Nursing Fundamental 2
transduction
activation of pain receptors
ROM
active or passive exercises to assess and facilitate joint mobility
nursing diagnosis
actual and potential health problems that nursing intervention can prevent or resolve. the goal of the nursing diagnosis is to focus on the patient's responses to health problems (NANDA)
nociceptive pain
acute pain; a pain sensation that results abruptly
adaptation theory
adjustment of living matter to other living things and environment
accommodation
adjustment, as the accommodation of the lens of the eye.
If client received at least 3 doses of Td
administer tetanus toxoid booster
salicylism
adverse reaction to a salicylate characterized by dizziness; impaired hearing; nausea; vomiting; flushing; sweating; rapid, deep breathing; tachycardia; diarrhea; mental confusion; lassitude; drowsiness; respiratory depression; and possibly coma
a person without fever is said to be what?
afebrile
vitamin A
affects visual acuity, skin, and mucous membranes, and immune function
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
postoperative
after surgery
A nurse during orientation notices that the preceptor gives all subcutaneous injections on a 45-degree angle. When the new nurse asks the preceptor the rationale for the practice the preceptors states, "This is how I do it, and this is how you will do it." The new nurse recognizes this behavior to be:
aggressive.
Which social force has most significantly impacted the future supply and demand of nurses?
aging
-INFORMED CONSENT
agreement to have procedure performed after explanation of risks, benefits, expectations and alternatives to procedure
The nurse is caring for a client with tuberculosis. Which precautions will the nurse select for this client?
airborne
The nurse is caring for an older adult with pulmonary tuberculosis. Which precautions will the nurse begin?
airborne
ABC
airway, breathing, circulation
A nurse is attempting to complete an admission database. While taking the history, the nurse notices the client appears uncomfortable and slightly tachypneic. The nurse should:
allow the client to set the pace.
side
allows drainage of oral secretions
ileostomy
allows liquid fecal content from the ileum of the small intestine to be eliminated through the stoma
antiembolism stockings
also called TED socks; elastic stockings that cover the foot (not the toes) and the leg, up to the knee or mid-thigh.
prevent constipation
ambulate as appropriate increase fluid intake administer stool softeners ie Colace
residual urine
amount of urine that remains in the bladder after voiding at least once.
The nurse caring for clients at an outpatient clinic determines that which client is at greatest risk for infection?
an 80-year-old woman
calculi
an abnormal concretion usually composed of mineral salts, occurring in the hollow body organs; a "stone," as a calculus in the kidney (pl: calculi); deposit on the teeth (tartar).
lordosis
an abnormal increase in the thoracic curvature of the spine, giving a hunchback appearance, commonly as a result of osteoporosis.
aphasia
an abnormal neurologic condition in which a person is unable to express oneself through speech or writing.
tumor
an abnormal new tissue growth that has no physiologic use and grows independent of its surrounding structures. May be benign or malignant.
what is a fistula?
an abnormal passage connecting two body cavities or a cavity and the skin. (tunneling)
fistula
an abnormal tube-like passage or channel, as an anal fistula or sinus tract.
deontologic
an action is right or wrong independent of its consequences
wellness
an active state of being healthy by living a lifestyle promoting good physical, mental, and emotional health
analgesics
an agent that relieves pain without causing unconsciousness.
vitamin E
an antioxidant that protects vitamin A
alias
an assigned name under which certain clients are admitted to (and records kept in) a healthcare facility in order to maintain anonymity.
short-term goal
an expected outcome or goal that a client can reasonably meet in a matter of hours or days.
short-term objective
an expected outcome or goal that a client can reasonably meet in a matter of hours or days.
sequela
an illness or injury that follows as a direct result of a previous condition or event.
For which client would the use of standard precautions alone be appropriate?
an incontinent client in a nursing home who has diarrhea
urinometer
an instrument that deter-mines urine's specific gravity; also called urometer, hydrometer.
personal space
an invisible, mutually understood area or zone around a per-son that is considered inappropriate for strangers to violate (varies between cultures). If a person invades another's personal space (comes too close), it may cause discomfort. Much nursing care must occur within the client's personal space.
What is pyrexia?
an oral temperature higher than 100°F or a rectal temperature of 101°F
long-term goal
an outcome or goal that a client hopes to achieve but may require an extended amount of time to do so
long-term objective
an outcome or goal that a client hopes to achieve but may require an extended amount of time to do so.
complication
an unexpected event in a disease's course that delays a person's recovery.
Carl Rogers (1961) studied the process of therapeutic communication. Through his research, the elements of a "helpful" person were described. They include all of the following except which choice?
analysis
SOAPIE: Evaluation
analysis of effectiveness of interventions
data analysis
analyzing each piece of information to determine its relevance to a client's health problems and its relationship to other pieces of information.
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
the nurse identifies which as a risk factor for a client to develop a pressure ulcer?
anemia
Warfarin
anticoagulant interferes with synthesis of vitamin K dependent clotting factors has prolonged action; duration is 2-5 days
heparin
anticoagulant used for short term therapy given IV or subQ inactivates thrombin dosage is adjusted according to PTT
family
any group of people who live together and depend on one another for physical, emotional, and financial support
The nurse is preparing to administer a medication that the client takes to treat a cardiac dysrhythmia. Which site should the nurse use to assess pulse in this client?
apical
transient incontinence
appears suddenly and lasts for 6 months or less
The nurse is preparing to measure an adult's radial pulse using a Doppler device. Place the following steps of the procedure in the correct order.
apply conducting gel to the site where the pulse will be auscultated place the Doppler probe tip in the gel adjust the volume of the device as needed maneuver the tip of the Doppler probe over the area until the pulse is heard count the number of heartbeats for 1 full minute wipe the gel off of the client's skin
Elastic bandages are used to
apply pressure and give support
The nurse assesses that a client is shivering. Which intervention is most appropriate to prevent further stress on the body?
applying a blanket
contact precautions
appropriate for: wound infections C. Diff Multi resistant strains respiratory syncytial virus
unintentional wound
are accidental; occur from unexpected trauma
normal pH of stomach
around 3 (hydrochloric acid)
The nurse is caring for a client with a new diagnosis of cancer, and allows the client to verbalize fears relating to how to tell the children. The nurse's intervention reflects which aspect of nursing?
art of nursing
when does discharge planning start?
as soon as the patient comes in the door
The client is self-monitoring blood pressure at home and reports that every reading is 150/90 mmHg. What is the priority nursing intervention?
ask the client to demonstrate self-blood pressure assessment
An evening shift nurse is caring for a client scheduled for a colon resection in the morning. The client tells the nurse she is afraid of waking up during surgery. The best response by the nurse is to:
ask the client why she thinks she will wake up during surgery.
A graduate nurse has been working on a telemetry unit for 6 months. The nurse arrives at work in the morning and overhears a night shift nurse talking about the graduate nurse. The night shift nurse is heard saying, "That new nurse is only here to meet a doctor and get married." The best response by the new nurse would be to:
ask to speak to the night shift nurse in private and explain how the comment made her feel.
A nurse is on his lunch break in the hospital cafeteria and sits at a table near a group of physicians eating their lunch. The nurse recognizes one of the physicians as being in charge of his clients. The nurse witnesses the physician point at the nurse and state, "That guy needs to get fired." The best response by the nurse would be to:
ask to speak to the physician in private and address any disrespectful remarks or behaviors.
A client arrives at the emergency department after experiencing several black, tarry stools. The nurse will develop a cause and effect by:
asking the client if he or she has recently taken ferrous sulfate (iron) or bismuth subsalicylate.
To make sure NG tube is reliably in correct position?
aspirate for gastric contents and check pH pH of gastric aspirate is 4 or less
battery
assault that is carried out
A nurse is completing a health history on a client who has a hearing impairment. Which actions should the nurse take first to enhance communication?
assess how the client would like to communicate
nursing process
assess, nursing diagnosis, identify expected outcomes, implement care, evaluate results
observation
assessment tool that relies on the use of the five senses to discover objective information about the client.
roles of the nurse in dx procedures
assist, be responsible for equipment needed, witness pt's consent, schedule tests, prepare pt physically and emotionally, provide care after test, dispose of used equipment, transport specimens
adjuvant
assisting or enhancing therapy given, especially in cancer, to prevent further growth or pain; therapy used which was originally intended for another purpose.
a 53-year-old client is admitted to the hospital for hematuria. the client has no previous history of illness, is married, and has 3 children in high school. which task of middle adulthood would most likely be disturbed by a physical disability?
assisting the children to grow to adulthood
The nurse graduated several years ago from a 2-year nursing program at a community college near the home city. Recently, the nurse has considered moving from providing direct client care into an administrative role, but recognizes the need for further education to be considered for such a position. The nurse most likely possesses which nursing qualification?
associate degree
A nurse mentoring second-year nursing students from a community college plans clinical experiences for them. These students will most likely graduate in which time frame?
at the end of the year
P wave
atrial activity precedes q QRS
ligament
attach cartilage to bones
tendon
attach muscle to bone
An obese client has developed peripheral edema as a consequence of heart failure, making it very difficult for the student nurse to accurately palpate the client's peripheral pulses. How should the nurse proceed with this assessment?
auscultate the client's apical pulse
An ultrasonic Doppler is used for:
auscultating a pulse that is difficult to palpate.
pulse is regulated by what?
autonomic nervous system through cardiac sinoatrial node
nonmaleficence
avoid causing harm
nocturia
awakening at night to urinate
perception of pain
awareness of the characteristics of pain
A client suffers from bloody diarrhea after eating contaminated food at a local restaurant. The client has been infected with a(an):
bacteria.
impetigo
bacterial skin infection characterized by isolated pustules that become crusted and rupture Reddish macule becomes honey-colored crusted vesicle caused by Staph, strep Administer antibiotics
cellulitis
bacterial skin infection with involvement of CT
halitosis
bad breath
dys-
bad, painful, difficult
base of support
balance or stability provided by the feet and their positioning
race
based on PHYSICAL characteristics
Nursing Admission Assessment records what?
baseline data from which to monitor change (Helps forecast future needs)
rest
basic physiologic need allows body to repair its own damaged cells enhances removal of waste products from the body restores tissue to maximum functional ability before another activity is begun
tepid sponge bath
bath with water below body temperature, 70 to 85º F, used to reduce fever
perineal care
bathing genitals and surrounding area
liability
be proven to establish negligence or malpractice
The nurse is initiating isolation precautions for a client who has chronic Clostridium difficile infection. What should the nurse be sure to include with these precautions?
be sure that there are gloves of various sizes and gowns for use
Why is standardized terminology important in the EHR system?
because computers require standardized info that can be converted to numerical codes.
occupied bed
bed holding a client that is unable to get up as a result of his or her condition or generalized weakness.
postoperative bed
bed prepared for a client who is returning from surgery or another procedure that requires transfer into the bed from a stretcher or wheelchair.
open bed
bed that allows linens to be turned down, making it easier for a person to get into or out of.
unoccupied bed
bed that is empty at the time it is made up.
closed bed
bed used when preparing a unit for a new client—an unoccupied bed
preoperative
before surgery
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
value
belief about the worth of something; about what matters; standard to guide behavior; not born with values: formed from the environment, family, and culture
cultural imposition
belief that everyone should conform to the majority belief system
ethnocentrism
belief that ones ideas, beliefs, and practice are superior to those of another's culture
when teaching correct body mechanics to a nurse's aide, which of the following suggestions by the nurse is most appropriate?
bend knees when lifting objects
beneficence
benefit the patient; balance benefits against risks and harms
what is neurotic tissue?
black brown or tan that adheres firmly to the wound bed
ecchymosis
bleeding into the tissue sunder the skin, leaving small bruise.
sanguineous drainage
blood cells present; looks like blood
Thrombophlebitis
blood clot in a vein causes inflammation & pain unilateral edema warmth tenderness firmness of muscle of Lower extremity swelling localized redness over a vein with IV catheter
pulmonary embolism
blood clot in the arteries of a lung dyspnea tachypnea pleuritic chest pain
What is hemostasis?
blood clotting
occult blood in stool
blood that is hidden in the specimen or cannot be seen on gross examination
Ecchymosis/contusion
blood trapped under surface of skin *ex: black eye
What is sanguineous drainage?
bloody drainage
transfer board
board made of hard plastic used to move patients who are unable to stand from the side of the bed to a chair.
