal (oral) cavity, genitals, and perineal region

Body metabolism increase ___% for every degree Celsius of metabolic needs of the body for nutrients

10

Pulse waves moves ___ time faster through the small arteries than the ejected volume of blood

100

When large amounts of thyroid hormones are secreted, the BMR can increase ____% above normal

100

6 year old normal BP

105/65

10-13 year old normal BP

110/65

14-17 year old normal BP

119/75

How long is the ECG interval?

12 seconds

respirations for healthy adult

12 to 20 breaths/min

Respiratory rate for adult

12-20

Normal respirations

12-20 breaths/minute

Hemoglobin

12.0 to 18.0

A nurse obtained a telephone order from a primary care provider for a patient in pain. Which chart entry should the nurse document?

12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO Dr. Day/J. Winds, RN, read back.

Infant heart rate

120-160

average blood pressure for healthy adult

120/80

Of the following values, which value would be considered prehypertension?

120/80 in a middle-aged adult

Stage 1 hypertension (systolic)

140-159 mmHg

How many calories does a young child need per day?

1400-1800

Pulse waves move ___ times faster through the aorta

15

Stage 2 hypertension (systolic)

160 mmHg and above

True or False: Ensure the patient is bearing weight on the hands atl all times with the crutch gaits.

True

albumin normal lab values

3.5-5

Women who have stopped menstruating often experience periods of intense body heat and sweating lasting from:

30 seconds to 5 minutes

The nurse is caring for a newborn infant in the hospital nursery. She notices that the infant is breathing rapidly but is pink, warm, and dry. The nurse knows that the normal respiratory rate for a newborn is _____ breaths per minute.

30 to 60

How long should the tubing be?

30-40 cm

What temperature will a patient experience uncontrolled shivering, loss of memory, depression and poor judgment?

34 C and 93.2 F

The newborns body temperature is usually within:

35.5-.7.5 C 95.9-99.5 F

True or False: If one side of the patient is weaker than the other, get the patient out of bed and into the wheelchair on the strong side

True

True or False: Neglect is giving insufficient attention, respect and care to someone who has a claim to that attention

True

The patient's blood pressure is 140/60. The nurse realizes that this equates to a pulse pressure of

80.

As much as ___% of the surface area of the human body radiates heat to the environment

85%

Toddler heart rate

90-140

Stage 1 hypertension (diastolic)

90-99 mmHg

1 year old normal BP

95/65

18 years or older normal BP

<120/<80

Severe hypothermia classification

<30 C <86 F

1. A patient has just learned that her cancer has returned after being in remission for 4 years. Her doctor has recommended an aggressive treatment of chemotherapy and radiation. The patient has decided that she will not take the recommended treatment. Although the nurse disagrees with the patient's decision, she respects her decision and helps her organize palliative care. This is an example of: 1. Nonmaleficence 2. Autonomy 3. Accountability 4. Human Dignity

Answer 2: Autonomy is defined as a persons right to make their own health care decisions. It is not a nurse's place to impose his or her own feelings of treatment on a patient. (Berman, pg 81)

B. Side effects of medications

Common causes of constipation in an aging adult include __________________. A. Ability to be mobile B. Side effects of medications C. Adequate water intake D. Hyperthyroidism

How many different types of thermometers are there?

5

Approximately what percentage of all back pain is associated with manual lifting tasks?

50

Adult heart rate

60-100

The patient has been diagnosed with a respiratory illness and complains of shortness of breath. The nurse adjusts the temperature to facilitate the comfort of the patient. What is the usual comfort range for most patients?

65° F to 75° F

School aged child heart rate

75-100

Vaginal speculum

A bi-valved instrument, with 2 opening blades used for the inspection of the vaginal cavity and cervix

Footboard

A board placed at the foot of the bed that supports the feet at right angles to the body

Draw-Sheet Method

A method of transferring a patient from a bed to a stretcher by grasping and pulling the loosened bottom sheet of the bed

Alzheimer's disease

A chronic neurologic disorder characterized by progressive and selective degeneration of neurons in the cerebral cortex. Displays symptoms of behavioral distrubances, memory loss, emotional apathy and difficulty with thought processes. It is usually accompanied with dementia. There is no cure.

1. Which of the following is not an example of an advocate's role: 1. Remain neutral when a client makes a health care choice 2. Assist in communication with health care providers 3. Help a patient explain to their family why they are making a health decision 4. Making sure that when they are at home they are adhering to their care plan

Answer 4: An advocate must respect the autonomy of the patient. They are there to help inform the patient about their rights and options to health care. They are not there to make sure they adhere to their care plan. (Berman, pg 93)

What is a physical restraint?

A human, mechanical and/or physical device that is used with or without the patient's permission to restrict his or her freedom of movement or normal access to a person's body and is not a usual part of treatment plans indicated by the patient's condition or symptoms

Hyperextension

A joint is overstretched or "bent backwards" because of exaggerated extension motion

During infant/child development, play is best recognized as

A means to interact with the environment and relate to others.

Temperature

A measure of the amount of heat below the skin and the subcutaneous tissues

Core Temperature

A measure of the amount of heat in the deep tissues

Respiration Rate

A measurement that consists of one inspiration and one expiration

Abduction

A movement which draws a limb away from the median sagittal plane of the body

Adduction

A movement which draws a limb closer to the median sagittal plane of the body

Of the following patients, which are in need of perineal care? (Select all that apply.)

A patient with urinary and fecal incontinence A patient with rectal and perineal surgical dressings A patient with an indwelling catheter A morbidly obese patient

Contracture

A permanently flexed joint that occurs with shortened muscle tissue

The nurse is attempting to start an exercise program in a local community as a health promotion project. In explaining the purpose of the project, the nurse explains to community leaders that

A sedentary lifestyle contributes to the development of health-related problems.

Stockinet

A soft, elastic, usually cotton fabric used especially for bandages and infants' wear

Pressure Ulcer

A sore caused by pressure or rubbing against somthing for a period of time (e.g., bed sheets, cast)

Mental Health

A state of mind in which the person copes with and adjusts to the stresses of everyday living by behaving in ways acceptable to society

Percussion

A technique in physical examination of tapping the body with the fingertips to evaluate the size, borders, and consistency of some internal organs, and to discover the presence of and evaluate the amount of fluid in a vacity of the body

Tongue depressors

A thin blade for pressing down the tongue during a medical examination of the mouth and throat. Used to inspet the oral cavity in the absence of other dental diagnostic instruments

Cotton forceps

A tweezer-like instrument used to transport small items to and from the mouth

Water soluble lubricant (KY Jelly)

A water soluble agent capable of diminishing friction and making a surface slippery; used to lubricate an examiner's gloved hand when performing rectal or vaginal assessments

Thready Pulse

A weak and rapid pulse

1. A patient who is in a persistent vegetative state has acquired a serious blood infection. They have are on a ventilator and the doctor has started them on an antibiotic regiment. The family arrives at the hospital and informs the nurse that they 'think this is too much for their loved one' and want to stop the ventilator and antibiotics. This is an example of: 1. Passive euthanasia 2. Termination of life sustaining treatment 3. Adhering to the advanced directive 4. Withdrawing life saving measures

Answer 2: This treatment is only keeping the patient alive. In such cases the family can choose to stop the life sustaining treatment if there is no prognosis of recovery. (Berman, 92)

3. Which of the following is an example of a nurses obligation in ethical decision making? (select all) A. Using judgment regarding individual competency when accepting and delegating responsibility B. Following what you believe is ethical rather than carrying out hospital policies C. Participating in the advancement of the profession through individual contributions D. Ensure that the individual receives sufficient information on which to base consent for care

A, C, and D are correct. Information regarding the ANA's Code of Ethics for Nurses and the International Council of Nurses Code of Ethics can be found on page 86 and 87. Box 5-6 on p. 88 states a couple examples of nurses' obligations in ethical decisions. This box states that "carrying out hospital policies" is an obligation in ethical decisions, which is why B would be an incorrect answer. Berman, 8th ed. (86-88)

Which form of euthanasia also known as "mercy killing" is in violation of the Code for Nurses? Select all that apply. A. Passive euthanasia B. Assisted suicide C. WWLST D. Active euthanasia

Answer: B, D. ANA's position statement state that both active euthanasia and assisted suicide are in violation of the Code for Nurses. Passive euthanasia is commonly referred to (WWLST) may be both legally and ethically more acceptable to most persons than assisted suicide. Berman text, p 92

A nurse did not look up the patient's drug allergies in the chart and ignored the red band on the patient's wrist. The nurse administered a contraindicated medication, which resulted in urticaria and angioedema in the patient. The nurse noticed later and administered a shot of epinephrine, symptoms went away; the patient got better. The nurse felt no need to report the incident. Which of the following moral principles did the nurse violate? Select all that apply. 1) Veracity 2) Fidelity 3) Beneficence 4) Non maleficence 5) Justice

ANSWERS: 1,3,4 Rationale 1) CORRECT: Veracity- omission of the truth is not telling the whole truth. 2) Fidelity-the nurse did not express a promise in this scenario. 3) CORRECT: Beneficence- it was not "good" to try and cover it up. 4) CORRECT: Non maleficence- the patient was in harm's way when administered the wrong medication, when it could have been avoided with a simple check of allergies. 5) Justice- the nurse was not faced with a trial of justice in this scenario. Moral Principles: Berman text Chapter 5 pg. 85-86

Which of the following exemplify goals of being a client advocate? Select all that apply. 1) Be subjective 2) Protect client's rights 3) Decide for the client 4) Disregard the family's decision 5) Intervene on client's behalf

ANSWER: 2,5 Rationale 1) The nurse must remain objective 2) CORRECT: This is the overall goal of an advocate 3) This disregards client's autonomy 4) Family, which could be primary decision-makers in some cultures. This is culturally insensitive. 5) CORRECT: The nurse intervenes on the client's behalf, often by influencing others. Advocate's Role: Berman text Chapter 5 pg. 93-94

Which of the following behaviors indicate unclear values? 1) A client with an endomorph build, diagnosed with diabetes is admitted to the hospital 2) A client decides to live a "simpler life" and retires early to avoid stress and live longer. 3) A client with COPD refuses to stop smoking even after doctor's advice 4) A client says that she breast feeds to ensure her baby's health.

ANSWER: 3 Rationale 1) Not enough information is provided to determine values. No behavior was stated in example. 2) No confusion or uncertainty about which course of action to take. Actions in sync with values. 3) CORRECT: Ignoring a health professionals advice 4) No inconsistencies in communication or behavior. Words in sync with values. Behaviors That May Indicate Unclear Values: Berman text Chapter 5 pg. 83 Box 5-3

A. Provide a caregiver who is the same gender as the patient

According to Potter & Perry when caring for patients from the Korean culture, ________________. A. Provide a caregiver who is the same gender as the patient B. Use the left hand to cleanse unclean procedures C. Include the patient's family in patient care D. Close the door and draw the curtain for privacy during care

Sodium diet

Acid base balance, nerve impulses, contractions Salt, processed foods, milk Hyponatremia, edema Hypertension, renal and cardio disease 1500mg and less of salt per day 1 teaspoon of salt contains 2300 mg of sodium

The patient is being fitted with a hearing aid. In teaching the patient how to care for the hearing aid, the nurse instructs the patient to

Adjust the volume for a talking distance of 1 yard.

The nurse is developing an exercise program for elderly patients living in a nursing home. To develop a beneficial health promotion program, the nurse needs to understand that when dealing with the elderly

Adjustments to exercise programs may have to be made to prevent problems.

Identify the purposes of a health care record. (Select all that apply.)

Communication Legal documentation Reimbursement Education Research

When utilizing Freud's psychoanalytical/psychosocial theory, the nurse recalls that

Adult personality is the result of resolved conflicts between sources of sexual pleasure and the mandates of reality.

Normal pulses:

Adults is 60-100 bpm Children is 100-120 bpm Infants is 120-160 bpm

2-4, 5-6

Adults usually void urine every __________ hours or _________ times a day

Normal respiration rates:

Adults: 12-20 bpm Children: 20-30 bpm Infants: 30-50 bpm

The incidence of hypertension is greater in which of the following?

African Americans

Older adult mouth hygiene

Age related changes, chronic disease, physical disability, lack of attention, medication, teeth brittle, drier, darker in color leads to edentulous or complete/partial dentures

When comparing developmental tasks of middle-aged persons versus older adults, what should the nurse infer?

All older adults will need nursing assistance to deal with loss.

A formerly independent and active older adult becomes severely withdrawn upon admission to a nursing home. When approaching this patient, which intervention should the nurse plan first?

Allow the patient to incorporate personal belongings into her room.

Physical and psychological prep of the patient for an examination include:

Allow the patient to relieve themselves prior to the exam and position them correctly depending on the system being examined

The patient is in the intensive care unit (ICU), which has strict posted visiting hours and limits the number of visitors to two per patient at any one time. The patient is asking to see his wife and two daughters. The nurse should

Allow the wife and daughters to visit at the patient's request.

A confused older adult patient is wearing thick glasses and a hearing aid. Which intervention is priority to facilitate communication?

Allow time for the patient to respond.

The 1994 Dietary Supplement Health and Education Act impacted herbal therapies in what way?

Allowed herbs to be sold as dietary supplements

Carotid

Along medial edge of sternocleidomastoid muscle in neck

1. The nurse refuses to check a blood pressure on a walk in patient with foot pain that states "HIV" as part of his health history. The nurse: A) has their actions covered under the ANA 2006 guidelines. B) should try to find another nurse to care for this patient. C) will have to care for this patient since it's just a blood pressure check. D) understands that this is a gray area and probably won't need to check a blood pressure.

Answer (C) The nurse has a responsibility to care for this patient ANA 2006 states that nurses have a moral obligation to care for an HIV-infected patient as long as risk doesn't exceed the responsibility. A and D are incorrect and B is a sub-optimal solution. (Berman, 8th ed, Ch 5, p. 91)

Delirium

An acute mental disturbance chaaracterized by altered consciousness, reduced attention span and awareness, memory dificits, disorientation, disorganized thinking, incoherent speech, altered perception, delusions, hallucinations, and sleep distrubances

What is the nursing process?

An approach to identify, diagnose and treat human responses to health and illness.

Define olfaction

An awareness and observation of the nature and souce of body odors can assist in detecting abnormalities that may not be detected using the other skills or tests

The patient has a fever, what do you expect to find?

An elevated pulse rate

The nurse manager is evaluating current infection control data for the intensive care unit. The nurse compares past patient data with current data to look for trends. The nurse manager examines the chain of infection for possible solutions. Arrange these items in the proper order. (All answers are utilized.)

An infectious agent or pathogen A reservoir or source for pathogen growth A portal of exit from the reservoir A mode of transmission A portal of entry to a host A susceptible host

Stethoscope

An instrument used for listening to sounds produced within the body; can be used to auscultate the heart, lungs, abdomen, bowels, and blood pressure

Penlight/flashlight

An instrument used to assess the pupil's response to light

Periodontal probe

An instrument with a long blunt working end calibrated from one to twn nm that is used to check the periodontal pockets

High Fowler's Position

An upright sitting position with the head of the bed raised to 90 degrees

2. Which of the following is not an example of a nurse's obligation in ethical decisions: A) Advising abortion patients that they should more carefully consider their decision. B) Carrying out hospital policies. C) Maximize the client's well-being and protecting other client's well-being. D) Support each family member and enhance the family support system.

Answer (A) It is part of the ethical code to present facts to the patient but not to second guess. B,C, and D are all examples listed in the reference. (Berman, 8th ed, Ch 5, p. 89)

3. The nurse is confused during the health interview of a 45 year old woman who keeps her arms crossed. The nurse's best course of action would be to: A) start the interview over because the nurse has probably offended the patient. B) ask the patient if anything is making her uncomfortable. C) be firm with the patient and let her know that this will be easier if she just relaxes. D) ignore the non-verbal communication and continue with the interview.

Answer (B) If this was enough to notice, ask an open ended question to see if this just might be normal behavior for the patient. A wastes time without confronting a potential problem, C assumes too much and may offend, D also ignores confronting a potential problem. (Berman, 8th ed, Ch 18, p. 324)

2) Research studies have shown that in hospitals: A) the greater the percentage of attending physicians, the lower the incidence of adverse client outcomes. B) the greater the percentage of registered nurses, the lower the incidence of adverse client outcomes. C) implementing the total care delivery model results in a superior quality of care. D) unlicensed assistive personnel and practical nurses are able match the level of care provided by registered nurses.

Answer B On page 112 in our Berman text, in the section "Research Note," a study is described that found the larger the percentage of registered nurses among total staff, the lower the incidence of adverse client outcome such as falls, errors and preventable infections. It also states that, "quality was lower on those units that used the total care delivery method. " It also states that quality was superior on "units that had all RNs as opposed to staffing that included unlicensed assistive personnel and practical nurses."

2) According to the video, "Chasing Zero," a hospital that is effective in reducing error will have: A) a culture of using checklists, safe practices and experienced staff. B) experienced staff, policies against overtime and a low patient to nurse ratio. C) engaged leadership, safe practices and technological support. D) technological support, BSN educated nurses and policies against overtime.

Answer C - The video, Chasing Zero, clearly states that the 3 most important characteristics a hospital needs in order to reduce/eliminate error are: engaged leadership that will prioritize the effort, safe practices that are outlined and implemented for staff and technology that will work to catch human error.

Question 2 A student enters a patient's room to check vitals and the patient says "Oh, I don't think that's necessary, no one cares if I live or die." The student does not notice the patient's attempt to talk about their feelings because the student is tired, hungry, stressed, and preoccupied with his/her own worries. What would help the student develop caring? a. Plan for nutritious food choices on stressful days and stop skipping meals b. Ask the student's doctor for anti anxiety medication c. Commit to going on a thirty minute run daily d. Sit quietly and imagine a warm glowing light from within the student. e. Cancel all recreational activities as the student needs to focus more on patient

Answer is A, C, D. These answers reflect elements of self care such as nutrition, exercise, guided imagery. It is essential to develop care for yourself if you want to have the capacity to care for others. Berman, p.457

3. The Nurse notes an advance health care directive in the patient's chart. What should a nurse know? Select all that apply. a. A living will is put to use when the patient can no longer make decisions for him/herself b. The patient can not make any changes to the advance directive once admitted into the hospital c. A durable power of attorney for health care appoints someone else to make decisions for the patient once s/he can no longer do so d. A living will appoints someone else to make decisions for the patient when the patient is in a vegetative state

Answer. A, C Berman, 65

1. A patient diagnosed with late-stage lung cancer is experiencing breakthrough pain and is asking for more pain medication. He was given morphine, an opioid-based drug, less than 3 hours ago. What should a nurse do, following Provision 1.3 of the ANA Code of Ethics? 1) give enough morphine to the patient to alleviate his pain 2) wait for further directives from the patient's oncologist 3) refuse to give more morphine due to risk of respiratory arrest 4) offer to give the patient a non-opioid pain medication instead

Answer: 1 Rationale: According to Provision 1.3 of the ANA Code of Ethics (the nature of health problems), the nurse should respect the rights, dignity, and worth of all those who require nursing services for health promotion, illness prevention, health restoration, comfort, and supportive care to those who are dying. As such, the nurse should provide necessary pain management to the patient even though this may hasten death. The emphasis is on avoiding needless pain and suffering by the dying patient. However, the nurse should not do so with the intent of ending the patient's life, regardless of the benevolence of intentions. Choices 2, 3 and 4 are not correct because delaying or holding back on pain relief to the extent that pain is not controlled is not acting in patient's best interests. (source: ANA Code of Ethics pdf handout)

A patient is deciding if she should move forward with an invasive cosmetic surgery, how should her nurse help her come to the best decision? 1. Ask, "Have you considered any other options?" 2. Provide a story about a patient who did this surgery and was happy. 3. Ask, "How will you discuss the surgery your family or friends?" 4. Ask, "Why are you second guessing yourself now that you're so close to what you want?"