What influences BMR?
body size lean muscle mass numerous hormone
what three things influence basal metabolism rate (BMR)?
body size lean muscle mass numerous hormones
Maslows level 2: safety and security needs
both physical and emotional components; being protected from potential or actual harm
scale used for predicting pressure sore risk
braden scale
orthopnea
breathe easier in an upright position
-pnea
breathing
inhalation
breathing in
exhalation
breathing out
disaster
broadly defined as a tragic event of great magnitude that requires the response of people outside the involved community
normal breath sounds
bronchial-heard over the trachea-high pitched, harsh sounds bronchiovesicular- heard over the mainstream bronchus-moderate"blowing" sounds, vesicular-heard over the base of the lungs-soft and low pitched
Non-shivering thermogenesis is the metabolism of what to produce heat?
brown fat
USE for
burns infection malnutrition physical stress
how do you asses bilateral equality?
by comparing the pulses on both sides of the body for equal volume.
What are disadvantages of SOAP?
can be ineffective and inefficient
complementary therapy
can be used with traditional medical interventions and thus complement them
Levodopa (L-dopa), antiparkinson drug, injectable iron compounds
can lead to brown or black urine
diuretics
can lighten the color of urine to pale yellow
antidepressant amitriptyline (Elavil) or B-complex vitamins
can turn urine green or blue-green
wound sinus
canal or passage leading to an abscess.
blood pressure regulation is influenced by what three factors?
cardiac function peripheral vascular resistance blood volume.
roles of nurses
caregiver, communicator, teacher/educator, leader, advocate
elective
case in which the client's condition is not life-threatening and may choose whether or not to have surgery; also called optional surgery
venous access lock
catheter used to maintain an open route to a client's venous system to give fluids and/or medications.
psychgenic pain
cause of pain cannot be identified (phantom pain)
independent variable
causes or conditions that are manipulated or identified to determine the effects on the dependent variable
CVP
central venous pressure -norm 2-6 mmHg
The nurse is caring for a client with tuberculosis. The prior shift's nurse has placed the client in droplet precautions. Which is the appropriate nursing action?
change to airborne precautions
orthopnea
changes in breathing when sitting or standing
The nurse is caring for a client with a surgical wound. Which action by the nurse best reduces the reservoir of infection?
changing the soiled dressing
insomnia
characterized by difficulty falling asleep, intermittent sleep, or early awakening from sleep
while a client is being treated for a wound infection, it is most important for the nurse to routinely perform which action
check and record the client's temperature
what is the most accurate way of checking the pulse?
checking the apical pulse
neuropathic pain
chronic pain or discomfort that continues for six months or longer and interferes with normal functioning.
overflow incontinence
chronic retention of urine, the involuntary loss of urine associated
What are rehabilitation and therapy notes?
chronological charting by therapist
circumduction
circular movement of a limb or the eye.
Vesicle
circumscribed, elevated, palpable mass w/ serous fluid
private law
civil law; regulates relationships among people (property, nursing, medicine, contracts)
If no S/Sx of infection
clean and dress wound as necessary
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
what are three characteristic primary intension?
clean wound sutured early results it hair line scar
serous drainage
clear and watery
acuity
clearness; or a disorder's level of severity; minimum level or need for healthcare services that must be met for a client to be admitted to an acute care facility.
Each of the following facilitates a therapeutic nurse-client relationship except:
closed-ended questions.
intellectual dimension
cognitive abilities, educational background, and past experiences
four essential competencies
cognitive, technical, interpersonal, ethical/legal
Herpes Simplex type 1
cold sores, fever blisters pruritic vesicular groupings on nose, lips, and oral mucous membranes chronically recurrent Spread by direct contact Administer antivirals
Eight principles
cold/heat, interior/exterior, excess/deficiency, and yin/yang (the chief principles) analyze symptoms and categorize conditions
The nurse is caring for a postoperative client. The health care provider has written a prescription for a pain medication, and the prescription gives a dosage range for the amount the nurse may give depending on the severity of the client's pain. This type of functioning within the health care team is called:
collaborative functioning.
Dermis
collagen fibers, blood vessels, nerves
atelectasis
collapse of all or part of a lung.
physical assessment
collect objective data about the patient, explain the exam to the pt and perform in warm, quiet, private environment
assess
collect, validate and communicate patient data, vital step-all remaining steps depend on complete, accurate, factual data, made at the beginning of care and throughout the course of care, goal is to come up with dx and interventions.
abscess
collection of pus in a localized area
integrative care
combo of allopathic and complementary
subjective
coming from that subject
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
conjunctivitis
commonly called pinkeye; inflammation of the conjunctiva.
indirect studies
commonly performed through radiography ex. abdominal ultrasound, MRI, abdominal CT scan, small bowel series, barium enema
Purpose
communication w/ dates to facitilitate pt. care financial and legal record helps in clinical research()quality review research) supports decision analysis
therapeutic communication
communication (usually verbal) with a client that is helpful and beneficial; creating a healing, curative, and safe milieu by using communication.
Interrelated roles of nurses
communicator, teacher, counselor, leader, researcher, advocate, collaborator
anesthesia
complete or partial loss of sensation.
initial comprehensive assessment
completed after pt has been admitted to the floor, purpose is to obtain all possible information about the pt, complete database for problem identification and care planning, past hx, allergies, and all pertinent physical findings (skin breakdown)
altruism
concern for welfare and well-being of others
health belief model
concerned with what people believe to be true about their health
criminal law
concerns state and federal criminal statutes- defines criminal actions ex. murder, theft
SOAP: Assessment
conclusion drawn from the subjective and objective data (diagnosis)
atherosclerosis
condition in which fatty deposits called plaque build up on the inner walls of the arteries; The build-up of fats, cholesterol, and other substances in and on the artery walls.
conscious sedation
condition in which internal sedative medications are used alone or in conjunction with local anesthetics and the client has a depressed level of consciousness but is still able to breathe and respond to verbal stimuli.
transmission
conduction along the pathways (a-delta and c-delta fibers)
holism
connection and interactions between parts of the whole
preparing for the physical exam
consider the needs of the patient, explain the process, ask pt to change into a gown and empty bladder, answer questions directly and honestly, gather necessary supplies, provide privacy, and a warm quiet room with adequate lighting
purulent
consisting of or secreting pus.
whole medical system (or alternative medical system)
consists of a philosophy and theory about health and illness along with specific types of treatment
non-rapid eye movement sleep (NREM)
consists of four stages; stage 1 and 2 consuming 5% and 50% of sleep time and are light-sleep states; stage 3 and 4 are 10% of sleep time and called deep-sleep states
When a nurse picks up a client's contaminated tissue without gloves and fails to wash the hands sufficiently, the nurse provides for the client's organisms to be spread by which type of
contact
scabies
contagious skin disease transmitted by the itch mite, commonly through sexual contact minute, reddened, itchy lesions linear burrowing of a mite at finger webs, wrists, elbows, ankles, penis Rash and itching may last for 2-3 weeks even though mite has been destroyed; treat with antipruritic
serous
containing clear fluid; drainage made up of serum
A rolled bandage is a what?
continuous strip of material
nonverbal communication
conveying information or messages without speaking or writing. Components include items such as therapeutic touch, gestures, body language, facial expression, and eye contact.
assertiveness
confidence without aggression or passivity, an important skill for a nurse to possess in interpersonal communication.
hypothermia blanket
cooling blanket; also called hypothermia blanket
pyorrhea
copious discharge of pus
hypothermia
core body temp too low
what is a secondary dressing?
covers or holds a primary dressing in place.
adventitious breath sounds
crackles-fine to course crackling sounds due to fluid in the air passages wheezing- high pitched,musical-generally from narrowing of air passages stridor-harsh high pitched heard on inspiration
efferent
creates effect and goes to body part from brain
tracheostomy
creation of an artificial opening into the trachea
SECONDARY LESSION
crust erosion fissure scales ulcer
PRIMARY LESSION
cyst macule papule vesicle wheel
hyperpyrexia can lead to what?
damage to cells (especially in the brain) confusion delirium seizures coma
Impaired Skin Integrity is appropriate for patients who have experienced
damage to the epidermis or dermis
necrosis
death of tissue
Nursing Interventions for elevated temp
dec oxygen demand provide warmth when chilled remove coverings provide cool air when warm provide extra fluids to replace fluids lost through inc metabolism, insensible water loss, diaphoresis administer antiphyretics Give sponge bath if appropriate encourage intake of oral fluids
flexion
decrease angle of joint Ex: bending elbow
corticosteroid drugs
decrease body's ability to repair wounds; suppress immune system
A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin. The nurse can anticipate that the digoxin will:
decrease the apical pulse.
hypotension
decreased blood pressure
bradypnea
decreased respiratory rate
bradypnea
decreased respiratory rate; occurs in some pathologic conditions
the nurse expects which physiological change to occur to a client during episodes of acute pain?
decreased skin temperature
Change in pattern of urine elimination as usually associated with aging d/t
decreased sphincter reflexes
parasympathetic stimulation on pulse
decreases heart rate
The nurse is preparing to assess a client's oral temperature. The nurse should plan to place the thermometer probe in which area of the client's mouth?
deep in the posterior sublingual pocket
ischemia
deficiency of blood in a particular area
Florence Nightingale
defined nursing as both an art and science, differentiated nursing from medicine, created freestanding nursing education, published books; founder of modern nursing
Nurse practice act
defines legal scope of practice, excludes untrained or unlicensed people from practicing, establishes education and licensing criteria, creates a state board of nursing, makes and enforces rules and regulations
desiccation
dehydration
Risk for Impaired Tissue Integrity is appropriate for clients with Impaired Skin Integrity who are at risk for
delayed healing
What does the database consist of?
demographic data nursing assessment data history and physical data family and social history data
What are three admissions data?
demographic information insurance data contact info
Abrasion
denuded skin
focused assessment
detailed assessment of a specific problem. pt has abdominal pain- Ask questions about urinary problems, bowel problems, allergies, menstrual hx, assess vital signs and abdominal structures
after administering pain medication to a client, it is most important for the nurse to take which action?
determine whether the medication is effective
elements of cultural competence
developing self-awareness; demonstrating knowledge and understanding of a patients culture; accepting and respecting cultural differences; understanding and respect your views may differ from patient; be open and comfortable with cultural encounters
Instruments
devices used to collect and record the data
dx
diagnosis
what is pulse pressure?
difference between systolic and diastolic pressure
protein electrophoresis
differentiates between protein fractions
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
orthopneic position
difficult breathing, relieved by sitting or standing erect; orthopneic position: sitting and leaning forward, to facilitate breathing.
dyspnea
difficult or labored breathing
dyspnea
difficulty breathing
somatic pain
diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves
radiation
diffusion of heat by electromagnetic waves (such as an uncovered head)
dysphasia
difficulty in understanding or expressing language.