Answer: 1 and 3 are examples of ways a nurse could clarify patient values. 1 is an example of "listing alternatives" and 3 is an example of "choose freely" (Berman, 82). The other choices are too opinionated or coercive. I got 1 point off because I need to "make alternatives about the same length, sentence structure; be sure you include 'select all that apply' when there is more than one correct answer." She did use one of my questions on the last exam but changed it.

Which of the following are examples of a health disparity? 1. Blacks have a 10 times higher rate of new AIDS (acquired immune deficiency syndrome) cases than whites. 2. Women get breast cancer more frequently then men. 3. More black women dye more from breast cancer than white women, despite the fact that more white women get breast cancer than black women. 4. People living in rural areas that live closer to a hospital than people in the city.

Answer: 1 and 3. A health disparity is when one population experiences different care when compared to a different population (Berman, 317-318). Answer 1 comes from textbook, answer 2 is made up, answer 3 is from our group presentations, and answer 4 is made up.

Choose the actions that are considered to restore a patient's health in the HEALTH Traditions Model. A) Patient prays for healing, and asks for a religious ritual to be performed. B) Patient resists wearing a hospital gown. He wants to wear symbolic clothing. C) Patient avoids specific people, believing they can cause illness. D) The patient requests an exorcism to rid himself of sickness.

Answer: A and D. These are each examples of health restoration in the HEALTH Traditions Model. Answers B is an example of health maintenance in the HEALTH Traditions Model, and answer C is an example of a patient protecting his health in the HEALTH Traditions Model. (Berman, pg 321)

The nurse is caring for a patient who has undergone external fixation of a broken leg and has a cast in place. To prevent skin impairment, the nurse should

Assess all surfaces exposed to the cast for pressure areas.

The nurse identifies that a patient has received Mylanta (simethicone) instead of the prescribed Pepto-Bismol (bismuth subsalicylate) for the problem of indigestion. The nurse's next intervention is to

Assess and monitor the patient.

Question 1: An ER nurse is caring for a Southeast Asian female patient who has been diagnosed with appendicitis but refused surgery. Which of the following responses by the nurse would be considered most appropriate? 1. wait for the patient's husband to arrive to assist with decision making 2. do nothing because the patient has autonomy to refuse treatment 3. advocate for the patient and her decision of not getting the surgery 4. prepare the patient's discharge paperwork along with pain medication

Answer: 1 is correct because of the Asian culture, most often, the head of household or family members ultimately make health decision. In contrast, patients with Western views want control over their health rather than allowing a family member to contribute in their decision. The nurse with this understanding should wait for the husband to arrive and with his presence the patient may be more comfortable with the idea of having surgery. 2. incorrect because the nurse is giving in rather than to think holistically in regards to patient's cultural background. 3. incorrect because the nurse is lacking in the knowledge and the differences of cultures when making health decisions. 4. incorrect because the nurse is not advocating for the patient in respect to her cultural background. Berman text, pg 93

A nurse is asked to obtain a consent form from a patient. After the patient signs the form it asks the nurse to sign as well. By signing these forms the nurse is confirming which of the following? Select all that apply. 1. The signature is authentic. 2. The nurse explained the procedure to the client. 3. The client gave consent voluntarily. 4. The client appears competent to give consent.

Answer: 1,3,4. The nurse's signature on the form of does not require the nurse to explain the procedure, but it does indicate the nurse saw the client sign it and it was given voluntarily and the person was competent enough to give consent. Berman pg. 62

Which of the follow best defines prejudice? 1. A preconceived notion that is not based on adequate knowledge; it can be beneficial or unbeneficial. 2. Assumptions about a racial group. 3. The differential and negative treatment of individuals on the basis or their race, ethnicity, gender, or other group membership. 4. Making the assumption that an individual reflects all characteristics associated with being a member of a group.

Answer: 1. "Prejudice is a preconceived notion or judgment that is not based on sufficient knowledge. It may be favorable or unfavorable" (Berman, 317).

A 70 year old man had a heart attack and was resuscitated. After waking with several broken ribs and in severe pain the man decided that he does not want to go through this situation again. The patient decides he wants to sign a DNR, but the family of the patient thinks that the patient is making a rash decision. What should the nurse do? 1. Order the necessary forms for the patient. 2. Talk to the patient from the family's perspective. 3. Wait until the family is gone and talk to the patient about different options. 4. Ask a doctor to talk to the patient.

Answer: 1. It is the nurse's moral responsibility to honor the patient's right to autonomy and allow the patient to sign a DNR. Berman pg. 85

A nurse suspects that a treatment ordered by a physician will harm her patient; what would be the proper action for the nurse to take? 1. Refuse to carry out orders and report the situation to her nurse supervisor 2. Carry out the orders, then immediately report to her nurse supervisor 3. Inform the patient and allow her to choose whether or not to accept treatment 4. Report the physician to hospital's human resources department

Answer: 1. rationale: Even though it is the physician's orders that the nurse is following, the responsibility of any nursing actions will be the responsibility of the nurse. The proper action would be to avoid doing anything that would harm a patient and report to the nurse supervisor. (Berman, p. 58)

Question 2: A patient who is diagnosed with a terminal cancer and was instructed by a physician to start chemotherapy. What is the most appropriate question that the nurse should ask the patient? 1. Are you aware of the side effects of chemotherapy? 2. Can I share my story as a breast cancer survivor? 3. How do you feel about your decision? 4. Do you want to know your prognosis?

Answer: 3 is the correct answer because the nurse is asking the patient to clarify his/her perspectives and values. Asking about the patient's feeling will initiate a dialogue and the nurse will truly find out what's most important value in the patient's care plan. 1. incorrect because asking about awareness of side effects will not clarify client's value in order for the nurse to plan effective care. 2. Sharing a positive story will not help in identifying client's value towards the newly diagnosed cancer. 3. raising the question of prognosis will help with clarifying the client's value. Instead the question will even stop the dialogue. Berman text pg. 82

2. Which of the following does not reflect a violation of the conflicts of interest provision in the ANA Code of Ethics? 1. a nurse who cares for the football coach of his/her son who promised more playing time for the son 2. a nurse who hands out free samples from the pharmaceutical company where his/her spouse works 3. a nurse who refers elderly disabled clients to a family member who runs a private home care agency 4. a nurse who requests to be removed from the care of a patient who had assaulted his/her daughter

Answer: 4 Rationale: According to the ANA Code of Ethics (provision 4.4), a conflict of interest occurs when a nurse's personal interests interfere with the patient's best interests or the nurse's professional responsibilities. The nurse should never exploit the patient for any type of personal gain. When the nurse perceives a potential conflict of interest, he/she should reveal the potential conflict to parties involved, and in some instances, remove himself/herself from the situation. Choices 1, 2 and 3 are all violations of the conflicts of interest provision. (source: ANA Code of Ethics pdf handout)

(3) A novice nurse has just discovered that their nursing manager has a secret drug problem. The nurse should: 1) Keep the nursing manager's secret 2) Report the manager to the police 3) Talk to their manager about rehab 4) Report the manager to their employer

Answer: 4 - Reporting the manager to their employer may save the manager's license and/or life. Berman p 63

Who does the BRN (Board of Registered Nursing) represent? Select all that apply A. The public B. Certified Nursing Assistants C. Registered nurses D. Healthcare professionals

Answer: A (Source: BRN website: http://www.rn.ca.gov/about_us/whatisbrn.shtml) The BRN represents the public and regulates registered nurses in the state of California.

Which of the following is ethical. Select all that apply A. Respect a patient's advanced directive of DNR even though the family disagrees. B. Helping a terminal patient administer lethal medication in Oregon. C. Refusing to assist in an abortion due to religious or moral principles. D. Suggest a new medicine to a patient because your friend told you it was effective.

Answer: A, B, C are correct. For A, since the patient completed an advanced directive, the nurse is ethically responsible for voicing that decision. B is correct because euthanasia is legal in certain states, including Oregon. C is correct because conscience clauses allow nurses to refuse assisting with an abortion if it violates moral principles. D could be true if the 'friend' was someone credible, but more research should be done before suggesting a medicine to a patient since nurses are supposed to maximize the client's well-being. Berman, page 89-93

1) Which of the following statements illustrate behaviors of unclear values? Select all that apply. a) Patient with diabetes who will not stop consuming sodas and processed foods b) Obese patient expresses she wants to lose weight but do not want to exercise. c) A patient who continually seeks helps to stop smoking but cannot cut down. d) Patient with high blood pressure who is thinking about cutting down salt intake. e) Patient who is anorexic ignores doctor's recommendation on healthy lifestyle.

Answer: A, B, C, E Rationale: Answers A & E ignore health professional's advice. Answer B demonstrates inconsistent behavior/communication. Answer C exhibits patient's numerous admissions to a health agency for the same problem. Answers A, B, C, and E exemplify behaviors that may indicate unclear values. Answer D demonstrates that patient is in the precontemplation stage. Berman, pg. 83, 285

2. A nurse who is completely against homosexuality is refusing to provide care for a 45 year old gay patient with AIDS. Which of the essential nursing values is this nurse lacking? Select all that apply. A. Human dignity B. Altruism C. Utility D. Social justice

Answer: A, B, D. This nurse does not show concern for the welfare of her patient (altruism); this nurse does not show respect for the inherent worth and uniqueness of individuals (human dignity); this nurse does not provide fair treatment regardless of sexual orientation (social injustice). Utility is not an essential nursing value. Berman text, p 81

2) A nurse who is aware of one's relationship to others, fosters trusting relationships, and presents oneself as someone who respects others and demands respect demonstrate which 6 Cs of caring in nursing? Select all that apply a) Compassion b) Capability c) Confidence d) Conscience e) Comportment

Answer: A, C, E Rationale: Answer B is not part of the 6 C's of caring in nursing. Answer A: A nurse exemplifies compassion when one is aware of one's relationship to others and participates in the experience of another. Answer C: A nurse who has the quality that foster trusting relationships and comfort with self, client, and family shows confidence. Answer E: A nurse that is in harmony with a caring presence and present oneself as someone who respects others and demands respect illustrates comportment. Berman, pg. 451

1. Which of the following could be considered a social determinant of health? A. Living in an area where there are plenty of social meeting spots, i.e. cafes, parks B. Attending a quality school C. Frequenting a restaurant that does not have a wheelchair accessible ramp D. Not having access to the internet

Answer: A,B and D Rationale: A, B, and D are all social determinants of health but C is an example of a physical determinant of health. The lack of a ramp can be a physical determinant of health. (Healthy People 2020)

1. Occasionally, the client's best interest is contrary to the nurse's personal belief system. What is this contradiction referred as? A) Moral Distress B) Moral Conflict C) Moral Disagreement D) Moral Discrepancy

Answer: A. Moral distress causes serious issues in the workplace and nurses might need assistance with coping. The four A's to help nurses cope with moral distress are: ask, affirm, assess, and act. (Berman, pg 89).

Obtaining informed consent for treatments and procedures is the responsibility of the a. Primary care provider b. Nurse c. Nurse manager d. CNA

Answer: A. Primary care provider. Obtaining informed consent is the responsibility of the one who is going to perform the procedure, generally primary care provider or surgeon. Can also be NP, nurse anesthetist, nurse midwife, PA, or clinical nurse specialist. Berman, 59.

3. If an institution denies medical care to a group of people based on their sexual identity, what cultural concept are they exemplifying? A. Discrimination B. Stereotyping C. Racism D. Generalization

Answer: A. The institution is giving negative or differential treatment to a specific group of people. This is absolutely wrong, as all people deserve the same quality of care regardless of their gender, sexual identity, race, or ethnicity. (Berman, p. 317)

3. Which of the following choices best defines the idea of personal standards of what is right and wrong? A. ethics B. morality C. fidelity D. veracity

Answer: B Rationale: According to Berman and Snyder, morality is defined as "private and personal standards of what is right and wrong in conduct, character, and attitude." They define ethics as "the rules or principles that govern right conduct", fidelity as being "faithful to agreements and promises" and veracity as telling the truth. (source: textbook, pages 82-86).

2. Upon request, a medical professional gives a terminally ill patient a lethal dosage of medication that the patient can administer at home. This can best be described as: A. active euthanasia B. assisted suicide C. passive euthanasia D. voluntary manslaughter

Answer: B Rationale: Assisted suicide occurs when a patient is given the means to end his life himself, upon request. Active euthanasia involves actions that bring about a patient's death directly (e.g. a medical professional administering a lethal dose of medication). Passive euthanasia occurs when life support is removed. Manslaughter may or may not be a punishment for euthanasia and assisted suicide, depending on the circumstances. (source: textbook, page 92)

What is a term used to describe an area with little access to large grocery stores with fresh and affordable foods needed to maintain a healthy diet? A. Rural B. Food desert C. Wasteland D. Urban

Answer: B (Source: Group 4's Health of the Community presentation "West Oakland: Food Desert")

The nurse is caring for a patient in restraints. Which of the following pieces of information about restraints requires nursing documentation in the medical record? (Select all that apply.)

Attempts to distract the patient with television are unsuccessful. The patient has been placed in bilateral wrist restraints at 0815. Bilateral radial pulses present, 2+, hands warm to touch Released from restraints, active range-of-motion exercises complete

Question 3 A nurse is caring for incarcerated individuals at a state prison. The nurse attentively listens to each patient, provides quality care, and views them as a holistic person and deserving of care. What aspect of the ANA code of ethics is this nurse fulfilling? a. The nurse advocates for patients safety and rights b. The nurse practices with respect for the uniqueness of every individual regardless of social/economic status or nature of health problem c. The nurses primary commitment is the the patient, whether an individual, family or community D. The nurse is aaccountable for individual nursing practice and appropriate delegation of tasks.

Answer: B, This is an example of our ethical duty and the fundamental right of all individuals to receive care. ANA Guide to the code of ethics for nurses p. 1-41

3. You are assigned to take care of a patient who just had an abortion, but your beliefs are against abortions. It is best if you: A) Tell the charge nurse why you cannot take care of the patient. B) Take care of the patient because you are in a professional role. C) Ask another nurse is he/she could cover your shift with the patient. D) Forget about your own beliefs and assist the patient with her needs.

Answer: B. According to the ANA code of ethics for Nurses, the nurse's primary commitment is to the patient. In addition, the International Council of Nurses Code of Ethics mentions that the nurse's primary professional responsibility is to people requiring nursing care. A nurse does not necessarily have to forget about his/her own beliefs, but rather just put them aside and not let them conflict with their professional role. A nurse's responsibility is to give the best quality care and be non-judgmental towards patient's decisions. (Berman, 87-88)

2. There is an 80-year old man suffering from bone marrow cancer. The patient is extremely depressed and no longer wants to live. They have requested that the nurse please give them a lethal dose of morphine to let them die peacefully and without anymore pain. The nurse refuses, what is the client asking the nurse to perform? A. Passive Euthanasia B. Active Euthanasia C. Termination of life-sustaining treatment D. Withdrawing

Answer: B. In this case the client is asking the nurse to perform active euthanasia, or "mercy killing". This is illegal and would result in criminal murder charges against the nurse if they had gone through with the act. This scenario involves a patient asking the nurse to administer lethal medication to end their suffering. (Berman, p. 92)

• 1. Which of the following scenarios best reflects the concept of nonmaleficence, rather than beneficence? A. Administering painkillers to a post-op patient B. Helping a patient brush her teeth C. Intervening when a colleague is not following proper aseptic technique D. Educating a patient with a broken hip about physical therapy

Answer: C Rationale: Administering medications, aiding with personal hygiene, and referring patients for further healthcare all fall under beneficence, which menas "doing good". Nonmaleficence, on the other hand, means to "do no harm". Preventing the improper use of aseptic technique is an example of doing no harm. (source: textbook, pages 85-86, and Dr. Saulo- Lewis lecture)

3. A nurse states "My patients family just offered me some pasta they made from scratch...but cmon', only Italians like me know how to make pasta!" What does this statement indicate? A. Prejudice B. Discrimination C. Ethnocentrism D. Stereotyping

Answer: C Rationale: Ethnocentrism is the belief that ones own culture or lifestyle is superior to others. The nurse felt that only Italians like herself can make good pasta. (Berman e.g., p.317)

3) Patient is fighting end-stage of ovarian cancer. In the patient's advance directives, it specifically states to withhold special attempts to revive. This is an example of which end-of-life issue? a) Active euthanasia b) Assisted suicide c) Passive euthanasia d) General suicide

Answer: C Rationale: Passive euthanasia is commonly referred to as WWLST, withdrawing or withholding life-sustaining therapy that involves the withdrawal of extraordinary means of life support and allowing patient to die of the underlying medical condition. Active euthanasia involves actions to bring client's death directly (with or without client's consent). Assisted suicide is providing client with resources to kill themselves under his/her request. Berman, pg. 92

1. According to Berman, what are the two key words for a healthy lifestyle? A. Eat and Exercise B. Diet and Diligence C. Balance and Moderation D. Mind and Body

Answer: C. Key words for a healthy lifestyle are balance and moderation. Berman text p. 456

Q2. A 19 year girl was rushed to hospital, had a miscarriage and was not aware that she was even pregnant. The parents arrived to the hospital not knowing what has gone wrong. The girls asked the doctor and the nurse not to tell her parents about the miscarriage. What be the Nurse response when the parents ask about their girls health? a) Tell them the truth and inform them that their daughter did not want them to know. b) Tell them it is none of their business as their daughter is over the age of 18. c) Tell them their daughter is well and due to patients privacy they are not able to disclose any information. d) Talk aloud in front of doctor about the girl's condition so her parents could over hear the case.

Answer: C: Nurse and Doctor have to respect the patient's wishes and request for their privacy. Also, present the information to their parents in an ethical way of not offending or disrespecting like in the answer B. The patient has the right to decide whether she wants to disclose her information to her parents or not and as a Nurse you have to respect that decision and honor it in every way so talking aloud so parents could hear would also violate this ethics. (PowerPoint, Nursing Ethics, slide 35-39)

2. Which of the following would least likely help develop psychological homeostasis? A. A life experience that provide satisfactions B. A family environment that includes parents who are healthy role models C. Having parents that give kind but firm consistent discipline D. A social environment that encourages values of honesty, giving and tolerance.

Answer: D Rationale: Healthy role models, appropriate discipline, and a life experience that provides satisfactions are all examples of developing psychological homeostasis. Social values like honesty and tolerance are more specific to the family unit. (Berman e.g., p.277)

1. A 16-year old girl comes into your clinic pregnant and seeking an abortion. Based on your personal religious beliefs you are against abortion, and thus do not feel comfortable continuing care with this patient. What would be the more appropriate response? A. Preach your religious faith and try to "save" the client by stopping her from receiving an abortion. B. Give her a pamphlet on why abortion is wrong, however say that the decision is up to her. C. Tell her you are against abortion and that she cannot seek treatment there. D. Refer to a clinic that can help her with the appropriate treatment options that she is seeking.

Answer: D. Most states have laws allowing nurses to refuse to assist in an abortion is it violates religious or moral principles. But, based on the code of ethics, nurses must support the right for clients to be informed and have counseling to make informed decisions free of judgment and without coercion. (Berman, p. 91)

2. You are about to take a patient's blood pressure and the patient physically withdraws his/her arm. You should: A) Assume the patient's arm hurts and assess the other one. B) Continue the procedure and check the patient's vitals. C) Ask the patient if something is bothering him/her. D) Step back and inform the patient about the procedure.

Answer: D. Patients may physically withdraw from nurses and other health care providers if they feel that he/she is too close. The concept of personal space depends on the culture. For instance, Western societies tend to be more territorial and will either move back or mention that someone is in his/her space. Stepping back and letting the patient know what is going to be done prior to the assessment should be considered. (Berman, 326).