An acute medicine unit of a hospital currently has a number of clients who have tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Which measures should the nursing staff prioritize in preventing the spread of MRSA to clients who are currently MRSA-negative?
diligent handwashing practices
primary health promtion
directed towards PROMOTING health and PREVENTING the development of disease processes or injury; example: immunization clinic, family planning services, accident prevention education
gravital plane
direction of gravitation pull; an imaginary vertical line through the top of the head, center of gravity, and base of support.
line of gravity
direction of gravitation pull; an imaginary vertical line through the top of the head, center of gravity, and base of support.
defecation
discharge of solid waste matter (feces) from the intestines.
acute disease
disease or illness that develops suddenly and runs its course in days or weeks; illnesses that interfere with the continuum for a short period of time.
local anesthesia
disruption of sensation to a specific body area without causing unconsciousness; caused by infiltration or topical application of anesthetic, usually to a small area; not general.
Disturbed Body Image should be used if the patient is experiencing
distress about the wound
chronic wound
do not progress through stages of healing; healing impeded
PIE: Intervention
document the nursing actions you take for each nursing diagnosis
nursing progress notes(nurses' notes):
documentation by nurses of care given and observations made; charting data input
when witnessing the clients signature during informed consent, it is most important for the nurse to make which assessment?
does the client give consent voluntarily
negligence
doing something you shouldn't have done, or not doing something you should have done
Emergency assessment
done when there is a life threatening problem. Identify conditions that could lead to worsening health problems, or death, BIGGEST emergency has to do with breathing, if not breathing, nothing else matters
diplopia
double vision
Crust
dried residue of serum, blood or pus on skin surface, large adherent crust= scab
laxatives
drugs that induce emptying of the intestinal tract
constipation
dry, hard stool; persistently difficult passage of stool; incomplete passage of stool
nurse practice acts
each state has its own; protects public with legal scope of nursing practice
Montgomery straps
easily removable straps that stay in place to facilitate dressing removal
A nurse is caring for a client admitted to the hospital for dehydration. The physical findings consistent with the diagnosis include:
easy wrinkling of the skin and sunken eyes.
the nurse assesses the elderly client in the outpatient clinic. which statement does the nurse expect the client to make?
eating just does not appeal to me anymore
sociocultural dimension
economic level, lifestyle, family, and culture
Safety and security needs
effective handwashing use of PPE proper use f electrical equipment proper administration of meds effective transfer techniques
hypertension
elevated blood pressure
Wheel
elevated mass w/ transient border, vary in size and color, caused by movement of serous fluid into dermis
Papule
elevated, palpable solid mass
The nurse understands that accurate blood pressure taking is dependent on several factors. Which example will most likely render an accurate blood pressure reading?
elevating the client's arm at heart level
A nurse is preparing to provide discharge instructions to a postpartum client regarding infant care. Before beginning the education session, the nurse should:
eliminate as many distractions as possible.
projectile vomiting
emesis expelled with great force.
A family has lost a member who was treated for leukemia at a nursing unit. The nurse provides emotional support to the family and counsels them to cope with their loss. Which quality should the nurse use in this situation?
empathy
administrative law
empowered by executive officers (Board of Nursing, City Board of Health) ex. narcotics
Communication
enables healthcare professionals to plan and evaluate treatment and monitor health status over time
statutory law
enacted by legislative body (State Nurse Practice Acts) ex jayco
Cyst
encapsulated fluid-filled or semisolid mass, ocated in SQ tissue or dermis
bioethics
encompasses # of fields of life sciences
one the morning before surgery, a client signs an operative consent form. soon afterward, the client tells the nurse that the client does not want the surgery. which action will the nurse take first?
encourage the client to discuss reasons for canceling the surgery
Which nursing action best exemplifies the nurse's role in promoting health?
encouraging a group of junior high school students to engage in regular physical activity
an elderly client is admitted to the hospital to undergo abdominal surgery. admitting orders include activity as desired, standard bowel prep, and an intravenous infusion of 5% dextrose in water to infuse at 75ml per hour starting at 1800 on the evening before surgery. the nurse understands the primary purpose of administering intravenous fluids to a client prior to surgery includes which reason?
ensure the client remains adequately hydrated
documentation
enter data asap, if it isn't recorded, it didn't happen, summarize, use pt's own words, avoid non-specific terms
Chronic pain
episode of pain that lasts for 3 months or more Serves no useful function characterized by weight loss or gain, fatigue
chronic pain
episode that lasts 6 mo or longer may cause depression, weight gain, fatigue, immobility
acute pain
episode that lasts from a split second - 6 mo may cause decreased healing, vital sign changes, diaphoresis
most important when caring for a client in pain
establish a trusting relationship with the client
which nursing action is most important when caring for a client in pain?
establish a trusting relationship with the client
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
which nursing action is most important when caring for a client in pain?
establishing a trusting relationship with the client
goal-oriented
establishment of objectives or specific desired outcomes early in the nursing process.
how often should restraints should be checked
every 1-2 hours
lumbar lordosis
exaggerated concavity in the lumbar region
kyphosis
exaggerated convexity in thoracic region
urinalysis
examination of urine
lithotomy
examination position in which the client is lying on his or her back with the feet in stirrups.
Fowler's position
examination position in which the client is lying on his or her back with the head elevated.
Sims' position
examination position in which the client is lying on his or her left side with right knee flexed.
deductive reasoning
examines a general idea and then considers specific actions or ideas
hemorrhage
excessive bleeding(internal or external); escape of blood from non-intact blood vessels.
polyuria
excessive output of urine (diuresis)
hyperextension
excessively increase angle of joint Ex: bending head backwards
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
Kegel exercises
exercises designed to increase sphincter tone by tightening, holding, and releasing the muscles of the pelvic floor and sphincter, used to improve incontinence.
traction
exertion of a pulling force; an apparatus attached to the client to maintain stability of a joint or aligned fracture or to exert a pulling force elsewhere, as in the lower back, to relieve pressure.
What are 4 disadvantages of electronic health records?
expenses downtime difficulties associated with change lack of integration
reflex incontinence
experience emptying of the bladder w/o sensation of the need to void
trial and error problem-solving
experimental problem solving that tests ideas to decide which methods work and which do not.
MASLOW's Heirarchy Patient teaching
explain new and unfamiliar procedures to patients to decrease anxiety
PATIENT TEACHING
explain proper skin care, change position every 2 hours on reclining check the skin, esp bony prominence for signs of pressure 2x/day do an exercise program, ROM's 8H
nurse as expert witness
explain to judge and jury what happened based on patients record and offer opinion about whether nursing care met acceptable standards
Impaired Tissue Integrity is appropriate for patients with wounds that
extend into the subcutaneous tissue, muscle, or bone
pronation
face down; laying on your stomach
supination
face up; laying on your back (spine)
When assessing a client's nonverbal communication, the nurse will assess which characteristic as the most expressive part of the body?
facial expressions
Heart failure
failure of the cardiac muscle to pump sufficient blood to meet the body's metabolic needs manifestations dyspnea orthopnea pleural effusion dependent edema bounding pulses
The client is an 18-month-old in the pediatric intensive care unit. He is scheduled to have a subgaleal shunt placed tomorrow, and his mother is quite nervous about the procedure. The nurse feels for the mother and tells her that the surgeon "has done this a million times. Your son will be fine." This is an example of what type of nontherapeutic communication?
false reassurance
tachy-
fast; rapid
tetanus
fatal disease caused by bacterium that can live for a long time in soil and dirt can enter blood via wounds after a dirty wound, the tetanus toxoid booster is given to ensure protection against tetanus
which of the following fears is most important for the nurse to consider when planning care for a 4-year-old about to have surgery
fear of mutiliation
a person with fever is said to be what?
febrile
what is an example of behavior control of temperature?
feeling hot and turning up the air conditioner
pain
feeling of suffering, distress or agony, caused by stimulation of specialized nerve endings, a protective device of the body; a subjective sensation (reported by the client).
body cue
feelings experienced in response to body rhythms, self-monitoring
Modified Trendelenburg
feet elevated 20 degrees head slightly elevated Increased venous return increased blood supply to brain
what does pyrexia mean?
fever
what is an antipyretic?
fever reducer
anti-pyretic
fever reducing agent
SYMPATHETIC
figh or flight inc BP, HR, RR, blood glucose levels dec blood flow to skin vasoconstriction
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
crackles
fine to course crackling sounds due to fluid in the air passages
Five elements
fire, earth, metal, water, and wood correspond to organs and tissues and explain how the body works
Scales
flakes secondary to desquamated, dead epithelium, flakes sticks to skin surface
gliding joint
flat surfaces of the bone slide over one another; carpals of wrist and tarsals of feet
Macule
flat, w/ nonpalpable skin color change
percussion tones
flat-soft muscle dull-medium-liver(solid organs resonance-loud-lung (air) Hyperresonance-very loud-emphysema (more air pockets) tympany-loud-gastric (air bubble)
What is used to chart by exception?
flow sheet
MONITOR
fluid loss, skin color and temp check VS monitor for dec level of consciousness and seizure activity monitor WBC, Hmg, Mct monitor InO Monitor for electrolyte abnormalities and acid-base imbalance Administer antipyretic meds as ordered Give
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
client-oriented
focused on meeting individualized needs.
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
thrombophlebitis
formation of a blood clot in a vein, with inflammation
suppuration
formation or discharge of pus (adj: suppurative).
sordes
foul, dark matter that collects around the teeth and lips in low grade fever
Margaret Sanger
founder of planned parenthood
friable
fragile; easily broken
Nrsng considerations
frequency of turning should be increased pressure relieving devices usage skin kept clean and dry w/ min. force or friction massage of the area aboided bec it can cause trauma to deep tissues
Prevent pressure ulcers
frequent turning skin care; keep skin dry esp. incontinent pt. Ambulate as feasible Use draw sheet Balanced diet with adequate protein Use air mattress, flotation pads, elbow and heel pads, sheepskin
MENU
fresh uncooked fruits, dried fruits steamed veggies,bran, oatmeal
origination of the word "nurse"
from the latin word "nutrix" meaning to nourish
Impaired skin integrity
from wound trauma or surgery, prolonged pressure, irritation, or immobility become pressure u; depends on loc. and degree of impairment, infection, bleeding and further breakdown can occur; risk factors may be evaluated as physical and medical condition, continence, activity, mobility; prevention is priority;
Stabe 4
full-thickness skin loss w/ extensive damage, destruction or necrosis to muscle, bone and supporting structures
Stage 3
full-thickness wound w/ tissue damage or necrosis of SQ tissue
symptom
functional evidence of a disease or condition that a client perceives subjectively (as opposed to signs, which the examiner or others perceive).
flatus
gas
What is external respiration?
gas exchange between lungs (alveoli) and pulmonary blood supply
flatus
gas in the intestines or stomach; gas expelled through the anus.
health assessment
gather information about pt's health status, identify strengths and actual and potential health problems, pt's response to the condition, TO ESTABLISH A BASE FOR THE NURSING PROCESS
CLEAR LIQ DIET EX.
gelatin, popsicle, tea w/ lemon, ginger ale, bouillon, fruit juice w/o pulp,
physical dimension
genetic inheritance, age, developmental level, race, gender
T
getting ready to receive impulse
justice
give each his or her due and act fairly
Prevent negative nitrogen balance
give high protein and easily digestible diet in small, frequent feedings
verbal communication
giving information, news, or messages by speaking or writing.
communication
giving, receiving, and interpreting information (maybe verbal or nonverbal).
direct studies
going inside the body ex. colonoscopy, sigmoidoscopy
Theory of Animism
good spirits brought health and bad spirits brought sickness and disease; role of doctor was medicine man and nurse is mom taking care of family
public law
government is directly involved- regulates relationships between individuals and government (describing the powers of law)
Which personal protective equipment (PPE) should the nurse don to enter the room of a client who is diagnosed with Clostridium difficile?
gown and gloves
EKG
graphic recording of heart's electrical activity each square is o.o4 horizontal sq 12 lead-looks at heart activity in different views
theory
group of concepts that describe a pattern of reality- can be tested, changed, or used to guide research
nursing care plan
guidelines used by healthcare facilities to plan the care for clients.
What is piloerection?
hair stands up (goosebumps)
The nurse is preparing discharge instructions for a family member who will be caring for a client with an abdominal incision. Which concept should be the priority in the teaching plan?
hand washing
A lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the priority nursing action?
handwashing before leaving the client's room
Why are there relatively high risks for patient care error in paper health records?
hard to read hand writing papers can be lost
cartilage
hard, nonvascular connective tissue found in the joints; functions as shock absorber and provides smooth surface that reduces friction between moving parts of the joint
stridor
harsh high pitched heard on inspiration
Risk for Impaired Skin Integrity is appropriate for patients who....
have one or more risk factors for skin breakdown
Implement the care
have patient exercise, eat more fiber, increase fluids, give meds for constipation, etc.
isometric
having the same length or dimensions, as isometric exercises(pushing against stable resistance);also called muscle setting.
Fowlers
head elevated Increased venous return = maximal lung expansion
Nonsteroidal antiinflammatory drugs (NSAIDs) side effects
headache dizziness epigastric distress peptic ulcer disease prolonged bleeding renal impairment Administer with food
The nurse is caring for a client who developed pneumonia while hospitalized. How will the nurse document this condition?
health care-associated infection (HCAI)
components of health assessment
health hx and physical assessment
untreated heat stoke can cause damage to what?
heart brain kidneys other vital organs
-cadia
heart condition
tachycardia
heart rate above 100
bradycadia
heart rate below 60
what is an example of heat loss through conduction?
heat is transferred from a warm to a cool surface by direct contact (example: apply and ice pack to a warm area of the body)
Self-actualization needs
help achieve full potential focus on patient's strengths rather than weaknesses
vitamin K
helps the synthesis of certain proteins necessary for blood clotting
Internal bleeding is referred to as what?
hematoma
what are five complications of wound healing?
hemorrhage infection dehiscence evisceration fistulas
inflammatory phase consist of what two major processes?
hemostasis inflammation
occult
hidden
Wound diet
high in vitamin C high in protein (tissue growth) high in carbohydrates (used for energy so the protein is properly utilized for repair of tissue
wheezing
high pitched,musical-generally from narrowing of air passages
doctorate
higher level of practice
trapeze
horizontal bar suspended above and attached to the bed, which is used to pull up to a sitting position or to lift the shoulders and hips off the bed.
facilitating coping with disability or death
hospice, refer to support groups
environmental dimension
housing; sanitation; climate; pollution of air, food, and water
morbidity
how frequently a disease occurs
emotional dimension
how the mind affects body function and responds to body conditions
sister callista roy
humans are biopsychosocial beings existing within an environment; needs are created within interrelated adaptive modes; nursing interventions are required when individuals demonstrate ineffective adaptive responses
what is the difference between hyper and hypothyroidism
hyper: increase in thyroxine hypo: decrease in thyroxine
HTN
hypertension
The balance of temperature is controlled by what?
hypothalamus
purpose of documentation
if it isn't recorded, it didn't happen, to identify actual and potential health problems, plan appropriate care, evaluate the pt's responses to tx,
cultural blindness
ignores differences and proceeds as if they did not exist
health promotion model
illustrates how people react to their environment as they pursue health
illness is a manifestation of
imbalance or disharmony
paresis
impaired muscle strength or weakness
risk factors for pressure ulcer
impaired sensory perception (diabetic, paraplegic) impaired mobility altered LOC Shear Friction moisture anemia
what is a hemorrhage?
implies a profuse or rapid loss of blood
prostaglandins
important hormone-like substances that send additional pain stimuli to the CNS
vitamin c and zinc
important in wound healing
body language
impressions one conveys through body movements and posture, eye contact, and other non-verbal means.
planning
in nursing process, developing goals to prevent, reduce, or eliminate problems and identifying nursing interventions that will assist in meeting these goals..
evaluation
in nursing process, measuring the effectiveness of the other steps.
implementation
in nursing process, the carrying out of nursing care plans; also called interventions.
potential needs
in the nursing process, needs which may occur; identified as at risk for...
incontinence
inability to control urination or defecation (adj: incontinent).
urinary retention
inability to empty the bladder of urine.
what are symptoms of a heat stroke?
inability to sweat rapid breathing rapid bounding pulse
hypoxia
inadequate amount of oxygen available to cells
extended family
includes aunts, uncles, and grandparents
extension
increase angle of joint Ex: straightening elbow
to have a bowel elimination, the patient should?
increase dietary bulk
"Shift to left"
increased # of immature neutrophils
physiological measures that indicate pain
increased blood pressure and pulse
frequency
increased incidence of voiding
Upon assessing a client who is hemorrhaging, the nurse is most likely to assess which compensatory change in vital signs?
increased pulse rate
tachypnea
increased respiratory rate
tachypnea
increased respiratory rate; may occur in response to increased metabolic rate
The temperature is 102°F (39°C) during a heat wave. The nurse can expect admissions to the emergency room to present with:
increased temperature.
sympathetic stimulation on pulse
increases heart rate
Release of epinephrine does what?
increases metabolism
serum albumin
indicator for malnutrition important part of nutritional assessment
What are examples of developmental level factors in body temperature?
infants older adults
Which age-groups are most susceptible to thermoregulation problems and why?
infants lose 30% of there body temperature from their head and older adults lose body temperature due to slower metabolism, decreased vasomotor control, and loss of subcutaneous tissue
The nurse is caring for a pediatric client who became very ill after being in a day care where a number of other children are sick with the same condition. How will the nurse document this condition? Select all that apply.
infectious disease communicable disease contagious disease
pediculosis
infested with lice
Localized infection
inflammation redness warmth swelling pain loss of function Drainage- serous, bloody cloudy, or purulent cellulitis
acne vulgaris
inflammation of the sebaceous glands comedones (blackheads and whiteheads) Papules Pustules Cysts occurring often on face, shoulders, neck, and back
What is advance directive?
information on client's wishes for the extent of care and medical support that should be given in the event of a life-threatening event
data
information the researcher collects from subjects in the study (expressed in numbers)
Pre-Op Check list
informed consent Lab tests, chest X ray, EKG Skin prep Bowel prep IVs NPO Preop meds, sedation, antibiotics Removal of dentures, jewelry, nail polish
modulation
inhibition or modification of pain
spinal anesthesia
injected into lumbar intervertebral space beyond dura mater into subarachnoid space blocks pain sensation and movements causes anesthesia of lower extremities, lower abdomen hypotensive possible
When assessing the abdomen what order should the techniques be performed
inspection, auscultation, percussion, palpation
techniques used during a physical exam
inspection,palpation, percussion, auscultation
otoscope
instrument used for visual examination of the ear
opthalmoscope
instrument used to examine the interior of the eye
hypoxemia
interference with blood oxygenation.
what are the four ways to describe a fever?
intermitted (temp alternates from norm to abnormal) remitted (temp fluctuates but remains abnormal) constant relapsing (reoccurring)
regional anesthesia
interruption of sensory nerve conductivity to specific area of the body (includes conduction block, field block, nerve block).
urinary incontinence
involuntary loss of urine
quantitative
involves concepts of basic and applied research
cystitis
inflammation of any bladder(most often refers to urinary bladder)
Laceration
irregular edbes and vein bridging at site of skin tear
not CLEAR LIq. DIET
is milk, juice w/pulp
How does hypothyroidism influence BMR?
it decreases BMR
how does hyperthyroidism influence BMR?
it increases BMR
What is serous fluid?
it is a thin clear fluid
inference
judgment-ask questions to validate
common law
judiciary system reconciles controversies, creates body of common law (malpractice)
fidelity
keep promises
Purpose of a drain
keep the tissues close together so healing can occur provide exit route (gravity or vacuum) for air, blood, and other material following surgery
The most important thing to remember is to use universal precautions to minimize the risk of cross-contamination when cleansing periwound or other nonwound skin.
key note
renal
kidney
What is a disadvantage of narrative format?
lack of standardization lead to lengthy notes
Word War II on the development of nursing
large #s of women worked outside the home, became more assertive and independent, led to increased emphasis on education, explosion in technology and medicine while broadening the role of nurses (1950s)
Physical decline decreased independence fear of death fear of nursing home placement
largest fear for elderly presurgery
mutilation
largest fear for preschool age presurgery
loss of control
largest fear for school age presurgery
Loss of independence; being different from peers
largest fear for teenagers presurgery
separation
largest fear for toddler age presurgery
scoliosis
lateral curvature in a portion of the vertebral column
Prevent thrombus formation
leg exercises- flexion and extension of toes and feet for 5 min q hr. Ambulate as appropriate Frequent change of position Use TEDs
licensure
legal document to offer skills and knowledge; may be revoked
vascular lesions
lesions of a blood vessel; involve blood or circulatory system
primary reason that elderly adults have constipation
less peristalsis decreased muscle tone in GI tract reduced activity
LOC
level of consciousness
nits
lice eggs
A prospective nursing student desires a career that will allow the opportunity to provide client care and to assist professional nurses with routine technical procedures. The prospective student needs to be employed in a full-time position quickly due to economic hardship. What type of nursing program would best suit this student?
licensed or vocational nursing program
psoriasis
lifelong scaling skin disorder inflammation recurrent itchy, erythematous papules/ plaques covered with silvery white scales chronic autoimmune reaction noninfectious elevated sedimentation rate with negative rheumatoid factor
Fissure
linear crack in skin , may extend to dermis
INTAKE FLUIDS
liquids by mouth NG or jejunostomy feeding tubes IV fluids blood and its components
auscultation
listening with the stethescope to lungs, heart and abdomen, listen for pitch, loudness,quality and rate
hepatic
liver
a client has a left modified radial mastectomy. upon transfer from the recovery room to the surgical unit, the nurse notices the hemovac drain is half filled with blood. which action should the nurse take first?
look at the recovery room record
eye contact
looking another person in the eye, as in "making eye contact."