Q1. A Senior Nurse always watching your work and points out all the errors you make. One day the same Senior Nurse was about to see a patient and gets an equipment that had a label stating, not functioning effectively and is set for repair. The Senior Nurse forgets to check and takes the equipment and you notice this happening. What would be your reaction? a) Let the Senior Nurse finish using the equipment and then tell her. b) Tell in front of everyone that Senior Nurse should check labels on the equipment before using it. c) Ignore what you saw and let the Senior Nurse do her job and eventually would find out that the equipments is not working. d) Go to the Senior Nurse personally and let her know that equipment is set for repair.

Answer: D: A Nurse job is not to just focus on her own work, but prevent evil or harm and remove evil or harm as a moral principal. Letting the Senior Nurse be aware about the equipment is also protecting the patient and the Senior Nurse. Safety of yourself, others staff members, and patients is very important and putting aside your personal feeling toward anyone. (PowerPoint, Nursing Ethics, slide 25 -26)

3. A client who has upper respiratory congestion is less congested in a supine raised head position but is in increased pain in this position due to recent rectal surgery. Which critical thinking attitude does the nurse utilize when quickly responding to the clients needs by suggesting they try a raised side lying position? a. Intuition b.The nursing process c. The trial-and-error method d. The research method

Answer: a Rational: When utilizing intuition experience is key to understanding needs; this nurse knew without consultation to others or research that this would be a likely solution. Trial-and-error includes several approaches and if this new position were unsuccessful, the nurse would likely move to a trial-and-error approach. (Berman text, p.168)

An example of the nurse's moral obligation according to the ANA Code of Ethics is: a) Withholding food and fluids to a dying patient if it is determined to be more harmful to administer them then to withhold them. b) Ensuring that the family members of the patient are aware of the advance directive and agree to the terms. c) Assisting with an abortion even if it is against the nurse's beliefs. d) Assisting a terminal patient's request to end his life by participating in active euthanasia.

Answer: a) According to the ANA Code of Ethics for Nurses (2005), this position is supported through the nurse's role as a client advocate and through the moral principle of autonomy. Rationale for incorrect answers: b) the family members do not have to agree to the advance directives if they are already in place by the patient. c) Most states have conscience clauses, which enables a nurse to have the choice of not assisting with abortions if it is against their beliefs. d) While assisted suicide is legal is some states, the ANA's position on euthanasia is that both active euthanasia and assisted suicide are in violation of the Code for Nurses. Berman, A. & Snyder, S. Kozier & Erb's Fundamentals of Nursing. pg 91-92

2. Which of the following would not apply to the nurse's role as an advocate? a. Convincing a patient that he or she should ultimately be making medical decisions for his or herself. b. Allowing a home-care patient to revert back to his or her unhealthy habits after being released from the hospital. c. Working at the government level to gain wins for the nursing profession in pertinent areas of public health. d. Providing a patient with the necessary information to make his or her own medical decisions and supporting those decisions.

Answer: a. Western tradition values a patient's control in making his or her own medical decisions. In other cultures, these responsibilities may be held by another individual, such as an elder or an entire community. The nurse needs to respect and accept these traditions, even if they don't correspond with his or her own values. Berman text, p. 93.

2. A physically combative client with AIDS is admitted to the emergency room for a bacterial infection. The emergency room is understaffed and the client is sent to the AIDS ward. The nurse on duty is directed to administer an antibiotic by intramuscular injection. Does the nurse have a moral obligation to care for this client? a. Yes, unless the risk is greater than the responsibility. b. No, the nurse can refuse on religious values and beliefs. c. Yes, the nurse's primary obligation is to the client. d. Yes, but not until an orderly is present to restrain the client.

Answer: a. Yes, but if a client is physically combative it may place the nurse at risk for a needle stick injury; the risk would exceed the responsibility b. the nurse cannot refuse on religious values and beliefs c. and d. Yes, but not if the risk is greater than the responsibility (Berman text, page 91)

Which of the following is a purpose of the nursing code of ethics: (Select all that apply) a) Guide the profession in self-regulation b) Provide ethical standards for professional behavior c) Enacting the conscience clause regarding personal beliefs and care. d) Strive for collaborative practice

Answer: a.b Nursing code of ethics have the following purposes: 1) Inform the public about the minimum standards of the profession and help them understand professional nursing conduct. 2) Provide a sign of the profession's commitment to the public it serves. 3) Outline the major ethical considerations of the profession. 4) provide ethical standards for professional behavior. 5) Guide the profession in self-regulation. 6) Remind nurses of the special responsibility they assume when caring for the sick. Berman, A. & Snyder, S. Kozier & Erb's Fundamentals of Nursing. pg 87

3. A nurse is directed to have a client sign a consent form for electromagnetic therapy. The nurse is responsible for which actions: 1. Explaining the procedure to the client and obtaining the client's voluntary signature. 2. Witnessing the client's signature and verifying the client received enough information. 3. The nurse is not responsible for obtaining a client's signature; only the physician. 4. Encouraging the client to sign the form, because the client will benefit from the surgery.

Answer: b. The nurse should witness the signature and advocate for the client by verifying that the client received enough information a. The nurse could be liable for providing incorrect information to the client. If the nurse has doubts about the client's understanding the nurse should notify the health provider c. It is the responsibility of the nurse to witness the client's signature d. The client's signature should be voluntary and not influenced by the nurse. (Berman text, page 59)

2) Which of the following actions best demonstrates a nurse understands the concept of values clarification? a) A nurse persuades the client to make a decision the nurse feels is in her/his own best interest. b) A nurse understands and adheres to the stated values of the institution she/he works for. c) A nurse respects the client's decision even though she/he does not agree with it. d) A nurse understands and adheres to the essential nursing values as set out by the AACN.

Answer: c Values clarification is a process nurses undertake to better understand and become aware of her/his own values. The goal is to avoid unintentionally or unconsciously imposing the values of the nurse on the client. (Berman, p. 81,82)

1. A nurse is dealing with an extremely uncooperative patient who will not take his medicine. What would be an appropriate response? a. Telling the patient, "You have to take your meds. It's what the doctor ordered, and it is in your best interest." b. Crushing the meds in the patient's food so that he gets them anyway, because he really needs to take them to get better. c. Informing the patient of the possible ramifications of not taking his meds, but accepting that he does not have to take them if that is his decision. d. Telling another nurse not to force the patient to take his meds because it is his decision not to take them. And, if he does not care about getting better why should his nurses.

Answer: c. Choice (a) violates the essential nursing value of autonomy. Choice (b) violates the essential nursing value of integrity. Choice (d) violates the essential nursing value of altruism. Berman text, p. 81.

1. A 75 year old woman with ovarian cancer rejects radiation and chemotherapy treatments, because she fears their effects. She wants to only pursue a natural, holistic treatment, because she believes it is the least painful option. What nursing action would be most helpful? a. Honoring the client's decision and not interfere with her choice to avoid a painful treatment. b. Helping her research the most effective, holistic treatments and choosing the best option. c. Verifying the client has accurate information and understands the consequences of her decision. d. Informing the client that radiation and chemotherapy are the best options for her survival.

Answer: c. Nurses need to help clarify client's values by examining the possible consequences of their choices; make sure the client has thought about possible results of each action. a. The client may not have accurate information. Not providing accurate information would be violating nonmaleficence. b. and d. These actions would be imposing the nurse's values on the client, which should never be done. (Berman text, page 82)

2. According to the American Nurses Association, participation in assisted suicide, or assisted euthanasia by a nurse is: a. currently upheld by the Supreme Court in the state of Oregon. b. permissible so long as it is by means of passive euthanasia. c. in accordance with the code of ethics with a physician's order. d. currently considered a violation within the Code for Nurses.

Answer: d Rational: The ANA considers both active and assisted euthanasia in violation of the Code for Nurses. Passive euthanasia is the cessation of life supporting means and is more commonly accepted and practiced than assisted or active euthanasia. (Berman text, p.92)

3) A nurse acts on behalf of the client in order to insure that she/he gets access to health care that meets her/his needs. The nurse is fulfilling which nursing role. a) Caregiver b) Case manager c) Change agent d) Client advocate

Answer: d The nurse as client advocate acts to protect the client, and represent her/his needs and desires to other health care providers. (Berman p.17,93)

1) A nurse decides it is inappropriate to keep information from a client about his/her condition, and acts on the decision displays which moral principal. a) Beneficence b) Fidelity c) Autonomy d) Veracity

Answer: d Veracity refers to telling the truth (Berman, p. 86)

3. Which of the following is not an acceptable example of giving informed consent? a. A father signing a consent for a tonsillectomy for her 16 year-old daughter who is worried the surgery will affect her singing voice. b. A husband giving consent for his comatose wife to receive a new treatment that is still in its trial stages. c. A surgeon assuming given-consent for an emergency procedure for an unconscious client whose next-of-kin cannot be located. d. A mother signing consent for her married 17 year-old son to participate in a research trial for a new ADHD medicine.

Answer: d. Minors who are married, pregnant, parents, members of the military, or emancipated are legally permitted to provide their own consent. The general rule under Maryland law indicates that if guardians and minors fitting these categories differ in opinion on consent, the IRB will go with the minor's decision. Therefore, a mother signing a consent for a married minor may not always be valid. Berman text, p. 60-62. http://www.hopkinsmedicine.org/institutional_review_board/guidelines_policies/guidelines/informed_consent_minors <--- under "Minors who are Married or the Parent of a Child"

Confusion

Being perplexed or disconcerted

Nonmaleficence is best portrayed by: a) Promising to return to a patient in a timely manner and following through. b) Agreeing to not tell the patient that they are terminal at the request of the family. c) Assisting a patient with their DNR paperwork d) Being unsure about wish medication to administer and asking for clarification.

Answer: d: Nonmaleficence is the duty to "do no harm". This includes intentional harm, unintentional harm, and placing someone at risk for harm. Asking for clarification about a medication that a nurse is unsure of, ensures that the patient is not harmed by the incorrect medication. a) is an example of fidelity. b) is an example of not following veracity. c) is an example of honoring autonomy of the patient. Berman, A. & Snyder, S. Kozier & Erb's Fundamentals of Nursing. pg 85-86. Powerpoint presentation by Mileva Saulo Lewis, EdD, RN. Slide 13, 25, 26.

2.My client was told that he terminal disease.In what way does the nurse shoe competence? A. A nurse who discusses the palliative treatment options with the client and his family B. A nurse wants to listen to the patient and and say if you need I will be here C. A nurse who states that he or she knows what the patient is going through D.. A nurse who participates in meditation with the client to help them relax

Answer:A Rationale: A competent nurse understands the patient's condition, its treatment, and its associated care. The competent nurse is able to provide assessment, planning, implementing, and evaluation of a plan of care with the client and with the clients family. So by discussing the palliative treatment option that will be the best treatment. (Berman text pg-451)

1:Which of the following is the example of the primary prevention? A.Ear infection is treated by the antibiotics B:Therapy given to a patient who was discharge from knee surgery C.Nutrition counseling for patient who has a family of obese and diabetes D.Removing tonsils for the patient with the condition of tonsillitis

Answer:C Rationale:Primary prevention address areas such as proper nutrition so early detection will minimise the risk factors of the illness.(Berman text pg -100).

3. The hospital's neonatal unit was understaffed due to a flu outbreak. As a result, a nurse was given too many patients and was unable to provide adequate care for all of them. Which would be an acceptable delegation of care by the nurse? Select all that apply. 1. asking a nurse from the intensive care unit for assistance with insertion of feeding tubes 2. asking a student nurse to administer parenteral medication to a baby in a stable condition 3. asking a new nurse to take the vital signs of a baby whose condition is not stable 4. asking a nursing assistant to teach the mother how to change her baby's dressing

Answers: 1 and 3 Rationale: Nursing delegation means entrusting the performance of selected nursing duties to individuals who are qualified, competent and legally able to perform such duties. The nurse is responsible for assessing the competency of other nurses and health care personnel before transferring or assigning care duties of patients to them. Choices 1 and 3 are correct because both nurses are qualified and have the knowledge and skill to perform assigned task. Choices 2 and 4 are not correct because unlicensed assistive personnel such as the student nurse and nursing assistant cannot be delegated tasks such as administering parenteral medications and client education. ((sources: ANA Code of Ethics pdf handout; Berman text, pgs. 524-525)

2. According to the ANA Code of Ethics for Nurses, "nurses must promote, advocate for, and strive to protect the health, safety, and rights of the patient". Additionally, nurses should advocate for their own colleagues who may show signs of impairment. Why might it be difficult for nurses to deal with an impaired colleague? Select all that apply. a. Fear of retaliation at work b. Fear of breaking friendship c. Assume the impaired nurse knows her situation well and where to get help d. Assume the problem will not persist long, wait for it to resolve itself

Answers: A, B. Nurses usually avoid dealing with impaired c0lleagues for fear of retaliation (or being called a whistle blower) and for fear of breaking friendship and their sense of teamwork. C/D Even though an impaired nurse may know her situation, it may be hard for her to admit it or seek help. She may not be aware of the programs available to help

Choose the answers that are examples of essential nursing values. A) A nurse treats all patients with same standard of care except those patients who are not insured. B) A nurse values and respects her patients, but not necessarily all of her colleagues. C) A nurse respects her patient's right to make decisions about her own health. D) A nurse shows concern for the welfare of her patients, and other healthcare workers.

Answers: C and D Rationale: C is an example of autonomy, and D is an example of Altruism. Answer A excludes patients who are not insured, so this is not an example of social justice. Answer B is not an example of human dignity, because the nurse does not respect her colleagues, it is not an example of altruism. (Berman, pg. 81)

When developing a plan of care concerning growth and development for a hospitalized adolescent, what should the nurse do? (Select all that apply.)

Apply developmental theories when making observations of the individual's patterns of growth and development. Compare the individual's assessment findings versus established normal findings. Recognize his/her own moral developmental level.

The patient is complaining of an inability to clear his nasal passages. The nurse instructs the patient to

Apply gentle suction using a pediatric bulb suction device

The patient complains to the nurse about a perceived decrease in hearing. When the nurse examines the patient's ear, she notices a large amount of cerumen (ear wax) buildup at the entrance to the ear canal. The nurse should

Apply gentle, downward retraction of the ear canal.

A patient is being discharged home. Which information should the nurse include?

Community resources

The nurse is admitting a patient to the hospital. The patient states that he is a very spiritual person but does not practice any specific religion. The nurse understands that these statements

Are reasonable.

A patient has been hospitalized from a motor vehicle accident for the past month. The nurse notices that the patient has been becoming withdrawn and asks the patient if something is upsetting him. The patient confides to the nurse that he wants to have sex with his spouse but is afraid to in a hospital. How should the nurse proceed?

Arrange a schedule with the patient to allow for intimacy at a time when the patient is well rested and able to participate in activity.

Arteriosclerosis vs. Atherosclerosis

Arteriosclerosis - hardening of the arteries vs Atherosclerosis - plaque build up in the arteries However, both accompany the aging process and restrict blood flow, but arteriosclerosis more associated with aging

How is pain recorded?

As a fraction with 10 as the bottom number. A complete documentation of pain will include other characteristics described by the patient

D. 1, 2, 3, 5

As a person ages, they can expect changes in their mouth. What changes are expected in the healthy older adult? 1. Less saliva 2. Less taste buds 3. Thin epithelium 4. More taste buds 5. Risk of infection

A nurse is in the hallway assisting a patient to ambulate and hears an alarm sound. What is the best next step for the nurse to take?

Ask another nurse to check on the alarm.

The nurse has been caring for a patient in the perioperative area for several hours. The surgical mask the nurse is wearing has become moist. The nurse's best next step is to

Ask for relief, step out of the surgical area, and apply a new mask.

Which teaching strategy is best to utilize with older adult patients?

Ask patients to recall past experiences that correspond with their interests.

The nursing instructor will need to provide further instruction to the student who states, "Development proceeds

At a slower rate during the embryonic stage."

When should you perfrom foot care?

At bath time

The nurse is interviewing a patient who is being admitted to the hospital. The patient's family went home before the nurse's interview. The nurse asks the patient, "Who decides where to go on vacation?" In asking this, what is the nurse trying to do?

Assess the family structure.

The nurse is completing an admission history on a new home health patient. The patient has been experiencing seizures as the result of a recent brain injury. The nurse diagnoses risk for injury with a goal of keeping the patient safe in the event of a seizure. Which interventions should the nurse utilize for this patient? (Select all that apply.)

Assess the home for items that could harm the patient during a seizure. Provide information on how to obtain a Medical Alert bracelet. Teach the patient to communicate to the caregiver plans for bathing. Discuss with family steps to take if the seizure does not discontinue.

An advanced practice nurse is preparing to assess the external genitalia of a 25-year-old American woman of Chinese descent. Which of the following nursing actions does the nurse do first?

Assess the patient's feelings and explain the purpose of the examination.

The nurse is preparing to reposition a patient. Before doing so, the nurse must

Assess the weight to be lifted and the assistance needed.

When temperature assessment is required, which of the following cannot be delegated to nursing assistive personnel?

Assessment of changes in body temperature

The patient is a 54-year-old male with a medium frame. He weighs 148 pounds and is 5 feet 8 inches tall. The nurse realizes that this patient is

At his desired weight.

How often is the restraint removed for the patient's position to change?

At least every 2 hours

What do you do at the end of the medical history interview?

At the end of an interview, review the discussion and ask the patient for anything that might have been missed (General overview)

What do you do if orthostatic hypotension occurs?

Assist the patient to a lying position and notify the health care provider in charge

What do you do after the examination?

Assist the patient with dressing (if necessary), return the patient to a comfortable position, document the findings on the appropriate form(s), report to a nurse or physician, and clean the examination area per the local protocol

Which situation will require the nurse to obtain a telephone order?

At 0100, a patient's blood pressure drops from 120/80 to 90/50 and the incision dressing is saturated with blood.

The word spirituality derives from the Latin word spiritus, which refers to breath or wind. Today, spirituality is

Awareness of one's inner self and a sense of connection to a higher being.

As HR increases without change in SV what happens to blood pressure?

BP decreases

As HR slows, filling time is increases what happens to blood pressure?

BP increases

A nurse should instruct the parents of a 10-year-old child to keep which of the following theoretical principles in mind when dealing with a behavioral problem at home?

Bargaining about chores in exchange for privileges may be an effective method of encouraging helpful activities.

The health care model that utilizes Maslow's hierarchy as its base is the _____ Model.

Basic Human Needs

What do changing norms and values about family life in the United States reveal?

Basic shifts in attitudes in our society

1. A client asked their nurse to please help with the pain she currently has from a surgery she had done a couple of hours ago. When the nurse replies, "I will be right back with your pain medication," and she follows through with that promise, the nurse is practicing: 1. Beneficence 2. Fidelity 3. Justice 4. Veracity

Best answer- 2 Rationale: 1- Beneficence is the obligation for nurses to do good, to implement actions that benefit clients and their support persons. 2- This is the best answer because fidelity means to be faithful to agreements and promises. 3- Justice is fairness. 4- Veracity refers to telling the truth- does not lie, because it could lead to loss of trust. (Berman p. 86)

1. Which of the following would be considered a violation of the ANA Code of Ethics for Nurses (2005) for end of life issues? 1. A nurse honoring competent and informed client's decision to withhold food and fluids. 2. A nurse withholding food and fluids because it is determined to be harmful by the physician. 3. A nurse withholding life sustaining treatment because she knows the client is about to die. 4. A nurse keeping clients families informed that they can reevaluate life sustaining decisions.

Best answer- 3 Rationale: 1- The nurse is honoring the patient's decision which is competent and informed. 2- The nurse is honoring that sustaining life is more harmful, as decided by physician. 3- Best answer, this is not the nurse's decision to make, it is up to the client, family or physician. 4- The nurse is allowing the family to know their alternatives, so they are well informed. (Berman p. 92)

1. A frail elderly client has decided that he does not want any more surgeries, but his family and surgeon insist he continue these surgeries. Which of the following is an example of caring-based reasoning? 1. "This surgery, which he may not even survive, will cause him to suffer more and his family will feel guilty later." 2. "This is violating this clients right to autonomy, this man has a right to choose what happens to his body." 3. "My relationship with this man makes me want to protect him; I must help his family understand his needs." 4. "If this man doesn't want the surgery, we shouldn't do it, he may die from the surgery and it will be a waste."

Best answer: 3 Rationale: 1- The nurse is practicing principles-based reasoning which involves logical and formal processes and emphasizes individual rights, duties, and obligations. 2- This is practicing reasoning based on autonomy which is the right to make one's own decisions. 3- Is the best answer because caring-based reasoning stresses courage, generosity, commitment, and the need to nurture and maintain relationships. 4- Is a consequence-based reasoning which looks at outcomes (consequences) of an action judging whether that action is right or wrong. (Berman p. 84-85)

When are immunization boosters recommended?

Between 4 and 6 years of age, and between 11 or 12 years

Isotonic, isometric, and resistive isometric are three categories of exercise. They are classified according to the type of muscle contraction involved. Of the following exercises, which are considered isotonic?

Bicycling, swimming, walking, jogging, dancing

600-1000 mL

Bladder holds ______________ of urine

First Korotkoff sound

Blood-pressure measurement typically involves five different phases of sound called Korotkoff sounds. The initial sound that coincides with the systolic blood pressure is the first Korotkoff sound and is recorded as the top number of the blood pressure, the systolic blood pressure.

Which statement is true of the ovulation phase?

Body temperature is at previous baseline levels or higher

Why asses the skin?

Body's largest organ covers 20 square feet of surface area in average adult; guards the body from environmental stresses; adapts to environmental influences; tells us about internal/external processes

Oral cavity

Bordered by the lips, palate, cheeks, tongue; contains the teeth and gums, tongue, and salivary glands.

Mrs. Harrison's father died a week ago. Mr. Harrison is experiencing headaches and fatigue, and keeps shouting at his wife to turn down the television, although he has not done so in the past. Mrs. Harrison is having trouble sleeping, has no appetite, and says she feels like she is choking all the time. How should the nurse interpret these assessment findings as the basis for a follow-up assessment?

Both Mr. and Mr. Harrison likely are grieving.

Presbycusis

Changes in the inner ear result in predominantly high-frequency sensorineural hearing loss in the elderly patient. Causes include genetic factors, prenatal abnormalities, trauma and diseases. Usually becomes noticeable by late middle age. Signs patient may display include speech problems and complaining that others are mumbling. Although presbycusis cannot be cured, some patients may benefit from the use of a hearing aid

Social scientists have identified four threats facing the family in today's American society. Of the choices below, what are the four threats? (Select all that apply.)

Changing economic status Homelessness Family violence Presence of illness

The nurse is caring for a patient who has a pulse rate of 44. His blood pressure is within normal limits. In trying to determine the cause of the patient's low heart rate, the nurse would suspect

Calcium channel blockers or digitalis medications.

The patient has new-onset restlessness and confusion. His pulse rate is elevated, as is his respiratory rate. His oxygen saturation, however, is 94% according to the portable pulse oximeter. The nurse ignores the oximeter reading and calls the physician to obtain an order for an arterial blood gas (ABG). The nurse does this because many things can cause inaccurate pulse oximetry readings, including which of the following? (Select all that apply.)

Carbon monoxide inhalation Nail polish Hypothermia at the assessment site Intravascular dyes

Rectal precautions

Care with insertion

When focusing on older adults, the nurse must be aware that

Caregivers may be spouses or middle-age children.

Skin color and tone

Color varies from very pale to ivory, cream to beige, light to dark brown or black

A woman is called into her supervisor's office regarding her deteriorating work performance since the loss of her husband 2 years ago. The woman begins sobbing and saying that she is "falling apart" at home as well. The woman is escorted to the nurse's office, where the nurse recognizes the woman's symptoms as which of the following?

Complicated grief

Fiberglass

Composite structural material of plastic and fiberglass that is used in casting for children and elderly for light weight properties

The patient has a temperature of 105.2° F. The nurse is attempting to lower his temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. The nurse is attempting to lower the patient's temperature through the use of

Conduction.

During assessment of an older adult's skin integrity, expected findings include which of the following?

Decreased elasticity

Older adult: hair

Decreased growth; decreased in axillary and pubic; facial hair (women)

Arteries

Contain elastic fibers, which allow their walls to stretch with systole and recoil with diastole

2. Which of the following situations are appropriate for lawsuits that fall under the doctrine of res ipsa loquitur? a. A patient is delivered a wrong diagnosis because the nurse couldn't work the ultrasound machine properly. b. A patient develops an infection after surgery in response to a piece of gauze that was left inside him. c. A patient is given the wrong medication after the nurse mixes up two similar looking vials. d. A patient is subjected to prolonged smoke inhalation because the nurse couldn't locate the fire extinguisher.

Correct Answer: b. This doctrine encompasses the cases that cannot be traced back to a specific nurse or doctor. In this case, it cannot be determined which health care provider left the gauze in the patient. Incorrect Answers: a, c, d. These are examples that fall under the doctrine of respondeat superior. A specific employee can be blamed for the harm. In situations a and d a lawsuit can also be filed against the employer for lack of training and proper facility orientation. Berman pg. 68

3. An off duty nurses witnesses an accident involving a tree and a bicyclist in which the bicyclist is thrown from his bike. The nurse decides to take action under the Good Samaritan Act. Which of the following is the appropriate action the nurse should take? a. Stabilize the injured cyclist and then go get help. b. Insist on applying pressure to any obvious wound. c. Provide general first aid while waiting for additional help. d. Stay on scene without touching the bicyclist until help arrives.

Correct Answer: c. The guidelines for nurses who wish to render emergency services under the Good Samaritan Act suggest the nurse, "limits actions to those normally considered first aid". It also states that the person providing emergency care should not leave the scene until another qualified person arrives. Incorrect Answers: a. Leaving the injured person to get help is not recommended. b. The person rendering emergency care should only offer assistance, not insist upon giving it. d. The Good Samaritan Act protects those that provide assistance against malpractice claims. Therefore, a health care provider should not be afraid to give hands on care if necessary. Berman pg. 73

Question #3 The nurse understands the idea of autonomy by: A. Thoroughly explaining the procedures with possible outcomes using easily understood language. B. Respecting the patient's rights by allowing them to smoke in the hospital room. C. Suggesting that the nurse favor one procedure over another due to their personal opinion D. Give an unbiased, informative description of the different procedures available to the patient.

Correct Answer: A (A) By explaining the procedures and possible outcomes the nurse allows the patient to practice their right to autonomy. (D) The nurse provides unbiased information to the patient, but by not describing the possible outcomes the patient is unable to make a fully informed decision. Berman, Audrey., Snyder, Shirley. Fundamentals of Nursing.New Jersey: Pearson Education, Inc., 2012. Print. (Chapter 5, page 85)

2) The nurse is preparing an English-speaking client of Hispanic background for a pacemaker insertion procedure. The client has pinned a religious medal to her hospital gown and carries it with her at all times. The nurse knows that the client must remove her gown in the OR. What is the best way to care for this client? a) Remove the medal without informing the client before surgery and put it back after. b) Send the medal to the OR with a note explaining the significance of it to the client. c) Explain to the client that the medal does not have any healing power or value. d) Say, "I will hold the medal for you until you return from the operation room."

Correct Answer: B Rationale: When nursing care fails to be compatible with the patient's beliefs and values, there may be signs of conflict, noncompliance and stress. Culturally compatible care is provided by preserving the client's familiar life-way and by making accommodations in care that is satisfying to the client. (Berman, 8th ed, Ch 25, p.450)

Question #1 Which action best represents the nurse understands provision 1 in the ANA Code of Ethics? A. The nurse believes they are capable of making a treatment decision for a patient due to their inability to speak. B. The nurse acts in a manner to relieve a dying patient's pain, although it poses the risk of hastening the patient's death. C. The nurse doesn't report a charting error made by their colleague in order to maintain a positive relationship with that colleague. D. The nurse attempts to allot equal time to each patient, regardless of their condition, attempting to respect the worth of each patient.

Correct Answer: B (B) The measures that the nurse takes to comfort a patient outweighs the possible risk of a hastened death. Reference: ANA Code of Ethics. Nursing World. Provision 1. (Pages 3-5) Berman, Audrey., Snyder, Shirley. Fundamentals of Nursing.New Jersey: Pearson Education, Inc., 2012. Print. (Chapter 5, page 86)

1) A nurse is working with an elderly client and his wife to prepare discharging the husband. The wife wants to provide care for her husband at home despite repeated requests by the family to admit him to a long term nursing facility. What is the nurse's role in family disagreements? a) Help the wife to understand family's concern. b) Be an advocate for the husband and wife. c) Say, "you need to discuss it with your family." d) Do not interfere and let the family decide.

Correct Answer: B Rationale: Nurses are advocates for both the client and the family. Through advocacy, nurses are champions for their clients. They empower clients and families through activities that enhance well-being, understanding, and self-care. (Berman, 8th ed, Ch 25, p.451)

1. A nurse on a medical unit notices a client has just developed a temperature and does not have an order for acetaminophen. Which of the following is the most appropriate action for the nurse to take? a. call the primary care provider immediately and then review the client's chart b. review the client's chart and have all information ready prior to calling the primary care provider c. talk with the charge nurse, give the client acetaminophen, and then call the primary care provider d. give acetaminophen because an order for over-the-counter medication is not needed

Correct Answer: B Reviewing the client's chart gives the nurse the opportunity to note whether an order for acetaminophen was missed or if the client has an allergy that would contraindicate the medication. Any medication given to a client in a health care facility has to be ordered by a primary care provider. Berman & Snyder pg. 73-74 Berman, PhD, RN, A., & Snyder, EdD, RN, S. (2012). Kozier & erb's fundamentals of nursing: concepts, process, and practice. (9th ed.). Upper Saddle River, New Jersey: Pearson Education, Inc.

Question #2 Veracity is best demonstrated by: A. A nurse ruling out a strenuous exercise program that would improve the patient's general health, but puts the patient at risk for a heart attack. B. A nurse promises a patient that she will be back in 5 minutes due to the need to assist another patient. The nurse returns in 5 minutes. C. A nurse clearly explaining that car accident that the patient survived from resulted in the death of the patient's spouse. D. A nurse catches a patient that is falling while incidentally leaving a dark blue bruise on the patient's arm.

Correct Answer: C (C) This demonstrates that veracity involves telling the truth, even though the resulting truth could lead to the patient feeling anxiety and fear. (B) The nurse speaks the truth to the patient, however the fulfillment of a promise more closely resembles adherence to fidelity. Berman, Audrey., Snyder, Shirley. Fundamentals of Nursing.New Jersey: Pearson Education, Inc., 2012. Print. (Chapter 5, pages 85-86)

3. A nurse observes a client crying as he reads from his devotional book. What intervention by the nurse would be the most appropriate? a. contact the hospital's spiritual services b. inquire as to what is making him cry c. provide quiet times for these moments d. turn on the television for a distraction

Correct Answer: C Providing privacy and time for the reading of religious materials supports the spiritual health of the client. Asking the client about crying or providing a distraction could be interpreted as being disrespectful of the client's beliefs. Berman & Snyder pg. 288-289 Berman, PhD, RN, A., & Snyder, EdD, RN, S. (2012). Kozier & erb's fundamentals of nursing: concepts, process, and practice. (9th ed.). Upper Saddle River, New Jersey: Pearson Education, Inc.

2. An adolescent client is admitted to the emergency department with a fever. None of the client's family members are present, and the client is tearful and withdrawn. Which of the following statements made by the nurse is an example of therapeutic communication? a. "I know you are frightened, but we will find out what is wrong with you soon." b. "Let me show you around so that you are less frightened." c. "Tell me why you are so frightened." d. "You look frightened."

Correct Answer: D This answer demonstrates an empathetic and caring attitude where the nurse is addressing nonverbal behavior in an open and honest manner. Answer A diminishes the value of the client's feelings and is giving false reassurance. Answer B, the nurse is making an assumption the client is tearful and withdrawn because he or she is in a strange environment. Answer C isn't correct because "why" questions may make a client defensive. Berman & Snyder pg. 449-451 Berman, PhD, RN, A., & Snyder, EdD, RN, S. (2012). Kozier & erb's fundamentals of nursing: concepts, process, and practice. (9th ed.). Upper Saddle River, New Jersey: Pearson Education, Inc.

3. A nurse has a 75-year-old Christian African American female patient who is from the South. Which act would demonstrate that the nurse is providing the patient culturally congruent care? a. The nurse states different facts of African American history each time she see the patient b. The nurse makes sure s/he address the patient as "Ma'am" whenever s/he addresses the patient c. The nurse gets a Bible for the patient's room, knowing that the room does not have one. d. The nurse asks the patient if she wants an African American nurse to provide her. care.

Correct Answer: c Rationale: For this case, the nurse is making accommodations in care that are satisfying to the patient. Since the patient is a religious woman, obtaining a Bible for her is showing the nurse is aware that Christians like to read the Bible as part of their culture.

1. During Dr. Saulo-Lewis's lecture on ethics, what moral principle did she discuss? (Select all that apply) a. Fidelity b. Beneficence c. Veracity d. Nonmaleficence

Correct Answers: b &d Rationale: In the lecture, Dr. Saulo-Lewis discussed beneficence, do good, and nonmaleficence, do no harm, in terms of applying moral principles to the nursing practice with patients, peers, and others nurses come in contact with. (Dr. Saulo-Lewis lecture, Ethics Student Part One June 11, slides 25-26)

2. A middle aged, obese woman repeatedly returns to her healthcare provider complaining of ankle pain but does not attempt to lose weight. The best response by the nurse when clarifying the client's values would be: a) "Have you thought about losing weight as that will help alleviate the pain?" b) "Let's look over the various actions that could possibly help alleviate the pain." c) "We have a great program for losing weight. Would you like more information? d) "It is important to follow the plan of care. Are you following the doctor's orders?"

Correct answer (b). Listing alternatives may help a client become aware of all actions available if the client appears to hold unclear or conflicting values related to a particular health problem. The nurse assists client to think through each question but does not impose personal values. Behavior that may indicate unclear value: Numerous admissions to a health agency for the same problem. (Berman, p.82-83)

3. A nurse is completing a health history on her 34 year-old female patient. When the nurse arrives at the sexual history section, the first question she asks is if the patient is using birth control. The client responds no. What should this nurse ask next: a) "What is the reason for not using anything?" b) "Are you pregnant or trying to get pregnant?" c) "Are your partners male? female? Both?" d) "Have you used birth control in the past?"

Correct answer (c). Cultural competency is a ongoing process where the nurse strives to work effectively within cultural context of a client. It's important to establish what might be the sexual activity concerns of this patient by inquiring about partners. The original question about birth control in the stem already assumes heterosexuality and is not the best question to ask in the first place. Answer A could be the answer but may put the patient in awkward position of how she answers. Answer B assumes the patient is not using birth control because she is pregnant rather than understanding that this patient may not have male partners. Answer D isn't necessarily relevant at this stage of the assessment.

1. Which are guidelines for the Good Samaritan Act? Select all that apply. 1. Insist on giving emergency treatment. 2. Have someone go get help or call 911. 3. Leave after you've done your part. 4. Accept payment from the client or family.

Correct answer is B. (Did I trick you with the select all that apply??) It is necessary that appropriate care and transportation is provided to the client. The nurse should assign someone to call 911 or get assistance. Why not.... A: You should offer, not insist. C: You should stay until the client has been transferred or care is passed off. D: There should be no compensation. Berman & Snyder page 73

1. A client is in the hospital with terminal cancer. He states that he doesn't want parenteral nutritional therapy when he starts to decline. The nurse knows that he should create an advance directive. The information she should give the patient is in which of the following? 1. The patient's bill of rights 2. Nursing standards of practice 3. The patient self-determination act 4. The patient protection act 5. The bible

Correct answer is C. The patient self-determination act requires that patients have the right to accept or refuse care and use an advance directive. Berman & Snyder page 22

1. The Healthy People 2020 Initiative explains there are a powerful, complex relationships that exist which influence an individual's or populations health. These factors are called determinates of health, which include the following (circle all that apply) a) literacy level b) racism c) legislative policies d) birth order e) socioeconomic status

Correct answer: all except d. "Powerful, complex relationships exist between health and biology, genetics, and individual behavior, and between health and health services, socioeconomic status, the physical environment, discrimination, racism, literacy levels, and legislative policies. These factors, which influence an individual's or population's health, are known as determinants of health." http://www.healthypeople.gov/2020/about/DisparitiesAbout.aspx

Successful critical thinking requires synthesis of knowledge, experience, information gathered from patients, critical thinking attitudes, and intellectual and professional standards. Once the assessment has been done, it is important for the nurse to understand that

Critical thinking is ongoing.

Older adult skin hygiene

Daily bathing, water that's too hot, or harsh soap leads to very dry flaky skin

GI system in older adults

Decreased chewing ability, food that isn't chewed well is not digested easily; peristalsis (a contraction that propels food through the gastrointestinal tract) and esophageal emptying slows which slows absorption of nutrients in the intestinal mucosa. Muscle tone in the perineal floor and the anal sphincter weakens, may cause trouble for the older adult in terms of his or her ability to control defecation (passage of feces (waste or excrement from the GI tract) through the digestive tract

The nurse is caring for a patient who is complaining of severe foot pain due to corns. The patient states that she has been using oval corn pads to self-treat the corns, but they seem to be getting worse. The nurse explains that

Depending on severity, surgery may be needed to remove the corns.

The nurse correctly describes psychosocial theories on aging as theories that

Describe role changes in behaviors in older adults.

While attempting to obtain oxygen saturation readings on a toddler, what should the nurse do?

Determine whether the toddler has a tape allergy.

A 62-year-old male patient has had chronic obstructive pulmonary disease (COPD) for many years but has been unable to quit smoking. When approached by the nurse, he states that he would be "better off dead." He states that he has always supported his family, and now the doctor says he can no longer work because of his condition and oxygen dependency. His wife will now have to go to work, and he is sure that she will not make enough money to pay the bills. In preparing the patient for discharge, the nurse should

Develop a plan of care for the family.

Spiritual distress has been identified in a patient who has been diagnosed with AIDS. Upon evaluating the following interventions, which are appropriate for the diagnosis of Spiritual distress? (Select all that apply.)

Develop activities to heal body, mind, and spirit. Offer to pray with the patient. Offer to pray with the patient.

DBP

Diastolic blood pressure

The advanced practice nurse is conducting a comprehensive eye examination on an 80-year-old African American woman. Which of the following findings requires the nurse to contact the patient's physician for further examination?

Dilated pupils

The nurse is admitting a patient who is a member of the Seventh Day Adventist religion. The physician has written an order for specific tests to be done the next day, which is Saturday. The nurse should

Discuss the patient's beliefs about the Sabbath.

A patient who had an ostomy placed 1 month ago states that he is feeling depressed and does not want to participate in sexual activities anymore because he is afraid that his partner is not physically attracted to him. Which nursing intervention will be most effective in helping this patient resume sexual activity?

Discuss ways to adapt to new body image so the patient will be comfortable in resuming intimacy.

What do you need to do BEFORE applying restraints?