Nursing assessment
looking for patient's response to health problems. Response to medications ordered for HTN, Is BP at a normal reading, Information relayed to physician if patient is not responding to tx
inspection
looking to observe-using eyes look for symmetry in body parts, color
ideal rate of weight loss
losing 1-2 lbs per week
what is heat loss through radiation?
loss of heat through electromagnetic waves emitting from surfaces that are warmer than the surrounding air. (warm person to cool air)
Erosion
loss of superficial epidermis, depressed, moist area
pneumonia
lung inflammation, with consolidation and drainage
supine
lying on back
exercise
maintain joint mobility and function promotes muscle strength stimulates circulation promotes optimum ventilation stimulates appetite promotes elimination enhances metabolic rate
POSITIONING
maintaining proper body alignment, prevent injuries,optimize ROM and comfort, facilitate breathing, eliminate secretions, promote CVasc function, encourage normal ADLs such as feeding, bathng and elimination and sleep various devices used in positioning process prevention of pressure, friction and skin shear needs
CLEAR LIQUID DIET
maintains fluid balance for surgical clients clients w/ acute vomiting or diarrhea used to empty GI tract to prevent aspiration -does not provide good energy sources and nutrition
ROMs
maintains joint mobility improves or maintains muscle strength prevent muscle atrophy
activity
maintains muscle tone and posture serves as outlet for tension and anxiety
What are advantages of POR system?
makes it easier to monitor the patients progress the finding can be easily reviewed
What does it mean to make nursing visible?
making nursing care and its effect on patient outcomes more visible in patient record to demonstrate the value of nursing.
In the role of entrepreneur, the nurse's primary responsibility is:
managing a health-related business.
gait
manner or style of walking
Highly sensitive C- Reactive protein (hsCRP)
marker of inflammation
exudate
material that escapes from blood vessels and is deposited in tissues or on tissue surfaces; usually contains protein substances.
flotation mattress
mattress or pad filled with a gel-type material which supports the body in a way to pro-vide comfort and avoid creating pressure points, thereby helping to prevent skin breakdown.
single-parent family
may be separated, divorced, widowed, or never married
anticoagulants
may cause hematuria (blood in urine), leading to pink or red color
U
may or may not be present repolarization of muscle tissue holding the valves -purkinjie conduction
culturally competent nursing
means that care is planned and implemented in a way that is sensitive to the needs of individuals, families, and groups from diverse populations within society
expected outcome
measurable behavior that indicates whether a person has achieved the expected benefit of nursing care
when measuring a wound
measure from left to right and then top to bottom
vital signs
measurements of temperature, pulse, respiration, and blood pressure.
health-illness continuum
measures a persons health on a graduated scale
ADT
measures damage to liver and heart normal is 10- 40 u/L
bleeding time
measures the duration of bleeding after standardized skin incising
meaning of healing
mending and getting better from disease
1,4,6- chp, foundations of psychic nursing
mental health (week 1 readings)
What is nonshivering thermogenesis?
metabolism of brown fat to produce heat
how is heat produced in the body?
metabolism, skeletal muscle movement, nonshivering thermogenesis
peripheral neurovascular assessment
method for evaluating the status of an extremity in a bandage or case
logroll turn
method of turning a client that keeps the body in straight alignment, used for clients with injuries to the back and/or spinal cord.
the nurse understands that which of these common foods are the most likely cause of eczema and should be eliminated from the diet?
milk, wheat, egg whites
accreditation
min standards of education
flat/ supine
minimizes hip flexion
cultural assimilation
minorities living within a dominant group lose the characteristics that made them different; replace values with those of dominant culture
critical thinking
mix of inquiry, knowledge, intuition, logic, experience, and common sense.
What is serosanguineous drainage?
mix of serous and sanguineous (bloody and clear)
serosanguineous drainage
mix of serum and blood cells; light pink to blood tinged
rapid eye movement (REM) sleep
more difficult to arouse; consumes 20-25% of sleep time; dreaming occurs
abduction
move body part away from midline of body
adduction
move body part toward the midline of the body
rotation
move joint around central access
The nurse is caring for a client who has been hospitalized and placed in airborne precautions for a week. Which nursing intervention is appropriate to provide sensory stimulation?
move the bed and furnishings to a different place in the room
pulmonary ventilation
movement of air in and out of lungs
What is pulmonary ventilation?
movement of air into and out of the lungs
opposition
movement of thumb across palm to touch each fingertip on same hand
isokinetic exercise
muscle contraction with resistance
isometric exercise
muscle contraction without shortening
isotonic exercises
muscle shortening and active movement
What are 4 common formates for nursing progress notes?
narrative format problem intervention evaluation (PIE) SOAP/SOAPIE/SOAPIER focus charting FACT system Electronic entry
What is vasoconstriction?
narrowing of blood vessels
vitamin C
necessary for formation of cartilage in CT maintain integrity of intracellular cement (ie capillary walls)
PASSIVE ROM
need assistance to exercises, start with head then sides of body -repeat exercises 3x -improve joint mobilization -circulation -prevent contractures
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
unintentional tort
negligence malpractice
malpractice
negligence by professional personnel
granulation tissue
new tissue that forms when old destroyed tissue is sloughed off.
apnea
no breathing
Stage 1
non blanching erythema of intact skin
Which of the three ways of heat production is used mostly in infants?
non shivering thermogenesis
Pressure ulcers 4 stages
nonbalnching erythema of intact skin
Eupnea means:
normal breathing
nociception
normal pain transmission
eupnea
normal, unlabored breathing, one respiration to four heartbeats
alternative therapy
not included in the scope of conventional medical care
What is graphic data?
numerical data
Graduate education-masters
nurse practitioner, educator, management
what is central to the care-based approach
nurse-patient relationship
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
Ernestine wiedenbach
nursing as an art; nursing is providing nurturing care to patients
sign
objective evidence of disease that another person can note (as opposed to symptom, which only the client can describe).
objective data
observable and measurable data that can be seen heard or felt by someone other than the pt. vital signs- a number or a lab
science
observing, identifying, describing, investigating, and explaining events and occurrences that are perceived in the world
intraoperative
occurring during a surgical operation.
open wound
occurs from intentional and unintentional trauma; skin surface is broken, providing a portal of entry for microorganisms
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
ethical distress
occurs when the nurse knows the right thing to do but either personal or institutional factors make it difficult to follow the correct course of action
friction
occurs when two surfaces rub against each other
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
A nurse is caring for four clients. Which client has the highest risk of infection?
older male with an enlarged prostate
crackle
on auscultation, an abnormal discontinuous non-musical respiratory sound heard on inspiration; formerly called rale.
SUPINE/FLAT
on back good for aligning verterbrae minimal hip flexion eextremities and head need to be supported
inductive reasoning
one builds from specific ideas or actions to conclusions about general ideas
The nurse who is caring for a client in contact isolation is preparing to conduct an assessment. Which stethoscope will the nurse choose to auscultate the client's bowel sounds?
one that remains in the client's room
What is charting by exception?
only charting the abnormal (only chart significant findings)
dehiscence
opening or separation of the surgical incision.
What are normal oral and rectal temps?
oral: 98 (36.7) rectal: 98.6 (37)
developmental theory
orderly and predictable growth and development from conception to death
value system
organization of values each ranked according to importance, leading to code of conduct
What is problem-oriented record systems?
organized around the problems of the patient promotes greater collaboration
The nurse places a client experiencing labored breathing in an upright position. The nurse notes that the client is able to breathe more easily in this upright position and documents this condition on the chart as:
orthopnea
gurney
our-wheeled cart; also called gurney, wheeled stretcher. A litter scale is used to weigh clients who cannot stand.
epidermis
outer layer dead squamous cells no blood supply
maceration
overhydration
Maslows level 1: physiologic needs
oxygen, food, water, sex, rest, physical activity; physiologic needs are highest priority
Physiologic needs
oxygen, water, food, temperature, elimination, sexuality, physical activity and rest
NLN identified 10 trends to watch for in nursing education
p. 20
Nursing social policy statement of issues nurses address
p. 24 under subject heading Nursing Knowledge
aquathermia pad
pad which produces a dry heat by the use of temperature-controlled water flowing through a waterproof shell.
trochanter roll
padding placed onsides of legs and feet of a client in bed, to prevent abnormal outward rotation and related sequela.
a client with ovarian cancer experiences severe pain. which principle should the nurse remember when caring for this client?
pain medication is more effective if given before pain becomes severe
chronic pain
pain that may be limited, intermittent, or persistent but that lasts beyond the normal healing period
dysuria
painful or difficult urination
following surgery, the nurse becomes concerned because the client has not voided since before surgery which was 10 hours ago. which nursing action is most appropriate?
palpate for bladder distention
paraplegia
paralysis both legs
quadriplegia
paralysis of both arms and both legs
hemiplegia
paralysis one half of the body
the nurse cares for a client beginning intermittent heparin therapy. the nurse knows which laboratory test is used to monitor the effectiveness of heparin
partial thromboplastin time (PTT)
melena
passage of dark-colored stools containing partially or fully digested blood; also used to mean abnormal blood in the stool or vomitus.
flat line
passage of impulse through AV node
micturition
passage of urine from the urinary bladder; also called voiding, urinating.
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
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
the nurse knows which of the following statements describes an important consideration when spinal anesthesia is used
patients must be protected from injury since sensation is impaired
parasomnias
patterns of waking behavior that appear during sleep
ulcer
pen sore on an external or internal body surface that causes gradual disintegration of tissues, often an ulcer of the stomach (pepticulcer) or a pressure sore (decubitus ulcer).
open drainage system
penrose drain; promotes drainage passively
The nurse is recovering from a very mild upper respiratory infection with no fever. The nurse is assigned to care for four clients. What is the appropriate nursing action?
perform meticulous hand hygiene and don a new mask with each client encounter
Isometric exercise
performed by client alternate contraction and relaxation of muscle without moving joint maintains muscle strength when joint is immobilized
passive ROM
performed by nurse without assistance from client
restoring health
performing assessments that detect an illness refering questions and findings to other healthcare providers, providing direct care, collaborating, planning, teaching and carrying out rehabilitation for illnesses, working in rehab programs
apnea
periods when no breathing occurs
What are the compensatory mechanisms for decreasing body temperature?
peripheral vasodialtion sweating inhibition of heat production
What three things happen when the heat sensors in the hypothalamus are stimulated and they send out impulses to reduce the body temperature?
peripheral vasodialtion sweating inhibition of heat production
Where is heat lost in the body?
periphery
contracture
permanent contraction of a muscle
colostomy
permits formed feces in the colon to exit through the stoma
defendant
person being accused of a crime
plaintiff
person bringing suit
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
What specialized WBC's ingest the invaders and secrete pyrogens?
phagocytes
trauma
physical injury
human dimensions that compose the whole person
physical, intellectual, environmental, spiritual, sociocultural, and emotional
what is a primary dressing?
physically touch the wound
MASLOW'S HEIRARCHY OF NEEDS
physiologic safety and security love and belongingness self-esteem self-actualization
client reminder device
piece of equipment, most often a vest or a belt, used to ensure the safety of the client (ie, helping client to remain in a chair without falling); also called a client reminder device.