Evaulate if all less restrictive measures have been explored

Second hour

Every 30 minutes

How often should you check on a patient who is bathing?

Every 5 min

In what step do you modify nursing diagnosis, goals, and plan of care as needed?

Evlauation

A nurse is a member of an interdisciplinary team that uses critical pathways. According to the critical pathway, on day 2 of the hospital stay, the patient should be sitting in the chair. It is day 3, and the patient cannot sit in the chair. What should the nurse do?

Document the variance in the patient's record.

One benefit of meditation over other forms of behavioral therapy is that meditation

Does not require memorization.

A diabetic patient presents to the clinic for a dressing change. The wound is located on the right foot and has purulent yellow drainage. Which of these interventions would be most appropriate for the nurse to provide?

Don gloves and other appropriate personal protective equipment.

The nurse is caring for a patient on the medical-surgical unit. The nurse and the physician have completed an invasive procedure. What is the next step in handling the instruments used during the procedure?

Don gloves, gather instruments, place in transport carrier, and send to central sterile for cleaning and sterilization.

The patient that will cause the greatest communication concerns for a nurse is the patient who is

Dyspneic, has a tracheostomy, and is anxious.

During a preschool readiness examination, the nurse prepares to perform visual acuity screenings. Given the children's age, the best equipment to test central vision is which of the following?

E chart

An older couple expresses concern because they are easily fatigued during sexual intercourse and cannot reach climax. The nurse knows that older adults may have changes in sexual functioning. What strategies to increase sexual stamina could the nurse offer? (Select all that apply.)

Eat well-balanced meals, and eliminate excess fats and sugars. Avoid alcohol and tobacco. Plan sexual activity around a time when the couple feels rested.

A recently widowed 80-year-old male is dehydrated and is admitted to the hospital for intravenous fluid replacement. During the evening shift, the patient becomes acutely confused. The nurse's best action is to assess the patient for which of the following reversible causes? (Select all that apply.)

Electrolyte imbalance Hypoglycemia Drug effects Cerebral anoxia

Active-Assistant Exercises

Exercises perfromed by the patient with some assistance

Continuous Passive Motion (CPM)

Exercises that are performed by motorized exercise machinery that keeps a joint in constant slow motion

Passive exercises

Exercises that are performed by the Corpsman/Technician when the patient is unable to move a body part independently

Vital signs

measurements of physiological functioning, specifically temperature, pulse, respirations, and blood pressure, but may also include pain and pulse oximetry

The patient has had a colostomy placed but has not yet been able to look at it. The nurse is given the task of teaching the patient how to care for it. The nurse sits with the patient, and together they form a plan on how to approach dealing with colostomy care. Which caring process is the nurse performing?

Enabling

The teaching plan for a 3-year-old child who is at risk for developmental delay should include which of these instructions for the parents?

Encourage play as your child is exploring his or her surroundings.

The infection control nurse is reviewing data for the medical-surgical unit. The nurse notices a spike in postoperative infections on this unit and categorizes this type of health care-associated infection as _____ infections.

Exogenous

What gender has a higher BMR and why?

men because testosterone increases BMR

An 18-month-old patient is brought into the clinic for evaluation because the mother is concerned. The 18-month-old child hits her siblings and says only "No" when communicating verbally. According to Piaget's theory, what recommendation should the nurse make a priority?

Encourage the mother to seek psychological counseling for the child.

Congrats admin.

Encourage to drink lots of fluids to pass contrast

During middle adulthood, the 50-year-old patient is likely to adapt favorably to a changing body image if he or she

Engages in good hygiene practices.

The palliative team's primary obligation to a patient in severe pain includes which of the following?

Enhancing the patient's quality of life

The nurse is caring for a patient who is in the final stages of his terminal disease. The patient is very weak but refuses to use a bedpan, and wants to get up to use the bedside commode. What should the nurse do?

Enlist assistance from family members if possible and assist the patient to get up.

True or False: Ensure that the handgrip of the cane is lower than the greater trochanter or the lunar crease of the wrist when the arm is straignt down at the side

Ensure that the handgrip of the cane is LEVEL with the greater trochanter or the ulnar crease of the wrist when the arm is straight down at the side

What is the best suggestion a nurse could make to a family requesting help in selecting a local nursing center?

Explain that it is probably best for the family to visit the center and inspect it personally.

The nurse is caring for an elderly patient and notes that his temperature is 96.8° F (36° C). She understands that this patient is

Expressing a normal temperature.

The patient has had a stroke that has affected her ability to speak, and she becomes extremely frustrated when she tries to speak. She responds correctly to questions and instructions but cannot form words coherently. This patient is showing signs of _____ aphasia.

Expressive

As the aging population in the United States increases, the nurse knows that the

Extension of the average life span has also increased

"I know it seems strange, but I feel guilty being pregnant after the death of my son last year," said a woman during her routine obstetrical examination. The nurse spends extra time with this woman, helping her to better bond with her unborn child. This demonstrates which nursing technique?

Facilitating mourning

A nurse encounters a family that experienced the death of their adult child last year. The parents are talking about the upcoming anniversary of their child's death. The nurse spends time with them discussing their child's life and death. The nurse's action best demonstrates which nursing principle?

Facilitating normal mourning

True or False: Nursing diagnosis and medical diagnosis is the same thing.

False: Nursing diagnosis and medical diagnosis is NOT the same thing. A medical diagnosis describes a disease or condition. The nursing diagnosis is formulated based on the patients needs because of the medical diagnosis.

True or False: Pain and comfort both are both individually objective experiences.

False: Pain and comfort both are both individually SUBJECTIVE experiences

True or False: Slight muscular resistance should not be felt as the extremity is passively moved by the examiner

False: Slight muscular resistance SHOULD be felt as the extremity is passively moved by the examiner

True or False: The nursing process is a linear cycle.

False: The nursing process is a continuous cycle.

True or False: Use less pressure on up strokes toward the head and more pressure on downward strokes

False: Use MORE pressure on up strokes toward the head and LESS pressure on downward strokes

The nurse is caring for an elderly patient who has no apparent family. When questioned about his family and his definition of family, the patient states, "I have no family. They're all gone." When asked, "Who prepares your meals?" he states, "I do, or I go out." Given the three different approaches to family nursing practice, which would be most appropriate for this patient?

Family as context

Different approaches may be taken to family nursing practice. When the nurse is caring for a patient who needs constant care in the home setting and for whom most of the care is provided by the patient's family, what is the best approach for the nurse to take?

Family as system

It is essential for family members to realize that a family's beliefs, values, and practices strongly influence the health-promoting behaviors of its members, and to understand that

Family environment in early life has a strong influence on later health practices.

Although the family as a whole differs from individual members, the measure of family health is more than a summary of the health of all members. Of the following, what areas are unique to family assessment? (Select all that apply.)

Family form Family structure Family function Family health

Balancing employment and family life creates a variety of challenges in terms of child care and household work for both parents. This has major implications in health care because

Fathers now participate more fully in day-to-day parenting responsibilities.

In preparation for the eventual death of a female hospice patient of the Muslim faith, the nurse organizes a meeting of all hospice caregivers. A plan of care to be followed when this patient dies is prepared. This plan of care would include

Female health care workers care for the body after death has occurred.

When describing relevant family psychosocial factors in middle adulthood that cause stress, the nurse would not include

Financial security and certainty.

Mouth

First segment of the digestive system and an airway for the respiratory system

What is the difference in procedures for taking a tympanic temperature for adults compared to children?

For adults, pull ear pinna backward, up and out. For children 3 years and younger, pull the pinna down and back. For children 3 years and odler, pull pinna up and back.

Jean Piaget's cognitive developmental theory focuses on four stages of development, including

Formal operations.

The nurse is ambulating a patient in the hall when she notices that he is beginning to fall. The nurse should

Gently lower the patient to the floor.

Pulmonic valve sound

Heard in 2nd intercostal space at left rib border

Aortic valve sound

Heard in 2nd intercostal space at right rib border

Tricuspid valve sound

Heard in 5th intercostal space left rib border

Mitral valve sound

Heard in 5th midclavicular intercostal space left side

During a routine pediatric history and physical, the parents report that their child was a premature infant and was so small that he had to stay in the neonatal intensive care unit longer than usual. They state that the infant was yellow when born, and that he developed an infection that required "every antibiotic under the sun" to cure him. Considering the neonatal history, the nurse determines that it is especially important to perform a focused _____

Hearing acuity

A teen with an anxiety disorder is referred for biofeedback because her parents do not want her on anxiolytics. The nurse recognizes that the teen understands her health education on biofeedback when she states, "Biofeedback will

Help me with my thoughts, feelings, and physiological responses to stress."

The nurse is caring for an unresponsive patient who has a nasogastric tube in place for continuous tube feedings. The nurse assesses the patient's oral hygiene because good oral hygiene

Helps prevent gingivitis.

The patient is describing moderate incisional pain that was not relieved by the last dose of hydromorphone (Dilaudid) given 90 minutes earlier. The patient is not due for another dose of medication for another 2 1/2 hours. The nurse repositions the patient, asks what type of music she likes, and puts on the music channel on the television, setting it to play that type of music. The nurse is attempting to utilize which health care model?

Holistic Health Model

A long-term outcome for an individual who is learning relaxation therapy is

Identifying tension in his body and consciously releasing the tension

Where are vital signs recorded?

In the patient's chart on a Chronological Record of Medical Care for SF 600, local forms, flow sheets, or electronic documentation.

The patient is being treated for cancer with weekly radiation and chemotherapy treatments. The nurse is aware that the patient's oral mucosa needs to be assessed because chemotherapy and radiation can

Lead to oral problems.

Abdominal assessment sequence

Inspection, auscultation, light palpation

A patient in the emergency department is complaining of left lower abdominal pain. The comprehensive abdominal examination would include, in proper order, which of the following?

Inspection, auscultation, palpation

The nurse is urgently called to the gymnasium regarding an injured student. The student is crying in severe pain with a malformed fractured lower leg. The proper sequence for the nurse's initial assessment is

Inspection, light palpation.

The nurse is developing a plan of care for a patient diagnosed with activity intolerance. Of the following strategies, which has the best chance of maintaining patient compliance?

Instructing the patient to use an exercise log to record day, time, duration, and responses to exercise activity

Which type of diabetes is Type 1?

Insulin dependent

What is the purpose or goal of pain management?

It seeks to reduce the adverse mental and physical effects of unrelieved pain. Pain management enhances healing and promotes both physical and mental well being. The goal of pain management is to use interventions to assist the patient on controlling pain

A patient states that she is pregnant and concerned because she does not know what to expect, and she wants her husband to play an active part in the birthing process. What should the nurse tell the patient?

Lamaze classes can prepare pregnant women and their partners for what is coming.

Anterior thoracic cage

Landmarks include: -suprasternal notch: u-shaped depression above sternum -sternum: breastbone; manubrium-top, body-mid, xiphoid-bottom -sternal angle: angle of louis at 2nd ICS; where trachea bifurcates -costal angle: angle between ribs at bottom; 90 degrees

A nurse identifies Pediculosis humananus capitis. Considering the possible complications of treatment, the nurse knows to not use which of the following treatment products?

Lindane-based shampoo

Inspection of the Mouth

Lips: color, moisture, cracking, or lesions -deeper, pinker (than facial skin), or may have bluish hue Tongue: color, surface characteristics, and moisture -pink, a thin white coating may be present -saliva is present Teeth: straight, evenly spaced, clean, free of debris

Measuring the apical pulse

Listen for S1 (lub) & S2 (dub) at the mitral area S1 and S2 (lub dub) together equal one heart beat

Define auscultation

Listening for sounds with a stethoscope. Should be used last, except when assessing the abdomen, after the other technique have provided information that will assist in interpreting what is heard

Validation of a dying person's life would be demonstrated by which nursing action?

Listening to family stories about the person

The nurse is caring for a female victim of rape. To perform the proper evaluation, the nurse should place the patient in which of the following positions?

Lithotomy

Examples of Angiotensin II receptor blockers

Losartan (Cozaar) and olmesartan (Benicar)

Dorsal Recumbent

Lying on the back, in the supine position, with the knees flexed; used for assessing the head and neck, anterior thorax and lungs, breast, axillae, hearts, abdomen and extremities

Characteristics of glass thermometers:

Made of a hollow glass stem and bulb filled with mercury. Must shake down thermometer to lower mercury level prior to use. Marked in 0.2 degree increments. Blue probe-Oral. Red probe-Rectal. Time delay for temperature readings: Oral-3min Rectal-3min Axillary-10min Health care agencies no longer use glass thermometers

Regular bedpan

Made of metal or hard plastic, has a curved upper end and a sharp-edged lower end and is about 2 inches deep

The nurse is caring for a patient with leukemia and is preparing to provide fluids through a vascular access device. Which nursing intervention is priority in this procedure?

Maintain aseptic technique.

The patient is diagnosed with pediculosis capitis (head lice) and was treated upon admission and was re-treated 24 hours later, yet the patient is still infested. The nurse should next

Manually remove the lice using a fine-toothed comb.

During a school physical examination, the nurse reviews the patient's current medical history. With a positive medical history of asthma, eczema, and allergic rhinitis, the nurse expects which physical finding on nasal examination?

Pale nasal mucosa

What is a down side to taking an oral temperature?

Measurements can be delayed if patient recently ingested foods or fluids, smoked or is receiving oxygen by mask/cannula

An acquaintance of a nurse asks for a nonmedical approach for excessive worry and work stress. The most appropriate CAM therapy that the nurse can recommend is

Meditation

The nurse is caring for an older adult who presents to the clinic after a fall. The nurse reviews fall prevention in the home. Which of the following should the patient avoid? (Select all that apply.)

Missing yearly eye examinations Using bathtubs without safety strips Unsecured rugs throughout the home Watering outdoor plants with a nozzle and hose

A nurse developed the following discharge summary sheet. Which critical information should be added? TOPIC DISCHARGE SUMMARY Medication Diet Activity level Follow-up care Wound care Phone numbers When to call the doctor Time of discharge

Mode of transportation

When assessing a patient's skin, the nurse needs to know that

Moisture on the skin can lead to skin maceration.

Which of the following statements by a new graduate nurse should be corrected by an experienced nurse?

Most older patients are ill and disabled. That's why we care for so many of them in the hospital

Plantar flexion

Move foot so that toes are pointed downward

Dorsal flexion

Move foot so that toes are pointed upward

Bones perform five functions in the body: support, protection, movement, mineral storage, and hematopoiesis. In the discussion of body mechanics, which are the most important? (Select all that apply.)

Movement support

What are some things that make "setting goals" effective?

Must be patient-centered, singular, observable, measurable, time-limited, mutual, realistic, and are set at the person's highest level of well being

The term "ethics" refers to the ideals of right and wrong behavior. As such, the "ethics of care" creates a professional relationship in which the nurse

Must become the patient's advocate based on the patient's wishes.

A nurse believes that the nurse-patient relationship is a partnership, and that both are equal participants. Which term should the nurse use to describe this belief?

Mutuality

A patient has been admitted to the hospital numerous times. The nurse asks the patient to share a personal story about the care that has been received. Which interaction is the nurse using?

Narrative

The organization that facilitates the evaluation of alternative medical treatments is the

National Center for Complementary and Alternative Medicine.

As a patient ages, the nursing plan of care

Needs to be individualized to the patient's unique needs.

When taking the pulse of an infant, the nurse notices that the rate is 145 beats/min and the rhythm is regular. The nurse realizes that his rate is

Normal for an infant

While the nurse is assessing the patient's respirations, it is important for the patient to

Not know that respirations are being assessed

After the patient's bath, the nurse should

Not offer a backrub for 48 hours after coronary artery bypass surgery.

Oral precautions

Not safe for some children, unconscious, Not accurate mouth breathing

What do you note when inspecting the genitourinary system?

Note discharge color, odor, amount, and consistency and gather information regarding the patient's voiding, pattern and/or difficulty

Question 3 A patient is being disrespectful to a nurse who is treating them. In an effort to control the patient the nurse places restraints on them. This is an example of: 1. Invasion of privacy. 2. False Imprisonment. 3. Battery. 4. Negligence

Number 2 is correct. As defined by Berman, false imprisonment is the "unjustifiable detention of a person without legal warrant to confine the person." Numbers 1, 3 and 4 are incorrect. Invasion of privacy is a breach of confidentiality. Battery would be touching the patient in an inappropriate way. Negligence is a failure to perform at the expected level. Berman pgs. 67 and 69 Berman, Audrey, and Barbara Kozier. Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice. Upper Saddle River, NJ: Pearson Prentice Hall, 2012.

Question 1 An elderly client tells her nurse that she fell the night before and was unable to get up because her caretaker had left due to a family emergency. Which response by the nurse is most appropriate? 1. Nothing. This issue is outside the scope of the nurse's duty to her client. 2. Report suspicions of elder abuse to the proper authorities. 3. Provide the client with information about how to recognize elder abuse. 4. Speak with client's caretaker about her responsibilities to her client.

Number 2 is correct. Nurses are mandated reporters and are required by law to report suspected abuse, neglect or exploitation. Neglect is the absence of care necessary to maintain the health and safety of a vulnerable individual such as a child or elder. In this case, the client was a victim of neglect because her caretaker left her alone and without care and the client suffered an injury as a result. Numbers 1, 3 and 4 are incorrect because nurses are mandated reporters and are required by law to report suspected abuse, neglect or exploitation of a vulnerable individual.

En elderly patient has a terminal illness. Their physician explains to them that additional treatment is futile and the patient agrees that a do not resuscitate (DNR) order is appropriate. In this case the client is: 1. Incompetent. A proxy decision is responsible for their decision. 2. Competent. The DNR order should be documented. 3. Lacking decisional capacity. The client is unable to make the decision. 4. Withdrawn. Their living will should decide their treatment.

Number 2 is correct. The patient has been given information by their physician and a competent client's values should always be given highest priority. Number 1, 3 and 4 are incorrect as there is nothing to imply that the patient's decision making is impaired. The physician has given the patient information and believes that a DNR is appropriate. The patient does not need a proxy decision maker or living will unless they choose so. Berman pg. 66

A patient informs the nurse that he or she participates in regular yoga and meditation classes to "increase my mental health and overall well-being." The nurse can conclude the patient practices which health behavior? 1.) Health protection 2.) Health promotion 3.) Secondary prevention 4.) Tertiary prevention

Number 2 is correct. The patient is seeking exercise to expand mental health, and increase his or her wellness. Number 1 is incorrect because the patient did not specify that practicing yoga or meditation was disease-specific. Number 3 and 4 are not applicable; secondary and tertiary prevention behaviors focus on identification, intervention and rehabilitation for specific diseases and illnesses. Berman pgs. 281 and 282

Question 2 A nurse is shopping at a mall and sees a crowd gathered around a person on the ground who is clutching their chest. Emergency Service is not yet on the scene. The nurse is unsure if they remember how to perform CPR correctly, should they administer care anyway? 1. Without the permission of the client, the nurse should not administer aid. 2. The nurse should administer aid regardless because the client's life is at risk. 3. The nurse should not do CPR because they are unsure how to perform it. 4. The nurse should perform CPR since they cannot be held liable.

Number 3 is correct. The nurse should not administer CPR. The nurse is unsure and it would be malpractice to perform below the standard of what is expected. The nurse may be held liable for any damages that occur from performing CPR incorrectly. Number 1 is incorrect. The nurse should not administer CPR because they are unsure how to perform it. Number 2 is also incorrect for this reason. Number 4 is incorrect. The nurse should not perform actions that they do not know how to do. If malpractice causes an injury, the nurse is held liable for damages that may be compensated. Berman pgs. 67-68

Question 2 A client tells his nurse that although he signed the informed consent form for his surgery, he is still confused about the procedure. Which statement by the nurse is most appropriate? 1. "I will explain the procedure to you and feel free to ask questions." 2. "You should not have signed the form if you have concerns." 3. "You will need to speak with your doctor about the procedure." 4. "I will notify the doctor this afternoon about your concerns."

Number 4 is correct because the nurse must notify the health provider if the client has questions about a procedure or if the nurse doubts the client's understanding of the procedure. Number 1 is incorrect because the nurse is not responsible for explaining medical or surgical procedures. Moreover, the nurse could be liable for providing a client with incorrect or incomplete information or interfering with the client -provider relationship. Number 2 is incorrect because a client has the right to refuse a procedure and can change their mind at any time, even after signing an informed consent form. Number 3 is incorrect because the nurse, not the client, must notify the health provider if the client has questions about the procedure or if the nurse doubts the client's understanding of the procedure. Berman, pg. 62

A nurse is caring for a patient from Thailand. The patient has been provided with several options of care for a pre-existing disease, yet the patient refuses to move forward with a decision about his care without his wife being present. How should the nurse proceed? 1.) "Would you like for me to bring a translator in to discuss your care?" 2.) "Your wife can provide advice, but your care is your choice." 3.) "I will refer you and your wife to your social worker for further information." 4.) "I will wait until your wife arrives to provide you information about your care."

Number 4 is correct. A nurse should provide culturally responsive care and recognize that patients from Southeast Asia may apply a group perspective to decision making, and not want to make decisions regarding their healthcare without family present. Number 3, 2 and 1 are incorrect. Number one and three are irrelevant to the topic. Number two is inconsiderate of the patient's cultural background and beliefs. Berman pg. 59

Question 3 Which of the following conditions have courts found to not be a disability under the Americans with Disabilities Act (ADA)? 1. HIV infection 2. Blindness 3. Hearing loss 4. Depression

Number 4 is the correct answer. Depression does not constitute a disability under the ADA. Berman, pg. 63 Berman, Audrey, and Barbara Kozier. Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice. Upper Saddle River, NJ: Pearson Prentice Hall, 2012.

To facilitate coping w/ disability or death

Nurse's role to provide "comfort" care

The nurse is assessing the patient and his family for probable familial causes of the patient's hypertension. The nurse begins by analyzing the patient's personal history, as well as family history and current lifestyle situation. Which of the following issues would be considered risk factors? (Select all that apply.)

Obesity Cigarette smoking Heavy alcohol consumption

When communicating with a newly admitted teenaged patient, the nurse should

Observe for congruency between the patient's facial expressions and verbal responses.

Which of these interventions would take priority and should be included in a plan of care for a patient who presents with pneumonia?

Observe the patient for decreased activity tolerance.

In what part of obtaining a medical history do you ask, "Does anyone in your famiily have any significant illnesses?"?

Obtaining a family history

In what part of obtaining a medical history do you ask "Where does it hurt the most?" or "How bad is it?" or "What have you done to fix it?"?

Obtaining a history of the present illness or health concerns

In what part of obtaining a medical history do you ask about risk factors, medications, "How many hours do you sleep each night?", and "What are your eating habits?"?

Obtaining a past health history

Fifth vital sign

Pain assesed on different scale depending on situation and facility

Emergency admission

Occurs when an acutely ill or injured patient is given initial treatent in the emergency room and then transferred to a ward an placed into a bed. All admissions must be authorized by a doctor

Normal temperature for the average adult:

Oral: 98.6 F Rectal: 99.6 F Axillary: 97.6 F Tympanic: 98.6

The nurse is precepting a student nurse and is careful to check with the student all components of the medication process. The nurse explains to the student that most errors occur in

Ordering and administering.

What do you do when you conduct a review of systems when obtaining a medical history?

Organize a general heat-to-toe assessment and include vital signs, height, weight, and an impression of each system (neurological, cardiovascular...etc.)

During the initial home visit, a home health nurse lets the patient know that the visits are expected to end in about a month. The nurse is in which phase of the helping relationship?

Orientation

What do you do if the patient cannot read the top number of the Snellen chart, even with glasses?

Position the patient closerto the chart and reord the score

A self-sufficient bedridden patient unable to reach all body parts needs which type of bath?

Partial bed bath

The nurse is working on a committee to evaluate the need for increasing the levels of fluoride in the drinking water of the community. In doing so, the nurse is fostering the concept of

Passive health promotion.

The patient is admitted with a stroke. The outcome of this disorder is uncertain, but the patient is unable to move his right arm and leg. The nurse understands that

Passive range of motion must be instituted to help prevent contracture formation.

The patient is being encouraged to purchase a portable automatic blood pressure device so he can monitor his own blood pressure at home. What are some of the benefits of this? (Select all that apply.)

Patients can provide information about patterns to health care providers. Patients can actively participate in their treatment. Self-monitoring helps with compliance and treatment.

In trying to determine patients' perception of caring, several studies have suggested that

Patients value both task performance and the affective dimension of nursing.

Many variables influence a patient's health beliefs and practices. Internal and external variables influence how a person thinks and acts. An example of an internal variable would be

Perception of functioning.

Define "Implementation" in the nursing process

Performing or carrying out the nursing measures using interventions developed during planning. In this step, care is given, reporting and recording observations.

One of the greatest challenges for the nurse caring for older adults is ensuring safe medication use. One way to reduce the risks associated with medication usage is to

Periodically review the patient's list of medications.

Pain influence on bowel elimination

Person tends to avoid going. Hemorrhoids (veins in lining of the rectum become permanently dilated and engorged with blood) rectal or abdominal surgery, fissures (linear splits in the perianal area

A nurse is sitting at the patient's bedside taking a nursing history. Which zone of personal space is the nurse using?

Personal

The patient was found unresponsive in her apartment and is being brought to the emergency department. She has arm, hand, and leg edema, her temperature is 95.6° F, and her hands are cold secondary to her history of peripheral vascular disease. It is reported that she has a latex allergy. To quickly measure the patient's oxygen saturation, what should the nurse do?

Place a nonadhesive sensor on the patient's ear lobe.

Of the following disorders, which is caused by a virus?

Plantar warts

Which of these toys, if selected by the parent of a 10-month-old child, would indicate that the parent has a correct understanding of infant growth and development?

Plastic stacking rings

Before meeting the patient, a nurse talks to other caregivers about the patient. The nurse is in which phase of the helping relationship?

Pre-interaction

The nurse is caring for a home health patient. After completing an assessment, the nurse has diagnosed the patient as being at risk for infection. Which of the following orders would the nurse question?

Prepare enough enteral feedings for 12 hours. Rinse feeding bag and tubing daily.

The nurse is inserting a peripherally inserted central catheter (PICC) into the patient. Aware of the potential for health care-associated infection, the nurse is careful to

Prepare the skin with 2% chlorhexidine gluconate.

The group leader is overheard saying to the gathering of patients, "Focus on your breathing once again...notice how it is regular...Now focus on your left arm...Notice how relaxed your left arm feels...Notice the relaxation going down the left arm to the hand." The nursing student asks the nursing preceptor what the unit group leader is doing. The best answer is which of the following?

Progressive relaxation training

When providing prenatal care, what information does the nurse expect to provide? (Select all that apply.)

Protecting against urinary infection Exercise patterns Proper diet

The nurse has cared for a patient for several days. The patient is terminal and is very near death. The nurse notices the heart rate on the monitor decreasing and then the absence of a pattern. The family is standing at the patient's bed, and when the nurse checks the patient and finds no pulse or blood pressure, the family begins sobbing and hugging each other. Some hold the patient's hand. The nurse is overwhelmed by the presence of grief and leaves the room to cry in the nurses' lounge. What is the nurse demonstrating?

Protective touch

During hospitalization, the nurse should encourage the parents of an 8-month-old infant to

Provide as much care as possible.

An older patient has fallen and broken his hip. As a consequence, the patient's family is concerned about his ability to care for himself, especially during his convalescence. What should the nurse do?

Provide information and answer questions as family members make choices among care options.

The nurse is teaching a young adult couple about promoting the health of their 8-year-old child. The nurse knows that the parents understand the developmental stage their child is in according to Erikson when they state, "We should

Provide proper support for learning new skills."

Depression

Psychoneurotic or psychotic disorder characterized by sadness, inactivity, difficulty in thinking and concentration, a significant increase or decrease in appetite and time spent sleeping, feelings of dejection and hopelessness, and sometimes suicidal tendencies

When performing a thorough psychosocial assessment on a young adult, what must the nurse realize?

Psychosocial health is often related to job and family stress.

A nurse wants to present information about flu immunizations to the elderly in the community. Which type of communication should the nurse use?

Public

In examining a patient for pediculosis capitis (head lice), the nurse would expect to find

Pustules or bites behind ears and at the hairline.

When heat loss mechanisms of the body are unable to keep pace with excess heat production, the result is known as

Pyrexia.

According to Piaget's formal operations level, a 13-year-old adolescent will likely

Question her parents about an upcoming presidential election.

A 25-year-old patient is brought to the hospital by police after crashing his car in a high-speed chase when trying to avoid arrest for spousal abuse. What should the nurse do?

Question the patient about drug use.

A husband brings his children in to visit their mother in the hospital. The nurse asks how the family is getting along at home without their mom around. The husband states, "None of her jobs are getting done, and I don't do those jobs, so the house and the kids are falling apart." The nurse suspects that this family structure is

Quite rigid.

RACE

R: rescue anyone in immediate danger A: activate the fire code and notify appropriate person C: confine the fire by closing doors and windows E: evacuate patients and other people to a safe area

Types of urine samples

Random, clean-voided or midstream, sterile, timed

3. The ANA code of ethics Provision 5 states that the nurse owes the same duties to self as to others. In what ways might this be true? Select all that apply. a. moral self respect: respecting the worth and dignity of all human beings extends to the self as well b. wholeness of character: the nurse owes it to self to integrate professional and personal values so to be part of a moral community c. professional growth and maintenance of competence: the nurse owes it to self to continue personal and professional growth d. preservation of integrity: the nurse may be faced with compromise but must maintain the integrity of personal and professional values

Rationale: A,B,C and D, all of the above. Respect for oneself, taking care of oneself, and treating oneself with the same integrity, value system and moral respect that one uses with others is important! ANA Code of Ethics, Provision 5

2. While doing her rounds in the hospital a nurse overhears a conversation between two family members regarding the nurse's patient. The conversation makes her suspect that the family physician has not been completely honest with them about the patient's condition. She is confronted with an ethical dilemma: her loyalties are torn between the patient and the doctor. What should she do? a. the ethical decision making process is a linear one, the nurse has her own moral compass and she should make a decision and stick with it b. the ethical decision making process is a linear one, the nurse knows that lying to a patient is a black- and-white situation and what the doctor has done is wrong, regardless of the reasoning behind the decision c. the ethical decision-making process is not a linear one, she should develop her reasoning, uncover any assumptions she may be making and evaluate alternative views before making a decision d. the ethical decision-making process is not a linear one, the nurse should report to the charge nurse so that her suspicions can be confirmed, ensuring that someone with the proper authority takes charge of the situation

Rationale: C is correct. The ethical decision making process is not linear and involves developing reasoning, uncovering assumptions and evaluating alternative views among other things. A and B are incorrect because the process is not linear. D is incorrect because it relieves the nurse of her own role in following the code of ethics Berman and Snyder, Fundamentals of Nursing Pg.90-91

1. A patient with chronic pain has been dropping hints to her nurse that she is considering using marijuana in addition to her prescription analgesics even though it is illegal. However, it is clear that the patient is unsure of herself and would feel more comfortable if her decision were supported in some manner by her health care professionals. The nurse is aware that there are multiple scientific studies showing that marijuana is effective for treating long term pain, and is considering informing her patient. What should she do? a. the nurse should ask herself "Am I doing the right thing?" As long as the nurse can defend the morality of her own actions her decision is the right one b. the wellbeing of the patient is the nurse's first priority, she should do whatever she can to help her patient regardless of whether it is legal or not c. the nurse should report the conversation to her charge nurse to protect herself from potential repercussions should anyone find out about the conversation d. the nurse should check what the hospital policies are with regards to illegal drug use before she says anything to her patient

Rationale: The correct answer is A. Conflicting loyalties and obligations make ethical decision making more difficult. However, in the end the most important thing is to be able to defend the morality of your own actions. The nurse must consider the legality of actions taken and cannot simply disregard the law as a matter of course (B), reporting the conversation violates the patients privacy and is not ethical (C) the patient is not using illegal drugs in the hospital, so the nurse does not need to check with hospital policies on drug use/abuse(D). Berman and Snyder, Fundamentals of Nursing Pg.88-91

Characteristics of electronic thermometers:

Read out unit that produces an audible beep when the measurement is complete and displays the reading on the screen. The probe requires a disposable plastic cover to prevent the spread of pathogens. Permanent battery models require recharging and disposable battery models require return to the base unit periodically.

Which behaviors indicate that the student nurse has a good understanding of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA)? (Select all that apply.)

Reads the progress notes of assigned patient's record Gives a change-of-shift report to the oncoming nurse about the patient

Open Reduction

Realigning a broken bone through surgery with incisions

The nurse is working the night shift on a surgical unit and is making 4 AM rounds. She notices that the patient's temperature is 96.8° F (36° C), whereas at 4 PM the preceding day, it was 98.6° F (37° C). What should the nurse do?

Realize that this is a normal temperature variation.

Enuresis is reported in a previously toilet trained toddler. While gathering a health history from the grandparent, the nurse asks about which factor as the most likely cause?

Recent parental death

During a genitourinary examination of a 30-year-old male patient, the nurse identifies a small amount of a white, thick substance on the patient's uncircumcised glans penis. The nurse's next step is to

Recognize this as a normal finding.

A holistic nurse would be a nurse who

Recognizes the mind-body-spirit connection.

Electrocardiograph (EKG)

Records the electrical activity of the heart, and electrocardiograms are records of heart activity

The patient is being admitted to the emergency department following a motor vehicle accident. His jaw is broken, and he has several broken teeth. He is ashen, and his skin is cool and diaphoretic. To obtain an accurate temperature, the nurse uses which of the following routes?

Rectal

The patient expresses his attraction to the nurse who is caring for him. The patient asks the nurse for her phone number. How should the nurse first attempt to handle the situation?

Redefine the boundaries of professionalism.

Erythema (boney prominences)

Redness of the skin due to congestion of the capillaries; very pale, ivory, beige skin: red, bright pink; brown or black skin: purplish tinge, but difficult to see; palpate for increased warmth with inflammation, taut skin, and hardening of deep tissue

The nurse is caring for an elderly patient with Alzheimer's disease who is ambulatory but requires total assistance with his activities of daily living (ADLs). The nurse notices that his skin is dry and wrinkled. The nurse should

Reduce the number of baths per week if possible.

A nurse is discussing the advantages of standardized documentation forms in the nursing information system. Which advantage should the nurse describe?

Reduced errors of omission

A nurse is caring for a patient who expresses a desire to have an elective abortion. The nurse's religious and ethical values are strongly opposed. How should the nurse best handle the situation?

Refer the patient to a family planning center or health professional.

What are the most common life events that occur during young adulthood? (Select all that apply.)

Refining self-perception and ability for intimacy Achievement and mastery of the surrounding world Examination of life goals and relationships

Equipment-related accidents are risks in the health care agency. The nurse assesses for this risk when using

Sequential compression devices.

A patient describes practicing a complementary and alternative therapy involving concentrating and controlling his respiratory rate and pattern, recognizing that breath work is to yoga as

Reiki therapy is to therapeutic touch

Perfusion

Relates to the ability of the cardiovascular system to pump freshly oxygenated blood to the tissues and return deoxygenated blood to the lungs

A nurse is using SOLER to facilitate active listening. Which technique should the nurse use for R?

Relax

The nurse is caring for a patient who needs a protective environment. The nurse has provided the care needed and is now leaving the room. Select the correct order for removal of the personal protective equipment and associated tasks. (All answers are utilized.) a. Remove eyewear/face shield and goggles.

Remove gloves. Remove eyewear/face shield and goggles. Untie gown, allow gown to fall from shoulders, and do not touch outside of gown; dispose of properly. Remove mask by strings; do not touch outside of mask. Perform hand hygiene. Leave room and close the door. Dispose of all contaminated supplies and equipment in designated receptacles.

The nurse enters the patient's room and notices a small fire in the headlight above the patient's bed. Immediately, the nurse assigns a nursing diagnosis of risk for injury with a goal for the patient to be safe. Which of the following actions should the nurse take first?

Remove the patient.

The nurse is caring for a patient in the endoscopy area. The nurse observes the technician performing these tasks. Which of these observations would require the nurse to intervene?

Removing gloves to transfer the endoscope

The nurse is performing hand hygiene before assisting a physician with insertion of a chest tube. While washing hands, the nurse touches the sink. What is the next action the nurse should take?

Repeat handwashing using antiseptic soap,

Blood Pressure

The force that circulating blood exerts against the arterial walls as the heart contracts and relaxes; the unit of measure is millimeters of mercury (mmHg). It is recorded as 2 separate pressures (e.g., systolic and diastolic) in fraction form

A home health nurse is preparing for an initial home visit. Which information should be included in the patient's home care medical record?

Reports to third party payers

What can you do to prevent pressure ulcers in inactive patients?

Reposition, keep linens smooth, maintain skin hygiene, do not massage bony prominences.

A 55-year-old female presents to the outpatient clinic describing irregular menstrual periods and hot flashes. What should the nurse explain?

The patient's age and symptoms point toward normal menopause.

Patients with diabetes mellitus need special foot care to prevent the development of ulcers. Knowing this, the nurse

Requests a consult with a nail care specialist.

If the patient is engaging you in an interesting conversation about birds while you are trying to take their blood pressure, what should you do?

Respectfully ask them to shut up

When evaluating a patient's risk for spiritual crises, which of the following are part of the evaluation process? (Select all that apply.)

Review the patient's self-perception regarding spiritual health. Review the patient's view of his/her purpose in life. Discuss with family and associates the patient's connectedness. Ask whether the patient's expectations are being met.

In providing oral care to an unconscious patient, it is important for the nurse to

Rinse the mouth and immediately suction the oral cavity.

What are the 2 types of patient admission to a medical treatment facility?

Routine and emergency admission

Standing order

Routine order Canceled by doctor

Define palpation

This skill is often used in conjuction with or directly after inspection by using the sense of touch to make delicate and sensitive measurements of specific signs, including: resistance, resilience, roughness, texture, and mobility

A nurse is caring for a 35-year-old female patient who recently started taking antidepressants after repeated attempts at fertility treatment. The patient tells the nurse, "I feel happier, but my sex drive is gone." Which nursing diagnosis has the highest priority?

Sexual dysfunction

Older adult hair hygiene

Shampoo too frequently leads to dry scalp and hair

Acute

Sharp or severe; having a rapid onset, a short course, and pronounced symptoms. Usually less than 6 months. - Source is usually identifiable - May have limited tissue damage and emotional response - Underlying cause is treated - Unrelieved acute pain can progress to chronic pain

The nurse and the patient have the same religious affiliation. Because of this, the nurse

Should not impose her personal values on the patient.

In preparation for a rectal examination of a nonambulatory male patient, the patient is informed of the need to be placed in which position?

Sims' position

A 72-year-old woman was recently widowed. She worked as a teller at a bank for 40 years and has been retired for the past 5 years. She never learned how to drive. She lives in a rural area that does not have public transportation. Which of the following psychosocial changes does the nurse focus on as a priority?

Social isolation

Palpating Systolic Blood Pressure

Useful for patients whose arterial pulsations are too weak to create Korotkoff sounds (i.e. severe blood loss, decreased contractility); SBP by palpation, not DBP

In assessing the spiritual health of her patients, the nurse understands that

Spiritual beliefs change as patients grow and develop.