What is granulation tissue?
pinky/beefy red tissue (shiny)
the nurse cares for a client with an abdominal wound. the nurse notes there is purulent drainage from the wound. which action should the nurse take first?
place the client on contact precautions
What are two examples of Planning and evaluation of client outcomes?
plan and evaluate treatment monitor health status over time
what is a nursing interview?
planned communication to obtain a history
ST
plateau
plantar flexion
point the toes away from the head
dorsiflexion
point the toes toward the head
visceral pain
poorly localized and originates in body organs in the thorax, cranium, and abdomen
PCA/ Patient controlled analgesia pump
portable device that delivers predetermined dosage of IV pain med
knee gatch
position with the lower section of bed under the knees is slightly bent
dangling
positioning of a client so that he or she is sitting on the edge of the bed with legs down and feet supported by a footstool or the floor. This is an exercise in preparation for sitting in a chair and/or walking.
scientific problem-solving
precise method of investigating problems and arriving at solutions
What is an example of providers orders?
prescriptions for meds, treatment, and activities
glycosuria
presence of sugar in the urine
what is stage 2?
pressure injury is open but shallow and with a red pink wound bed.
TYPES OF LESSION
primary and secondary
types of lesions
primary, secondary, vascular
prioritization
prioritizing: in the nursing process, following specific steps to determine the client's most important needs.
collaborative problem
problem in which nurses work with physicians or other healthcare providers.
What are 5 components of POR?
problem list initial plan progress notes discharge summery
continuity of care
process by which health care providers give appropriate, uninterrupted care and facilitate the patient's transition between different settings and level of care; ensures smooth transition between types of health care settings; depends on excellent communication as pts move from one caregiver to another
litigation
process of bringing and trying a lawsuit
What is thermoregulation?
process of maintaining a stable temperature
prognosis
projected client outcome.
DOCUMENTATION
promotes communication, legal record meets requirements of regulatory agencies required for third-party reimbursement legible accurate timely through well organized' concise proper grammar, spelling and authorized abbreviations
prone
promotes extension of hip joint
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
promoting health
promoting good physical, mental and emotional health by identifying, analyzing, and maximizing the patient's strengths as components of preventing illness, restoring health and facilitating coping with disability or death
Aims of nursing
promoting health, preventing illness, restoring health, facilitating coping with disability or death
function of skin
protection against injury temperature, water, and electrolyte regulation
albumin
protein formed in liver contributes to osmotic pressure transports enzymes, drugs, hormones indicates liver and nutritional status will be increased if dehydrated
proteinurea
protein in the urine; indication of kidney disease
An abdominal binder is used to
provide support to the abdomen
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
midazolam
provides anxiety reduction, sedation preop medicine given
vitamin D
provides calcium and phosphorus metabolism and stimulates calcium absorption
a 5-year-old is scheduled for a tonsillectomy and adenoidectomy. the child is given midazolam preoperatively. for which purpose is the nurse administer this medication?
provides sedation and anxiety reduction.
carotid pulse
pulse felt on either side of the neck, over the carotid artery.
apical pulse
pulse normally heard at the heart's apex, which usually gives the most accurate assessment of pulse rate.
venipuncture
puncture of a vein, usually with a needle. May be used to obtain a blood specimen or to start an intravenous infusion (IV).
misdemeanor
punishable by fines or less than 1 year imprisonment
felony
punishable by imprisonment for more than 1 year
Inspect wound for S/Sx of infections and
purulent drainage increased drainage, pain, redness and swelling in and around wound increased body temp increased WBC count
pyuria
pus in the urine; urine appears cloudy
Which term indicates a potentially serious client condition?
pyrexia
closed-ended question
questions that can usually be answered by one word, such as "yes" or "no;" also called close-ended questions.
open-ended question
questions used in therapeutic communication and interviews that promote in-depth answers and encourage clients to talk about themselves and their concerns.
How is heat exchanged between the body and the environment?
radiation convection evaporation conduction
Tachypnea
rapid breathing
acute pain
rapid in onset, varies in intensity and duration, protective in nature
acute illness
rapid onset of symptoms and lasts only a short time; examples: cold, diarrhea, pneumonia, appendicitis
rhonchi
rattling sounds in the throat that resemble snoring (singular, rhonchus).
apical-radial pulse
reading done by measuring both the apical and radial pulses simultaneously, used when it is suspected that the heart is not effectively pumping blood.
A nurse needs to assess the temperature of a client with high fever. Which site will most closely reflect core body temperature of the client?
rectum
normal stoma
red and moist
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
what is Purosanguineous exudate?
red-tinged pus.
preventing illness
reduce the risk of illness by avoiding or achieving early detection of illness or to maintain function within the constraints of an illness. Teach by example, educational programs, community programs, literature, and health assessments
morals
refers to personal or communal standards of right and wrong
agent-host-environment model
refers to the interaction of the agent, host, and environment creating risk factors that must be examined
AUTONOMIC NS
regulates HR, BP, influences artery constriction -control vascular system -change w/ aging -blood vessels do not constrict (loose elasticity )when older adults stand up -orthostatic hypotension -beta receptors are less responsive
A nurse is caring for a client who presents with a skin infection. While obtaining the client's medical history, it is determined that the client is an intravenous drug user. To foster effective communication, the nurse should:
remain honest, open, and frank.
biopsy
removal of a sample of body tissue or fluid for diagnostic examination, usually microscopic; most often used to detect the presence of cancer.
debridement
removal of devitalized tissue and foreign material
remove soft hand roll every 4 H
remove soft hand roll every 4 H
The nurse observes an unlicensed assistive personnel (UAP) collecting a urine specimen from a client with Staphylococcus aureus infection. Which action by the UAP would require the nurse to intervene?
removes gloves and walks out of the room
areas of concern for patient advocates
representing of patients, promoting self-determination, whistle-blowing, being politically active
human dignity
respect for inherent worth and uniqueness of individuals and populations
Self-esteem needs
respect patient's values, beliefs and culture encourage him to set reasonable goals promote support from family or significant others
autonomy
respect rights of patients to make health care decisions
5 vital signs
respirations, pulse rate, blood pressure, temperature, and pain
Propoxyphene/ Darvon side effects
restlessness Tremors Mild euphoria
secondary lesions
result from the changes that take place in the primary lesion due to infection, scratching, trauma, or various stages of a disease
HYPOTHALAMIC SET POINT IS INC
resulting to chills (make up the heat client feels warm-vasodilation and diaphoresis occurs
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
shear
results when one layer of tissue slides over another layer
A nurse who has been caring for a client for the past few days is preparing the client for discharge and termination of the nurse-client relationship. Which activity would the nurse be carrying out?
reviewing health changes
autonomy
right to self-determination
tinnitus
ringing or buzzing in the ears
tinea
ringworm; skin infection caused by fungus Pedis = athlete foot- vesicular eruptions in interdigital webs Capitis = ringworm- breakage and loss of hair; scaly and circumscribed red patches on scalp that spread in circular pattern Corporis- ringworm of body- rings of red scaly areas that spread with central cleaning Administer antifungal
inversion
rotate ankle and sole of foot inward
eversion
rotate ankle and sole of foot outward
radial flexion
rotate the hand inward at the wrist
ulnar flexion
rotate the hand outward at the wrist
ball-and-socket
rounded head of one bone fits into a cuplike cavity in the other; shoulder and hip joints
litter
same as gurney
Methadone/ dolophine side effects
same as morphine
oliguria
scanty or greatly diminished amount of urine voided in a given time; 24-hour urine output is less than 400mL
keloid
scar or scar tissue
The nurse is utilizing knowledge about a blood pressure medication's actions and side effects to determine whether or not to give a client, whose blood pressure is low, the prescribed blood pressure medication. What best describes the aspect of nursing demonstrated?
science of nursing
smegma
sebaceous gland secretion that may collect under foreskin of penis in an uncircumcised male.
a T-binder is used to?
secure dressings or pads in the perineal area
dorothea orem
self-care is a human need; self-care deficits require nursing actions; nursing is a human service
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
ethnicity
sense of identification with collective cultural group, largely based on the group's common heritage
substance P
sensitizes receptors on nerves to feel pain and also increases the rate of firing of nerves
What is dehiscence?
separation of one or more layers of a wound is called dehiscence
what are the 4 types of wound drainage?
serous, sanguineous, serosanguineous, purulent (special mention: Purosanguineous exudate)
the nurse knows that serum albumin is used as an indicator of malnutrition for which reason?
serum albumin is easy to measure, and can indicate a protein deficiency that may not be detected on physical examination
constitutions
serve as guides to legislative bodies
Dorothea Dix
served as superintendent of the female nurses of the army during civil war; responsible for recruiting and equipping a corps of army nurses
renal colic
severe, penetrating lower back pain, caused by a stone becoming lodged in the ureter
culture
shared system of beliefs, values, and behavioral expectations; provides social structure for daily living; learned by new generation
What happens when sensors in the hypothalamus detect cold and they send out impulses to increase heat production and reduce heat loss?
shivering release of epinephrine vasoconstriction
SOAP: Plan
short term and long term goals and strategies
pale stoma
shows signs of anemia
Sims
side with legs bent allows drainage of oral secretions (ab. tension)
lateral
side-lying
s/sx
signs and symptoms
Penrose drain
simple latex drain
sources of heat loss
skin (primary source), evaporation of sweat, warming and humidifying inspired air, eliminating urine and feces
What is the periwound?
skin around the wound
Ulcer
skin loss extending past epidermis, necrotic tissue loss, bleeding and scarring possible
erythema
skin redness produced by capillary congestion, as may follow a tuberculin test; bright red color associated with capillary dilation, can indicate fever or infection.
turgor
skin resiliency and plumpness; also called skin turgor.
dyssomnias
sleep disorders characterized by insomnia or excessive sleepiness
brady-
slow
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
delta sleep
slow-wave sleep
vesicle
small sac containing liquid; small blister.
papule
small, solid, circumscribed skin elevation, less than 0.5-1.0 cm in diameter.
the efferent system conveys via
somatic nervous system
variable
something that varies and has different values that can be measured
cancer pain
specific type of pain identified by IASP, caused by a malignancy; often intractable and severe; usually chronic
the nurse identifies which change in the pattern of urinary elimination as usually associated with aging?
sphincter reflexes decreased
spiritual dimension
spiritual beliefs and values
expectorate
spitting out and coughing up mucus or other fluid from the lungs and the throat.
statis
standing still; stopping
when listening to bowel sounds
start lower right and go up, across and down
Which is the best example of a nurse demonstrating the role of caregiver?
starting an intravenous line in the client's arm
tonus
state of slight contraction- the usual state of skeletal muscles
medical diagnosis
statement formulated by a primary healthcare provider that identifies the disease a person is believed to have, which provides a basis for prognosis and treatment decisions.
hypothesis
statement of relationships between the independent and dependent variables that the researcher expects to find
common pieces of equipment used during a physical assessment
stethescope, snellen chart, opthalmoscope, otoscope
Neuropsychosocial post op care
stimulate client post anesthesia measure LOC
vomitus
stomach contents expelled by vomiting or emisis
suppression
stoppage of urine production; normally, the adult kidneys produce urine continuously at the rate of 60 to 120 mL/h
urinary suppression
stopping or inhibition of urination. Suppression of secretion urine is not formed. Suppression of excretion urine is not expelled
ortho-
straight
striae
stretch marks
percussion
striking one object against another to produce sound to determine location, shape, size, and density of tissue
urgency
strong desire to void
gait belt
sturdy webbed belt used by the nurse to help provide support to the weak or unsteady person.
transfer belt
sturdy webbed belt used by the nurse to help provide support to the weak or unsteady person.