The nurse creates a referral to pastoral care when he/she realizes that the patient is in need of

Spiritual care.

A complex concept that is unique to each individual; is dependent upon a person's culture, development, life experiences, beliefs, and ideas about life; and is a unifying theme in peoples' lives is called

Spirituality.

The patient has been brought to the emergency department following a motor vehicle accident. The patient is unresponsive. His driver's license states that he needs glasses to operate a motor vehicle, but no glasses were brought in with the patient. The nurse should

Stand to the side of the patient's eye and observe the cornea.

The parents of a 15-month-old child express concern to the nurse about their child's thumb-sucking habit. Which of these explanations related to the child's age and developmental level would be most appropriate for the nurse to give the parents?

Sucking achieves a pleasing result for infants, and generalizing that action by thumb sucking is normal.

Second Korotkoff sound

Swishing sound

An older adult patient has developed acute confusion. The patient has been on tranquilizers for the past week. The patient's vital signs are normal. What should the nurse do?

Take into account age-related changes in body systems that affect pharmacokinetic activity.

The nurse is caring for a patient who is susceptible to infection. Which of the following nursing interventions will assist in decreasing the risk of infection?

Teaching the patient to select nutritious foods

Caring is central to nursing practice, but technological advances for rapid diagnosis and treatment should lead the nurse to realize that

Technology becomes a powerful tool when it works with caring.

A male older adult patient expresses his concern and anxiety about decreased penile firmness during erection. What is the nurse's best response?

Tell the patient that this change is expected in aging adults.

1. A nurse is caring for a client who is pregnant and unsure about whether or not she should have an abortion. The nurse begins to question herself by asking "Can I accept this?" and "What would I do in this situation?" What is the nurse doing in this situation? A. Gaining awareness of her professional values B. Questioning her professional beliefs C. Gaining awareness of her personal values D. Questioning her personal beliefs

The answer is C. According to Berman, reflecting on values about life, death, happiness and illness is important in dealing with ethical problems. One way for nurses to gain awareness of their personal values is by asking themselves to consider their own attitudes about issues such as abortion by asking questions such as "Can I live with this?" "Can I accept this?" and "What would I want done in this scenario?" By asking herself these questions, the nurse is attempting to gain awareness of her personal values. (Berman text, p. 82)

A homeless adult patient presents to the emergency department. The nurse obtains the following vital signs: temperature 94.8° F, blood pressure 100/56, apical pulse 56, respiratory rate 12. Which of the vital signs should be addressed immediately?

Temperature

After taking the patient's temperature, the nurse documents the value and the route used to obtain the reading. Why is this done?

Temperatures vary depending on the route used.

A patient is admitted to a rehabilitation facility following a stroke. The patient has right-sided paralysis and is unable to speak. The patient will be receiving physical therapy and speech therapy. What are these examples of?

Tertiary prevention

Risk factors can be placed in the following interrelated categories: genetic and physiological factors, age, physical environment, and lifestyle. The presence of any of these risk factors means that

The chances of getting the disease are increased.

Which of the following is characteristic of the cognitive changes in a preschooler?

The ability to classify objects by size or color

Expiration

The act of expelling air out of the lungs

Auscultation

The act of listening for sounds within the body

Inspiration

The act of taking air into the lungs

3. The new staff nurse working on the intensive care unit is concerned about her client's status. The client has continued to decline throughout the shift. The client's blood pressure, heart rate, and oxygen saturation have progressively dropped in a relatively short period of time. The nurse inquires with the charge nurse assigned to that shift. The charge nurse says "Don't worry, the client will be fine, he always does that." Which of the following actions should the nurse take? A. The nurse should call the nursing supervisor on duty to assist. B. the nurse should wait and see how the client does. C. The nurse should agree with the charge nurse because that nurse has more experience. D. The nurse should discuss this with other nurses on the unit.

The answer is A. Rationale: The nurse should escalate up the chain of command to advocate for the client. Option B, is incorrect because the client is exhibiting serious symptoms that could represent a grave diagnosis. Option C is incorrect because the nurse must trust her own clinical judgement even if it is in conflict with a more senior nurse. Option D, this might be an appropriate strategy, but a supervisor can provide more immediate assistance. Reference: Irwin, J. Barbara and Burckhardt, A. Judith. Kaplan 2013-2014 NCLEX-RN Strategies, Practice And Review (page 326).

1. The nurse discovers that the last dose of intravenous antibiotic administered to a client was the wrong dose. which of the following should the nurse do? A. Document the event in the client's medical record only. B. File an incident report, and document the event in the client's medical record. C. Document in the client's medical record that an incident report was filed. D. File an incident report, but don't document the event in the client's medical record, because information about the incident is protected.

The answer is B. Rationale: The event should be filed in an incident report and in the client's medical record. Option A the event should be filed both in an incident report and in the clients medical record. Option C, nurses should not document in the client's medical record that an incident report was filed. The incident report is for internal purposes of learning for the institution. Reference: Irwin, J. Barbara and Burckhardt, A. Judith. Kaplan 2013-2014 NCLEX-RN Strategies, Practice And Review (page 141).

3. During an assessment of a patient with a severe forehead injury, the nurse notices the patient has a red dot on their forehead. Which action by the nurse is appropriate? A) Work around the red dot and do not come in contact with it B) Ask the patient about the item and its significance C) Have the item temporarily removed to complete the examination D) No action is necessary

The answer is B. Rationale: The nurse should inquire about the red dot's meaning. These symbols are often seen as an important means of protection keeping one's health, spiritual protection, or ceremonious following a religious event. Reference: Berman, Audrey., Snyder, Shirley. Fundamentals of Nursing. New Jersey: Pearson Education, Inc., 2012. Print. (Chapter 18, pages 320-322)

3. A client's family asked the nurse not to tell the client of his diagnosis because they believe the truth may eliminate hope. The client later asks the nurse for information regarding his condition. What should the nurse do in this situation? A. Withhold information because the truth will cause fear and anxiety B. Respect the family's request by not telling the client about his diagnosis C. Tell the client the truth despite knowing this may eliminate hope or cause harm D. Ask the client to discuss his diagnosis with his family since they know the truth

The answer is C. One of the moral principles includes veracity which means truth telling. The choice to tell the truth may not always be clear especially when a nurse knows it might cause harm. However, lying to a patient is rarely the correct thing to do since this causes a loss of trust. The nurse's loyalty is always to the client first. (Berman text, p. 86-88)

2. A female patient arrives in the hospital unconscious and needs to be put on life support to survive. It is discovered that before the patient was married, she had created an advanced directive to not be put on life support. What should the nurse do if the husband is requesting his wife be put on life support? A) Allow the patient to be put on life support per the husband's wishes B) Check the organization's and state's healthcare policies C) Adhere to the advanced directive D) Allow the patient to be put on life support if the chances of recovery are high

The answer is C. Rationale: All 50 of the United States have enacted advance directive legislation which is a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. Reference: Berman, Audrey., Snyder, Shirley. Fundamentals of Nursing. New Jersey: Pearson Education, Inc., 2012. Print. (Chapter 5, page 92)

2. A patient who is terminally ill and has stage IV breast cancer decides she no longer wants to proceed with her treatment and is contemplating on the idea of euthanasia. The patient turns to her nurse and says "Please be honest. What would you do in my situation?" How should the nurse handle this scenario? A. Be honest and answer the question from the nurse's personal view B. Tell the patient there are other alternatives to euthanasia C. Ignore the question and change the topic because it is unethical D. Ask the patient "Are you considering other courses of action?"

The answer is D. According to Berman, it is the nurse's job to explore the client's value through discussion. The patient is unsure about what she should do and her conflicting values might be detrimental to her health. Therefore, the nurse should use value clarification as an intervention. However, the nurse should never impose her personal value, even if the patient asks for it since the nurse's decision would not be relevant to the patient's situation. Instead the nurse should redirect the question back to the client by asking questions such as "Are you considering other courses of action?" (Berman text, p. 82)

2. The nurse is assigned as the team leader on a busy medical/surgical unit. Which of the following BEST describes the "rights" of delegation the nurse must consider when assigning tasks to other members of the health care team? A. Right task, right timing, right client, right person, and right date B. Right task, right client, right direction, right supervision, and right date C. Right client, right direction, right day, right medication, and right unit D. Right task, right circumstance, right person, right direction, and right supervision.

The answer is D. Rationale: These are the five rights of delegation. Option A refers to the five rights of dispensing medications. Option B it still refers to medications. Option C does not refer to the delegation of tasks. Reference: Irwin, J. Barbara and Burckhardt, A. Judith. Kaplan 2013-2014 NCLEX-RN Strategies, Practice And Review (page 320).

1. What is the correct course of action to help an elderly male patient, who is terminally ill of cancer and in a high intensity of pain, would like be euthanized? A) Participate if the laws in your state allow for assisted suicide B) Participate only if your religion/morals beliefs agree with this practice C) Obtain consent from the patient (or the person with the power of attorney) before assisting D) Do nothing as euthanasia is a violation of the Code for Nurses

The answer is D. Rationale: While euthanasia and assisted suicide is has been upheld by the Supreme Court in the state of Oregon, the American Nurses Association's position that active euthanasia and assisted suicide are in violation of the Code for Nurses. Reference: Berman, Audrey., Snyder, Shirley. Fundamentals of Nursing. New Jersey: Pearson Education, Inc., 2012. Print. (Chapter 5, page 92)

A. Less saliva, some medications

The causes of dry mouth in the older adult include ________________ and _________________. A. Less saliva, some medications B. No teeth, periodontal disease C. Dentures, partial plates D. Financial limitations, poor dental care

S1 ("lub")

The first heart sound, heard when the atrioventricular (mitral and tricuspid) valves close; signals beginning of systole (contraction); corresponds with each carotid pulsation; loudest at the apex of the heart

A patient asks the nurse what signs and symptoms are associated with chlamydia. How should the nurse respond?

The first signs that chlamydia presents are frequency and burning upon urination.

True or False: Oral temperature route is contraindicated in children less than 6 years of age, patients who are mouth breathers, who have had oral or nasal surgery, a histroy of epilepsy, or who are unconscious, confused or uncooperative.

True

A patient asks the nurse what the term polypharmacy means. The nurse defines this term as

The concurrent use of many medications.

2. Which of the following is an example of beneficence? A. A nurse advised a patient at risk of seizures to incorporate a treatment involving bright flashing light to treat a separate disease B. A nurse advised a smoker at risk of lung disease of a plan to limit and/or quit the use of cigarettes C. A nurse advised a patient at risk of a heart attack about a strenuous exercise program to improve health D. A nurse advised a patient with a history of stomach ulcers to incorporate a healthy diet that includes citric fruit juices

The correct answer is B. Beneficence means "doing good." Sometimes, doing good can also pose a risk for doing harm, so it is important to know all the risks the patient has and to incorporate the whole health of the person into a specific plan. A, C, and D are all incorrect because they pose a risk of doing harm because the nurse has not taken into account all the risk factors the person may have. Berman, 8th ed. p 85

A nurse is helping a client to quit drinking alcohol. The nurse suggests to the client that the client remove all pint and shot glasses from the home. This strategy can help the nurse conclude the patient is in which stage of change? 1.) Contemplation 2.) Preparation 3.) Action 4.) Maintenance

The correct answer is Number 3. During the action stage, the nurse can encourage the client to "modify the environment to reduce stimulus to a problem behavior." By encouraging the client to remove alcohol-related items in the home, the client will be better able to implement a permanent behavior change. Contemplation is incorrect because during this stage, the client has not yet identified the behavior that he or she would like to change. Preparation is incorrect because the client has already begun his or her behavior change. Lastly, maintenance is incorrect because, in this stage, the client has already implemented and adapted to a new behavior change. Berman, pg. 294

1. Which of the following examples is reflective of a nurse who is properly utilizing contingency planning? (Select all that apply) A. The nurse set the brakes of the wheelchair before attempting to transfer the patient from the bed to the wheelchair B. The nurse lowered all the side rails on the bed so that the incontinent patient could have easier access to the bathroom at night C. The nurse set up an emesis tray at the patient's bedside because a certain procedure has a post-op risk of vomiting D. The nurse placed restraints on an adult to ensure they wouldn't move while placing a feeding tube

The correct answers are A and C. Contingency planning was discussed by Dr. Lewis; it is used for risk management when an exceptional risk that, though unlikely, would have catastrophic consequences. A contingency plan is a plan devised for an outcome other that in the usual expected plan. In A, the nurse planned for the possibility of the wheelchair rolling away while transferring the patient, so she placed the brakes ahead of time. In C, the nurse is aware that a certain procedure has a risk of vomiting, so by setting up an emesis tray ahead of time, he or she won't have to deal with a patient who decides to try and get up to vomit just after surgery, or won't vomit on themselves or elsewhere. B is incorrect because lowering all the side rails is unsafe. D is incorrect because it is illegal to place restraints without a doctor's order or to make a procedure easier.

Range of Motion (ROM)

The degree to which a joint is moved by flexion and extension; defined by the degress of a circle

Define "Assessment" in the nursing process

The deliberate and systematic collection of data to determine a patient's current and past health status, functional status and past and present coping patterns

The nurse is observing a family member changing a dressing for a patient in the home health environment. Which of these observations would indicate that the family member has a correct understanding of how to manage contaminated dressings?

The family member places the used dressings in a plastic bag.

Pulse

The human pulse is the palpable bounding of the blood flow in a peripheral artery.

Objective physical data describe air moving through small airways over the lung's periphery. The expected inspiratory-to-expiratory phase of this normal vesicular breath sound is which of the following?

The inspiratory phase is three times longer than the expiratory phase.

Abuse

The intentional physical or emotional mistreatment or harm of another person

Brachial pulses

The major artery supplying blood flow to the arm; antecubital fossa in the elbow medial to the biceps tendon

Femoral pulses

The major artery to the leg; just below the inguinal ligament hallway between the pubis and anterior iliac spine

Signs of fecal impaction

The most obvious sign is lack of bowel sounds for more than 3 days of a patient that usually has bowel movements easier to remove with an oil retention enema

Which situation will cause the nurse to intervene and follow up on the nurse aide's behavior?

The nurse aide is calling the older adult patient "honey."

A. Right lower

The nurse auscultates the _________________ quadrant first when assessing bowel sounds. A. Right lower B. Left lower C. Left upper D. Right upper

Which situation best indicates that the nurse has a good understanding regarding auditing and monitoring of patients' health records

The nurse determines the degree to which standards of care are met by reviewing patients' health records.

The nurse is caring for a patient in the hospital. The nurse observes the nursing assistant turning off the handle faucet with his hands. What professional practice supports the need for follow-up with the nursing assistant?

The nurse is responsible for providing a safe environment for the patient.

B. 2

The nurse performs an assessment of the heart on the adult. Identify where the nurse should place the stethoscope to auscultate the pulmonic area. A. 1 B. 2 C. 3 D. 4

When caring for a terminally ill patient, the nurse should focus on the fact that

The nurse's relationship with the patient allows for an understanding of patient priorities.

Which of these findings, if identified in a patient on a gerontological unit, would be most surprising to a culturally sensitive nurse?

The older person not being functionally independent

During the admission assessment, the nurse assesses the patient for fall risk. Which of the following has the greatest potential to increase the patient's risk for falls?

The patient takes Benadryl (diphenhydramine) for allergies.

The nurse has placed a patient on high-risk alert for falls. Which of the following observations by the nurse would indicate that the patient has an understanding of this alert?

The patient wears the red nonslip footwear.

The nurse is caring for a patient who has been trying to quit smoking. She has been smoke free for 2 weeks but had two cigarettes last night and at least two this morning. What should the nurse anticipate?

The patient will return to the contemplation or precontemplation phase.

A smiling patient angrily states, "I will not cough and deep breathe." How will the nurse interpret this finding?

The patient's affect is inappropriate.

The patient has been diagnosed with diabetes for the past 12 years. When admitted, the patient is unkempt and is in need of a bath and foot care. When questioned about his hygiene habits, the patient tells the nurse that baths are taken once a week where he comes from, although he takes a sponge bath every other day. To provide ultimate care for this patient, the nurse understands that

The patient's illness may require teaching of new hygiene practices.

What is vital to the success of the examination?

The patient's physical comfort

The patient is brought to the emergency department with possible injury to his shoulder. To help determine the degree of injury, the nurse should evaluate

The patient's range of motion

Who contributes to the health plan?

The patient, family, and health care team contribute to the care plan

Systolic Pressure

The peak pressure exerted on the arterial walls during ventricular contraction at which point, the left is emptied. This is the first blood pressure sound you will hear and is the top number on a blood pressure reading

Tinnitus

The perception of sound in the absence of a corresponding external sound. It is usually described as a ringing in the ears, although it may also be perceived by the patient as roaring, sizzling, whistling, or humming

S2 ("dub")

The second heart sound, heard when the aortic and pulmonic valves close; starts diastole (filling); loudest at the base of the heart

Anxiety

The sense of danger, apprehension, worry and dread in response to a trigger that is not a truly threatening experience

A. Normal

The strength of the patient's dorsalis pedis pulse is 2+. The strength of the patient's pulse is ___________ A. normal B. bounding C. weak D. absent

In discussing spiritual well-being, the nurse identifies that the vertical dimension involves

The transcendent relationship between a person and God.

A family is grieving after learning of a family member's accidental death. The transplant coordinator requests to talk with the family about possible organ and tissue donation. The nurse recognizes that

The transplant coordinator is working in accordance with federal law.

When assessing the temperature of newborns and children, the nurse decides to utilize a temporal artery thermometer. Why is this preferable to methods used for adults?

There is no risk of injury to patient or nurse.

Nurses need to provide competent care to young and middle adult patients. Why must nurses be knowledgeable about developmental theories to care for this group? (Select all that apply.)

These theories provide nurses with a basis for understanding the life events and developmental tasks of young and middle adults. Patients present challenges to nurses, who themselves are often young or middle adults coping with the demands of their respective developmental period. Nurses need to recognize the needs of their patients even if they are not experiencing the same challenges and events.

How are infants' height usually measured?

They are measured in the supine position with legs fully extended

What is the downside to taking a blood pressure electronically?

They are more sensitive to outside interference and are susceptible to error

D. Hold the labia apart while voiding into the specimen cup

To obtain a clean-voided urine specimen from a female patient, what should the nurse teach the patient to do? A. Cleanse the urethral meatus from the area of most contamination to least B. Initiate the first part of the urine stream directly into the collection cup C. Drink fluids 5 minutes before collecting the urine specimen D. Hold the labia apart while voiding into the specimen cup

B. 5

To palpate for edema, the nurse firmly depresses the skin over the tibia or medical malleolus for ____ seconds. A. 6 B. 5 C. 4 D. 3

Discharge

To release or dismiss

What is the NAVMED 6010/8 used for?

To safeguard things of value the patient brought to the ward

What is different for making a surgical bed (recovery bed)?

Top linens are fan folded laterally to the opposite side in which the patient will be put into the bed or fan folded to the bottom of the bed

The nurse is dressed and is preparing to care for a patient in the perioperative area. The nurse has scrubbed her hands and has donned a sterile gown and gloves. Which action would indicate a break in sterile technique?

Touching protective eyewear

When providing the patient with a complete bed bath using soap and water (not a bag bath), it is important to

Towel dry completely to prevent maceration.

Which technique will be most successful in ensuring effective communication? The nurse uses

Transpersonal communication to enhance meditation.

True or False: The Joint Commission supports the use of restraints only when clinically necessary and as a last resort.

True

True or False: The MTF cannot be responsible for valuables kept in a room on the ward.

True

True or False: The exam should be conducted systematically from head to toe so nothing is omitted or overlooked

True

The patient requires routine temperature assessment but is confused and easily agitated and has a history of seizures. The nurse's best option would be to take his temperature

Tympanically.