DAR: what is data?
subjective and objective data reflects the assessment phase
asphyxiation
suffocation- air does not reach the lungs and breathing stops
What is metabolism?
sum of all physical and chemical processes and changes that take place in the body
cutaneous pain
superficial pain involving skin or subcutaneous tissue
Stage 2
superficial partial-thickness wound that involves epi and dermis
POSITIONS
supine dorsal recumbent prone side lying SIms or side lying with legs bent Fowler's or head elevated
6 classes of nutrients
supply energy: carbs, proteins, lipids regulate body processes: vitamins, minerals, water
Love and belongingness
support patient in meeting this needs by including family and friends in care establish a nurse-patient relationship refer him to specific support groups
A triangular arm binder or sling is used to?
support the upper extremities.
ostomy
surgical opening from the inside of an organ to the outside
What is the preferred method of wound culture that may be performed by a registered nurse (RN)?
swabbing
A nurse is attempting to calm an infant in the nursery. The nurse responds to the highest developed sense by:
swaddling the child and gently stroking its head.
edema
swelling caused by excess fluid trapped in your body's tissues
distention
swelling or fullness, as in urinary distention.
sx
symptoms
nursing assessment
systematic and continuous collection and analysis of information about the client
A nurse is preparing to enter a client's room to perform wound care. The shift report revealed that this client has a tunneling wound in the sacral area that cannot be staged. The wound was also documented as having a foul odor. The nurse is nervous because she has not performed wound care on a complex wound in the past. Using effective intrapersonal communication, this nurse should:
tell herself to "remain calm" and remember that she was trained to perform this skill.
the clinic nurse interviews a middle-aged adult who come to the clinic reporting difficulty sleeping and ongoing fatigue. the nurse learns the client works as a security guard and frequently works nights. which is the best initial response by the registered nurse?
tell me about your usual sleeping habits
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
-thermia
temperature
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
Celsius
temperature scale in which water boils at 100 degrees and freezes at zero (formerly centigrade). "Normal" oral body temperature is 37 degrees Celsius. Celsius scale most often used in health care facilities.
What are the vital signs?
temperature, pulse, respiration, blood pressure
places you can record a pulse
temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis
nurse as fact witness
testimony based on first hand knowledge of event only, not assumptions
intractable pain
that which cannot be relieved; continuous, relentless, as in intractable pain.
mortality
the # of deaths resulting from a disease
what is tidal volume?
the amount of air taken in on inspiration
What is basal metabolism?
the amount of energy needed to maintain the body at rest
What is basal metabolic rate?
the amount of energy required to maintain the body at rest.
A pulse deficit is the difference between:
the apical pulse and the radial pulse rates.
general anesthesia
the blockage of all body sensations, causing un-consciousness and loss of reflexes.
center of gravity
the center of one's weight; half of one's body weight is below and half above, and half to the left and half to the right of the center of gravity. This concept is important in body mechanics.
The nurse is caring for assigned clients who are all stable. Which client should the nurse see first to minimize the spread of infection?
the client who is 48-hours postsurgical procedure
a liver scan is ordered for a client prior to surgery. the nurse understands which description best describes the procedure?
the client will be asked to lie still while a scanning probe is passed back and forth over the body
When the nurse communicates with a newly admitted client, the nurse must pay particular attention to nonverbal behaviors. The nurse considers which characteristic as nonverbal communication?
the client's tone of voice
yin-yang theory
the concept of two opposing, yet complementary, forces that shape the world and life
bioterrorism
the deliberate spread of pathogenic organisms into a community to cause widespread illness, fear, and panic
grounded theory
the discovery of how people describe their own reality and how their beliefs are related to their actions in a social scene
culture shock
the feelings a person experiences when placed in a different culture; may result in psychological discomfort or disturbances
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
nursing ethics
the formal study of ethical issues that arise in the practice of nursing and of the analysis used by nurses to make ethical judgements
enema
the introduction of a solution into the large intestine, usually to remove feces
infection
the invasion and multiplication of infective agents in body tissues with a resultant reaction(illness or injury) to their presence and/or their toxins.
pain threshold
the level at which a person experiences pain
pain tolerance
the maximum level of pain that a person is able to tolerate
pulse rate
the number of contractions over a peripheral artery in 1 minute
contralateral
the opposite side
stoma
the part of the ostomy that is attached to the skin
active exercise
the patient independently moves joints through their full range of motion (isotonic exercise)
passive exercise
the patient is unable to move independently, the nurse moves each joint through its range of motion
perioperative
the period surrounding surgery; includes the preoperative, intraoperative, and postoperative periods
evisceration
the protrusion of the intestines through an abdominal wound; removal of the internal body contents.
what is stroke volume?
the quantity of blood forced out by each contraction of the left ventricle.
intentional wound
the result of planned invasive therapy or treatment ex. surgery, intravenous procedure
utilitarian
the rightness or wrongness of an action depends on the consequences of the action
Activated Partial thromboplastin time (aPTT)
the same as just PTT range: 30-40 sec lab test used to monitor the effectiveness of heparin must be measured at least once a week
labyrinthine sense
the sensory organs in the inner ear provide this sense of position, orientation, and movement
the nurse identifies a staff member using standard precautions appropriately if which action is observed?
the staff member places contaminated linens in a leak-proof bag
philosophy
the study of wisdom, fundamental knowledge, and the processes used to develop and construct one's perceptions of life
What is cardiac output?
the total quantity of blood pumped per minute
What is heat loss through convection?
the transfer of heat through currents of air or water (example: standing in front of an air conditioner to cool off)
mitered (corners)
the type of beveled corners used when making a hospital bed.
axillary
the underarms
illness
the unique response of a person to a disease; an abnormal process involving changed level of functioning
body mechanics
the use of proper body positions to provide protection from the stress of movement and activity
proxemics
the use of space in relationship to communication.
dependent variable
the variable being studied
A dialysis nurse is educating a client on caring for the dialysis access that was inserted into the client's right arm. The nurse assesses the client's fears and concerns related to dialysis, the dialysis access, and care of the access. This information is taught over several sessions during the course of the client's hospitalization. Which phase of the working relationship is best described in this scenario?
the working phase
what is closed or resurfaced wounds?
the wound is completely covered with epithelium
general systems theory
theory for universal application; break whole things into parts to see how they work together in systems
In order to provide effective nursing care, the nurse should engage in what type of communication with the client and significant others?
therapeutic communication
the nurse understands which is the primary reason that elderly adults have constipation?
they have less activity and decreased muscle tone
eschar
thick, leathery scab or dry crust that is necrotic and must be removed before the stage can be determined accurately
purulent drainage
thick, musty or foul odor, varies in color
What is purulent exudate?
thick, often malodorous, drainage that is seen in infected wounds.
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
wet-to-dry dressing changes are ordered for a client. after the first dry dressing is removed, the client yells at the nurse, "ouch, that really hurts. are you sure you're doing it right?" which statement is the best response by the nurse?
this type of dressing cleans the wound so that it can heal. ill bring you some pain medication
suture
thread used to hold an incision together while it heals; also called stitches.
When assessing a client's pulse, the nurse is able to palpate the pulse for some time before losing it upon exerting a little bit more pressure. The pulse is beating at 80 bpm. Which of these should the nurse document as the character of the client's pulse?
thready pulse
The most accurate method for culturing a chronic wound is
tissue biopsy
Avulsion
tissue torn away from supporting structures
professional nursing organizations
to be considered a profession a professional organization needs to be in place to set standards for practice and education. This sets education minimums, and continuity of care
beta-adrenergic blockers
to block sympathetic stimulation and decrease cardiac output
voiding
to cast out wastes, as to urinate, micturate.
diuretics
to decrease fluid volume
the goals of research
to develop explanations (in theories) and find solutions to problems
quasi-experimental research
to examine cause-and-effect relationships between selected variables( often done in clinical setting to examine the effects of nursing interventions on patient outcomes)
experimental research
to examine cause-and-effect relationships between variables under highly controlled conditions (often done in lab setting)
dehumanization
to make a person/client feel like an object, to remove one's dignity.
ACE inhibitors
to prevent vasoconstriction by angiotensin II and decrease circulatory fluid volume by reducing aldosterone production
vasodilators and calcium channel blockers
to relax smooth muscles of arterioles and decrease peripheral vascular resistance
slough
to shed; to cast off (noun: slough—a mass of dead tissue).
aerates
to supply with air
guaiac
tool examination for blood; also known as Hemoccult.
What is evisceration?
total separation of the layers of a wound with internal viscera protruding through the incision and making contact with the outside of the body (required surgical emergency)
palpation
touching-assess temp with back of hand, turgor-pinch fold of skin, moisture, texture, shape-masses/lumps
Kardex care plan
trade name for a care plan documentation system that encompasses (1) prescriptions for nursing care related to activities of daily living (2) nursing diagnoses and related patient goals and nursing orders (3) the nursing care related to diagnostic measures and the medical regimen
nuclear family
traditional family; two parents and their children
allopathy
traditional medical care
Tx
treatment
true or false Swelling of the affected body part, pain, and changes in vital signs
true
What quality do clients most value in nurses?
trustworthiness
urinary catheter
tube inserted into the bladder through the urethra to remove urine.
Hematoma
tumorlike mass of blood trapped beneath skin
pronation
turn wrist so palm is down
supination
turn wrist so palm is up
Prevent stasis of respiratory secretions
turning coughing deep breathing High fowler position Administer postural drainage as appropriate Use incentive spirometer
inversion
turning foot inward
eversion
turning foot outward
ethical dilemma
two (or more) clear moral principles apply but support mutually inconsistent courses or action
dyadic nuclear family
two adults with no children
blended family
two parents and their unrelated children from previous relationships
ileal conduit
type of incontinent cutaneous urinary diversion; involves surgical resection of the small intestine, with transplantation of the ureters tot he isolated segment of small bowel, this separated section of small intestine is then brought to the abdominal wall where urine is excreted through a stoma (a surgically created opening on the body surface)
thrombolytic
type of medication designed to dissolve a clot and clear a blocked blood vessel.
nodule
type of skin lesion appearing as a small knot or protuberance
Kerlix
type of stretchy gauze used to hold dressings in place.
Stab
typically deepr than long, ahs well-defined edges
the nurse cares for a client with a body mass index of 17. what is the best description of the client's body weight
underweight
incident (has neg outcome and happened) report, occurrence(potentially could occur) report
unexpected occurrence that results in harm to a patient, staff, or visitor; used to identify risks, not punish employee
social justice
upholding moral, legal, and humanistic rights
enuresis
urinating during sleep or bedwetting
functional incontinence
urine loss caused by the inability to reach the toilet because of environmental barriers, physical limitations, loss of memory, or disorientation
mixed incontinence
urine loss with features of two or more types of incontinence
hydrometer
urinometer (used to measure specific gravity of a liquid, such as urine).
splinting
use of a pillow or large towel to provide support along a suture line.