Restraints can only be applied by licensed personnel under a doctor's order that tells you the type of restraint, among other things. What are they?

Type, location of restraint, specific patient behaviors justifying its use, and the length of time the device will be used

Hypertension

Typically asymptomatic abnormally high blood pressure; may cause rupture of the arteries and destruction of organs; sustolic blood pressure reading greater than 140mmHg and diastolic blood pressure reading greater than 90mmHg

Visual Analog Scale (VAS)

Typically used to measure strength, magnitude, or intensity of individuals' subjective feelings, sensations, or attitudes about symptoms or situations.

Models of health offer a perspective by which to understand the relationships between the concepts of health, wellness, and illness. Nurses are in a unique position to assist patients in achieving and maintaining optimal levels of health because nurses (Select all that apply.)

Understand the challenges of today's health care system. Identify actual and potential risk factors. Can minimize the effects of illness and assist to the return of optimal health

When is the plan of care developed?

Upon admission

The nurse is caring for a patient on Contact Precautions. Which of the following actions would be appropriate to prevent the spread of disease?

Use a dedicated blood pressure cuff that stays in the room and is used for that patient only.

Dorsalis Pedis Pulse

Use a very light touch; found just lateral to and parallel with the extensor tendon of the great toe

The nurse is caring for a patient who has multiple ticks on her legs and body. To rid the patient of ticks, the nurse should

Use blunt tweezers and pull upward with steady pressure.

Light palpation abdomen

Use first four fingers together Depress about 1 cm Make gentle rotary motion, sliding the fingers and skin of abdomen together Lift fingers (don't drag) and move to next clockwise location Expected finding: soft, nontender

The nurse is bathing a patient and notices movement in the patient's hair. The nurse should

Use gloves or a tongue blade to inspect the hair.

The patient is having a difficult time dealing with his AIDS diagnosis. He states, "It's not fair. I'm totally isolated from my family because of this. Even my father hates me for this. He won't even speak to me." The nurse needs to

Use therapeutic communication to establish trust and caring.

A patient has a diagnosis of pneumonia. Which entry should the nurse chart to help with financial reimbursement?

Used incentive spirometer to encourage coughing and deep breathing. Lung congested upon auscultation in lower lobes bilaterally. Pulse ox 86%. Oxygen per nasal cannula applied at 2 L/min per standing order

Otoscope

Used to inspect the auditory canal and tympanic membrane. It may be protalbe or wall mounted

Tape measure

Used to measure: infants head and length, circumference of extremities, abdominal girth, percent of body fat, draining wounds

Watch/clock

Used to time pulse and respiration

Define "Nursing Diagnosis" in the nursing process

Using the assessment information collected, a nursing diagnosis is a clinical judgment about individual, family or community responses to actual and potential health problems or life processes.

The school nurse is assessing the tympanic membranes of a 3-year-old child. Which of the following demonstrates proper technique?

Using an inverted otoscope grip while pulling the auricle downward

Dementia

Usually a progressive condition marked by the deterioration of cognitive functioning including impared memory and one or more of the following: loss of purposeful movements, speech distrubance, imparied social functioning and is often accompanied by emotional apathy. Dementia has a poor prognosis.

Define inspection

Visual or auditory observation. Should be used continually during the examination in order to observe for normal and abnormal findings.

A nurse suspects an abnormal thyroid shape during the physical examination. The nurse offers the patient a glass of water and observes her drinking to

Visualize an enlarged thyroid gland.

The nurse is caring for a patient who has a temperature reading of 100.4° F (38° C). His last two temperature readings were 98.6° F (37° C) and 96.8° F (36° C). The nurse should

Wait an hour and recheck the patient's temperature.

What do you do if the diastolic blood pressure is heart to zero?

Wait one minute to retake the blood pressure. Note the point at which sound decreases intensity or becomes muffled.

A 70-year-old patient is newly admitted to a skilled nursing facility with the diagnoses of Alzheimer's dementia, lipidemia, and hypertension, and a history of pulmonary embolism. Medications brought on admission included lisinopril, hydrochlorothiazide, warfarin, low-dose aspirin, ginkgo biloba, and echinacea. The nurse contacts the patient's medical provider over which potential drug-drug interaction?

Warfarin and ginkgo biloba

The nurse and the student nurse are caring for two different patients on the medical-surgical unit. One patient is in Airborne Precautions, and one is in Contact Precautions. The nurse explains to the student different interventions for care. What should the nurse include in her teaching? (Select all that apply).

Wash hands before entering and leaving both of the patients' rooms. Dispose of supplies to prevent the spread of microorganisms. Apply the knowledge the nurse has of the disease process to prevent the spread of microorganisms. Patients in Airborne Precautions wear a mask during transportation to departments.

The nurse knows that four categories of risk have been identified in the health care environment. Which of the following provides the best examples of those risks?

Wet floors, pinching fingers in door, failure to use lift for patient, and alarms not functioning properly

B. Mitral

What auscultation area of the heart is located at the fifth intercostal space, left midclavicular line? A. Tricuspid B. Mitral C. Pulmonic D. Aortic

D. 5

Where does the nurse put the stethoscope to count an apical heart rate? A. 1 B. 2 C. 3 D. 5

D. Thick dermis

Which one of the following are expected findings in the skin of a healthy older adult? A. Traumatic purpura B. Buildup of collagen C. Excess sebaceous glands D. Thick dermis

B. Systolic BP can be measured and diastolic BP can be measured

Which one of the following statements about blood pressure by palpation is false? A. Systolic BP can be measured but diastolic BP cannot be measured B. Systolic BP can be measured and diastolic BP can be measured C. It's measured with a sphygmomanometer but no stethoscope D. Useful for measuring BP in patients whose pulses are weak

nursing theory

differentiates nursing from other disciplines and activities in that it serves the purposes of describing, explaining, predicting, and controlling desired outcomes of nursing care practices

The nurse is preparing to insert a urinary catheter. The nurse is using open gloving to don the sterile gloves. Which steps are included in this process? (Select all that apply.)

With gloved dominant hand, slip fingers underneath second glove cuff. After second glove is on, interlock hands. Glove the dominant hand of the nurse first Lay glove package on clean flat surface above waistline.

A nurse and patient take action to meet health-related goals. The nurse is in which phase of the helping relationship?

Working

Family members gather in the emergency department after learning that a family member was involved in a motor vehicle accident. After learning of the family member's unexpected death, the surviving family members begin to cry and scream in despair. The nurse recognizes this as the Bowlby Attachment Theory stage of

Yearning and searching.

Do you document after you shampoo a patients hair?

Yes

When taking an axillary temperature, should you also inspect for skin lesions?

Yes

C. Erythema

________________ is redness of the skin due to congestion of the capillaries. A. Edentulous B. Edema C. Erythema D. Eupnea

suppository

a conical or oval solid substance shaped for easy insertion into a body cavity and designed to melt at body temperature

total incontinence

a continuous and unpredictable loss of urine, resulting from surgery, trauma, or physical malformation

orthostatic hypotension

a sudden drop in blood pressure resulting from a change in position, usually when standing up from a sitting or reclining position and often causing dizziness

dyspnea

difficult or labored breathing

Maslows level 5: Self-Actualization

acceptance of self and others as they are; each lower level must be met; focus of interest on problems outside oneself; respect for all people; focus on strengths and possibilities vs problems

Type of antipyretic drugs?

acetaminophen and non steroidal anti-inflammatory drugs such as ibuprofen, salicylates, and indomethacin.

Which nursing diagnosis are grouped with tachycardia, bradycardia, and dysrhythmias?

active intolerance, anxiety, decreased cardiac output, deficient/excess fluid volume, impaired gas exchange, acute pain, and ineffective peripheral tissue perfusion.

Hypotension, hypertension, orthostatic hypotension, and narrow or wide pulse pressures are defining characteristics of which nursing diagnoses?

activity intolerance, anxiety, decreased cardiac output, deficient/excess fluid volume, risk for injury, acute pain, ineffective peripheral tissue perfusion.

Respiratory rate data is used to define which characteristics of nursing diagnoses

activity intolerance, ineffective airway clearance, anxiety, ineffective breathing pattern, impaired gas exchange, acute pain, ineffective peripheral tissue perfusion, dysfunctional ventilatory weaning response

Vasodilators

acts on arteriolar smooth muscle to cause relaxation and reduce peripheral vascular resistance

What are the 2 types of behavior?

adaptive and maladaptive behavior

What do you cover rough edges on a cast with?

adhesive tape or moleskin-petaling

What is the legal purpose for defining the scope of nursing practice, licensing requirements, and standards of care? 1. To protect the public 2. To protect the care giver 3. To protect the hospital 4. To protect nurses

answer: 1. rationale: by following the Nursing Practice Acts, nurses are establishing a standard of care that ensures that their patients are cared for in a safe manner. (Berman, p. 55)

A nurse anesthetist is preparing to adminster anesthesia to a client prior to a procedure that a surgeon will perform. What would the proper action be to aquire the patient's consent for the anesthesia? 1. The doctor performing the surgeory should make sure that the patient signs the consent form 2. The Anesthesiologist should make sure that the patient signs the consent form 3. The nurse anesthetist should make sure that the patient signs the consent form 4. The hospital needs to make sure that the patient signs the consent form

answer: 3. rationale: The person performing the procedure is responsible for obtaining the proper consent from the patient. Because the nurse anesthetist will be administering the anesthesia, she should be sure that the patient has signed the consent document, orally consented, or epressed the nonverbal behavior that implies agreement.(Berman, p. 60)

Question 3: Which of the following has not been established by the courts? 1. the right to refuse treatment 2. the right to information 3. the right to self determination 4. the right to active euthanasia

answer: 4 correct answer because the question of suicide and active euthanasia remains a controversial subject. The ANA states that active euthanasia is a violation of the Code for Nurses. 1, 2, 3 are incorrect because the courts have mandated laws for the right to refuse treatment, the right to information, and right to self determination. Berman text pg. 92

2) A fully alert and competent 82-year-old client has end-stage kidney disease. The client says, "I'm ready to die," and refuses dialysis. The family urges the nurse to set up dialysis. What is the nurse's moral responsibility? a. request a nephrologist come speak with the family. b. honor the client's decision c. make arrangements for dialysis due to lack of written documentation stating the patient's wishes d. try to convince the client to change his mind

answer: B rationale: Fundamentals of Nursing, page 85, Nurses must honor patients' autonomy, even when their own choices may not seem to be in their best interest.

1) The ANA Code of Ethics makes provisions for all the the following EXCEPT: a. Right to self-determination b. Right to die c. Respect for human dignity d. Primacy of the patient's interests

answer: B rationale: according to our presenter Dr. Saulo-Lewis, we do not have a constitutional right to die, and no such provision is made in the ANA Code of Ethics.

3) Which of the following would NOT be considered a case of nursing malpractice? a. the client cannot be revived due to nurse's inability to operate new equipment b. the client complains of abdominal pain and the nurse does not note it in the chart. The client's appendix ruptures. c. the nurse leaves a baby unattended on a bath table and the baby falls and is injured. d. the nurse unintentionally gives the patient a double dose of vicodin.

answer: D rationale: Fundamentals of Nursing, pg 67. To prove a case of malpractice, 6 elements must be present: duty, breach of duty, foreseeability, causation, harm/injury, damages. In all of the above cases EXCEPT the last, there was injury to the patient. Although medication errors can be serious and result in death, the aforementioned did not explicitly state harm and would not fall under the definition of malpractice.

3. A terminally ill patient is suffering from uncontrollable pain. The patient asks the doctor to provide her with a lethal dose of pills to end her misery. This is an example of what of end of life ethical issue? a. active euthanasia b. assisted suicide c. passive euthanasia d. termination

answer: b rationale: Assisted suicide gives the patient the means to take their own life if they request it. (a) Active euthanasia involves bringing about the client's death with or without the client's consent. (c) Passive euthanasia is the withdrawal of extraordinary means of life support, such as a ventilator. (d) Termination is not a type of assisted suicide. (Berman text, p. 92)

According to Campinha, which of the following is NOT one of the five cultural competence constructs? a) Cultural awareness b) Cultural encounters c) Cultural comportment d) Cultural desire

answer: c. Cultural comportment is not one of the five cultural competencies. The five are: cultural desire, awareness, knowledge, skills, and encounters. Desire refers to wanting to engage in becoming culturally aware. Awareness refers to understanding ones own culture. Knowledge refers to getting an understanding of various world views. Skills refers to the ability to collect culturally relevant data. Encounters refers to engaging interactions with people from diverse backgrounds. (Berman and Snyder text, p 320)

2. A serious car accident left the patient in a persistent and vegetative state. The patient's advanced directive instructed that, if left without cognitive or neurological functions, to terminate all life-sustaining treatment. What is the role of the patient's nurse? a. withdraw care to patient b. comfort the patient's family c. focus on the other patients d. continue to care for the patient

answer: d rationale: The nurse must continue to provide sensitive care and comfort measures even though life-sustaining treatment has been terminated. (a & c) The decision to withdraw treatment is not a decision to withdraw care. (b) Comforting the patient's family does not become the primary role for the nurse. (Berman text, p. 92)

Apical pulse taken at the

at the fifth intercostal space at the left midclavicular line.

nocturia

awakening at night to urinate

How would you measure a surface temperature?

axillary

Which temperature for adults has been shown to be inaccurate and poorly reflect core temp?

axillary

Foods for constipation

beans, caffeine, leafy vegetables, apple juice, prune juice or prunes, fresh fruits except bananas, raw vegetables, spicy food, green beans, broccoli, fluids

CDC hand hygiene

before and after direct contact before donning gloves after contact with inanimate objects before and after eating after removing objects do not wear nails, jewelry

Orthostatic BP

bp increases with age first palpate the artery may have an auscultatory gap pulse pressure is widened elasticity of vessels decreases with old age many have orthostatic hypotension which puts them at a risk for falls

Pulse site used to assess status for circulation to lower arm and auscultate blood pressure?

brachial

The best pulse sit for assessing an infant/young child?

brachial or apical pulse

Respiration influenced by acute pain

breathing becomes shallow

PEG tube

check placement every shift and before feeding or med administration washing tube insertion type daily with soap and warm water cotton swab to remove any crust dry the site and document the characteristics and technique

Who is more at risk for fluid volume deficit and why?

children because they can quickly lose large amounts of fluids in proportion to their body weight

Elderly and meds

chronic medical conditions metabolism of drugs may be slower may be on long term inflammatory drugs for arthritis dysphagia pill organizer bp fluctuations more quickly dehydrated decreased kidney function limited finance impaired vision previous stroke may not be able to open bottles noncompliant

Beta-adrenergic blockers

combines with beta-adrenergic receptors in the heart, arteries and arterioles to block response to sympathetic nerve impulses; reduces heart rate and cardiac output.

Therapeutic communication

communication focused on the patients needs silence, open-ended questions, restating, clarifying, touch, elaborating, summarizing

Sustained fever

constant body temperature continuously above 38 C/100.4 F with little fluctuation

primary health promotion

directed towards PROMOTING health and PREVENTING the development of disease processes or injury; example: immunization clinic, family planning services, accident prevention education

Longer stethoscope tubing will do what to the transmission of sound waves?

decreases it

What are some long term complications of paralysis?

decubitus ulcers, urinary tract infections, urinary calculi, and stiffening of the joints

Florence Nightingale

defined nursing as both an art and science, differentiated nursing from medicine, created freestanding nursing education, published books; founder of modern nursing

Metabolism

mainly occurs in the liver drug is processed into a form which can be excreted by the body

Interview with the elderly

may need to redirect place in a quiet room may need to ask family is they cant remember speak slowly, clearly, and in a deeper voice

when measuring a wound

measure from left to right and then top to bottom

Droplet precautions

meningitis, pneumonia, epiglottis, sepsis, pertussis, pneumonic plague, pharyngitis, diphtheria, scarlet fever, adenovirus, influenza, mumps, parvovirus, rubella place in private room wear mask if within 3 feet of patient place surgical mask on when moving place with someone infected as well

What time of the day is your BP lowest?

midnight and 3 AM

Full liquid diet

milk yogurt, eggs, eggnog pudding, custard, ice cream pureed meats, cream soups strained fruit juices vegetable juices sweetened plain gelatin cooked refined cereals strained or blended gruel all other beverages cream, margarine, butter sherbet, popsicles

mmHg

millimeters of mercury

Type of blood flow desired for acurate BP

neutral, which is why the arm is resting unsupported arm can lead to a falsely high BP

Safety at home

nonskid bath matt night lights grab bars door buzzers or bed alarms remove extension cords, items, or animals that may cause them to fall hospital beds

eupnea

normal respiration

How are bowel sounds characterized?

normal, hypoactive or hyperactive

Orthostatic/postural hypotension

normotensive person develops symptoms and a drop in systolic pressure by at least 20 mm Hg or a drop in diastolic pressure by at lest 10 mm Hg within 3 minutes of rising in to an upright position.

coping with disability and death

nurses use optimal function of maximum strengths and potentials, refer to community support systems; provide care to families and patients during end-of-life care, hospice

Digestion in elderly

nutrient requirements do not change with aging except in the presence of disease or illness, although calorie needs decrease after each decade fifty years

Heat exhaustion

occurs when profuse diaphoresis results in excess water and electrolyte loss

maceration

overhydration

supine or dorsal recumbent position

patient lies flat on the back with the head and shoulders slightly elevated w/ a pillow

side-lying or lateral position

patient lies on the side and the main weight of the body is borne by the lateral aspect of the lower scapula and the lateral aspect of the lower ilium

Increased risk for infection

patients with an open wound elderly clients with decreased immune systems, skin integrity, respiratory function, urinary tract, and gastrointestinal tract

Relapsing fever

periods of febrile episodes and periods with acceptable temperature values

apnea

periods when no breathing occurs

colostomy

permits formed feces in the colon to exit through the stoma

Sleep apnea

person stops breathing for short periods of time during sleep obstructive apnea is the most common type and is the relaxation of soft tissues mild, moderate, or severe obstructive, central, or mild complex central apnea is the failure of the brain to communicate with respiratory muscles mild complex is a mixture of both

which part of the hypothalamus controls heat production?

posterior hypothalamus

Evisceration

protrusion of an internal organ through an incision if occurs; place patient supine place sterile dressings over viscera soak dressing in normal saline prepare to return to surgery NPO

dorsalis pedis pulse

pulse located on top of the foot

Hyperventilation

rate and depth of respirations increase

Bradypnea

rate of breathing is regular but abnormally slow

Recommended f/u for normal BP

recheck 2 years

What happens if the posterior hypothalamus sense that body temperatures are lower tan the set point?

the body initiates heat conservation mechanisms such as vasoconstriction of blood vessels

The most important factor in the control of ventilation

the control of CO2 in the arterial blood

Pulse pressure

the difference between the systolic and the diastolic blood pressures

footdrop

the foot is unable to maintain itself in the perpendicular position, heel-toe gait is impossible, and patient experiences extreme difficulty in walking; caused by patients feet being in planter flexion position over extended time

When to asses vital signs

•On admission to healthcare agencies •Based on policy and procedures (SOC) •With a change in condition/Use your judgement: More ill = More frequent •Before & after any procedures •Before & after activity that increases risk •Before giving medications that affect cardiovascular or respiratory functioning •With an order from the care provider

Individualize pain therapy

•Use different types of pain relief measures. •Provide pain relief measures before pain becomes severe. •Use measures the patient believes are effective. •Consider the patient's ability or willingness to participate in pain relief measures. •Choose pain relief measures appropriate for the severity of the pain as reflected by the patient's behavior.

Palpate skin thickness

•Use palms of hands •Healthy finding: Epidermis is uniformly thin over most of body, although thickened on palms and soles