I & O
use to evaluate fluid and electrolyte balance influences choice of fluid therapy
T- Tube drain
used after gallbladder surgery Placed in common bile duct to allow passage of bile
standards
used as guidelines for peer review (ANA)
INCENTIVE SPIROMETER
used to maximize lung expansion by opening closed alveoli and mobilizing secretions -boosts alveolar inflation -facilitates tissue oxygenation -loosens respiratory secretions
prothrombin time (PT)
used to measure therapeutic level of warfarin range: 11-15 seconds
snellen chart
used to measure visual acuity
acute wound
usually heal within days to weeks
Cut
usually longer than deep, edges well defined
QRS
v ventricular act
certification
validates specialty knowledge, experience, and clinical judgement in nursing
Biot's respirations
varying depth and rate of breathing, followed by periods of apnea; irregular
What are the compensatory mechanisms for increasing body temperature?
vasoconstriction shivering release of epinephrine
footboard
vertical support at the foot of a bed, helps to prevent footdrop.
Kussmaul respirations
very deep and rapid respirations
visual or optic reflexes
visual impressions contribute to posture by alerting the person to spatial relationships with the environment
VS
vital signs
urinary frequency
voiding more often than usual without an increase in total urine volume
evaluate the results
was the outcome achieved-did the pt have a bowel movement within two days?
what is heat loss through evaporation?
water is converted to vapor and lost from the skin (example: sweating)
nursing history
way of soliciting information from the client; may also be called a health interview.
health interview
way of soliciting information from the client; may also be called a nursing history.
credentialing
ways to ensure competence
Generalized infection
weakness headache malaise Fever increased P and change in BP
What are signs of heat exhaustion?
weakness nausea vomiting syncope tachycardia tachypnea muscle aches headache diaphoresis (heavy sweating) flushed skin.
hemiparesis
weakness of half of the body
If patient has lessions
wear gloves during palpation
identify expected outcomes
what do we want the patient to achieve as a result of nursing care?
subjective data
what pt says. things that are not apparent to another person or can only be felt or perceived by the pt
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
what is the initial phase of fever? (onset)
when fever is rising
what is the third phase of fever?
when temperature goes back to normal
what is the second phase of fever? (course)
when temperature reaches its maximum
When does heat stroke occur?
when the body's temperature regulation fails
BODY MECHANICS
wide base support low center of gravity alignment of line of gravity bending at the knees using stronger muscle groups holding the lifted object close to body facing the direction of movement rather than twisting avoid lifting push than pull alternate period of rest and activity
What is vasodilation?
widening of blood vessels
The most common and most noninvasive method to obtain a culture is
with a swab
febrile
with fever
afebrile
without fever
Care provided to a client following surgery and until discharge represents which phase of the nurse-client relationship?
working phase
Patterned
would caused by object which leaves imprint representing outline of object
If inflammation and infectin are present
wound culture may be ordered to indentify causal organism
What are three characteristic of secondary intention?
wound gaping and irregular granulation occurring epithelium fills in scar
what are three characteristic of tertiary intention?
wound not sutured granulation partially fills in wound granulation tissue sutured together
pressure ulcer
wound with localized area of injury to the skin and/or underlying tissue
crime
wrong against a person or the persons property as well as the public
what is slough tissue?
yellow or white tissue that adheres to the ulcer bed
jaundice causes
yellowish, itchy skin; bilirubin problem and liver not functioning properly
What are advantages of source-oriented record system?
you can easily locate the care provided by each discipline and the results of the laboratory and diagnostic tests.
objective
you can see the object
If you were to go outside and the temperature be 33 degrees F, how would this affect you body temperature?
you hypothalamus would detect it and you would begin to shiver to produce heat.
serosanguineous
fluid drainage com-posed of serum and blood.
Paramedics arrive in the emergency department with a victim of a motor vehicle collision. The paramedic reports the driver was restrained, the car was traveling about 30 miles per hour (48 Km/hour), and the air bags were not deployed. The paramedic continues to report the car was struck from behind and that all individuals in the car were able to self-extricate. Which statement made by the nurse is verifying the report from the paramedic?
"All of the victims got themselves out of the car?"
The nurse is collecting health data and avoids using closed-ended questions. Which are examples of closed-ended questions? Select all that apply.
"Are you ready to get out of bed?" "Do you smoke cigarettes?" "Is there any chance you might be pregnant?" "Does it hurt when I touch you here?"
The nurse observes a member of the nursing assistive personnel who is removing personal protective equipment (PPE) in the client's room, as seen in the image above. What education should the nurse provide to this member of the care team?
"Avoid touching the outside of your gown when removing it."
11. A group of nurses is discussing the advantages of using com- puterized provider order entry (CPOE). Which of the follow- ing statements indicates that the nurses understand the major advantage of using CPOE?
"CPOE reduces transcription errors."
The nurse is performing an admission interview with a new client diagnosed with acute coronary syndrome. For the nurse to obtain information and allow the client free verbalization, which question would elicit the most information?
"Could you tell me more about how you are feeling right now?"
A client admitted with dehydration reports feeling dizzy with ambulation. What teaching would the nurse provide to the client?
"Dizziness when you change position can occur when fluid volume in the body is decreased."
5. A registered nurse is admitting a patient of French heritage to the hospital. Which question asked by the nurse indicates that the nurse is stereotyping the patient?
"Do you bathe and use deodorant more than one time a week?"
The nurse is caring for a client who ascribes to the theory of animism. When attempting to explain this theory to other staff members, the nurse should state:
"Everything in nature is alive with invisible forces."
A nurse is discussing cataract treatment with a client. Which statement by the nurse would be most therapeutic?
"Have you ever thought of laser surgery?"
A pediatric client's caregiver states, "I will never give my child vaccinations." What is the priority nursing response?
"Help me understand your thoughts about vaccinations."
The nurse is caring for a client who requires droplet precautions. Which statement made by the client would indicate further teaching is required?
"I can leave my room any time I want as long as I wear a mask."
A nurse is obtaining a history from an adult female client. When the nurse asks how many times the client has been pregnant, the client answers, "I have four kids." Which statement, made by the nurse, seeks clarification of the original question?
"I understand you have four kids; how many times have you actually been pregnant?"
7. During a home health visit the nurse prepares to instruct a patient in how to perform range-of-motion (ROM) exercises for an injured shoulder. The nurse verifies that the patient took an analgesic 30 minutes before arrival at the patient's home. After discussing the purpose for the exercises and demonstrat- ing each one, the nurse has the patient perform them. After two attempts with only the second of three exercises, the patient stops and says, "This hurts too much. I don't see why I have to do this so many times." The nurse applies the critical thinking attitude of integrity in which of the following actions?"
"I understand your reluctance, but the exercises are neces- sary for you to regain function in your shoulder. Let's go a bit more slowly and try to relax."
The nurse is educating a client with human immunodeficiency virus (HIV) about ways the virus can be transmitted. Which statements made by the client demonstrates the education provided was effective? Select all that apply.
"If someone is exposed to my blood, I may transmit the virus to him or her." "I may transmit the virus to my child during pregnancy and childbirth." "I may transmit the virus if I share needles with another person."
The registered nurse is teaching a community health class about illness prevention. Which statement reflects understanding of this concept?
"It is important to enroll in a smoking cessation class."
The nurse is attempting to provide anticipatory guidance for the parents of an 18-month-old child. Which statement would be best for the nurse to make?
"Keep all medications in a locked cabinet."
2-7Which statement made by the nurse is an example of applying the principle of patient-centered care while focusing on alle- viation of a patient's fear and anxiety?
"Let's talk about the concerns that you have about going home."
A nurse is caring for a client experiencing biliary colic from uncomplicated cholelithiasis. The client asks, "My doctor says I should have surgery to remove my gallbladder. Do you think it is really necessary?" What is the nurse's best response?
"Share with me the advantages and disadvantages of your options as you see them."
A nurse is caring for a client with a diagnosis of metastatic lung cancer. The nurse finds the client sitting in a chair while staring out the window. The nurse conveys caring by saying:
"Tell me what is on your mind."
When taking the client's temperature, the student nurse will require further education when they state:
"The axillary route is the most accurate of all routes."
A client is scheduled for thoracentesis. The nurse assesses that the client appears anxious about the procedure and needs honest support and reassurance. What is the most appropriate response by the nurse to this client?
"The needle causes discomfort or pain when it goes in, but I will be by your side throughout and will help you hold your position."
The client presents to the Emergency Department reporting fever, chills, and a productive cough. The chest x-ray shows an area of infiltrate, and the primary care provider prescribes a broad spectrum antibiotic. Which client teaching statement from the nurse is most appropriate regarding the prescribed drug?
"This antibiotic is the best choice since the causative organism is not known."
The nurse educator is reminding a group of new nurses about precautions. Which statement by a new nurse requires further teaching by the nurse educator?
"Wearing an N95 respirator is critical when I care for clients in droplet precautions."
8. You ask another nurse how to collect a laboratory specimen. The nurse raises her eyebrows and asks, "Why don't you figure it out?" What would be the best response?
"When you brush me off like that, it takes me even longer to do my job."
The nurse has admitted a client on airborne precautions onto the medical-surgical unit. When the client asks, "When will these airborne precautions be removed?" what is the appropriate nursing response?
"When your sputum culture is negative."
The nurse faculty is observing a student nurse gather data from a client. Which question, if asked by the student, would indicate to the faculty that the student has a clear understanding of open-ended questions?
"Why did the health care provider prescribe this medication for you?"
6. Which of the following statements would be most likely to block communication?
"Why do you always put so much salt on your food?"
The home care nurse notices that the client only has a glass thermometer. What is the best response by the nurse?
"Would you consider using a digital thermometer?"
A nurse is assessing vital signs on a pregnant client during a routine prenatal visit. The client states, "I know labor will be so painful, it sounds awful. I am sure I will not be able to stand the pain; I really dread going into labor." What is the best response from the nurse?
"You're worried about how you will tolerate the pain associated with labor."
homeopathy
"like cures like": the notion that a disease can be cured by a substance that produces similar symptoms -"law of minimum dose": the notion that the lower the dose of medication, the greater its effectiveness
Pain definition
"whatever the person says it is, and it exists whenever the person says it does"
phenomenology
(both a philosophy and a research method) to describe experiences as they are lived by the subjects being studied
referred pain
(referring to pain) pain that is felt at a location other than its origination; when one physician sends (refers) a client to another physician or specialist.
Monocytes
*A type of white blood cell that transforms into macrophages, extends pseudopods, and engulfs huge numbers of microbes over a long period of time *An agranular leukocyte that is able to migrate into tissues and transform into a macrophage. increased in TB, rickettsial disease, and in convalescent phase of acute infections immature macrophages
Eosinophils
*What IgE-mediated cell secretes major basic protein and has elevated levels in the blood during asthma and parasitic infections? *What type of WBC is present in increased numbers during an allergic reaction?
SBAR
- a "hand-off" approach to communication: transferring responsibility for a patient from one caregiver to another -provides a framework for communication between members of the health care team about a patients condition - situation -assessment -recommendation (p169 for examples)
four scientific premises of therapeutic touch
- a human being is an open energy system - anatomically, a human being is bilaterally symmetrical -illness is an imbalance in an individuals energy field - human beings have a natural ability to transform and transcend their conditions of living
DIABETIC DIET
- balanced intake of CHO, fats, CHON based on client's metabolic needs
F CATH
--provide w/ continuous urine drainage
BLOOD PRESSURE CUFF
-BLADDER WIDTH OF BP CUFF SHLD BE APPROX 40% OF ARM CIRCUMFERENCE MIDWAY BET OLECRANON AND ACROMINION
5. A nurse who is working on a surgical unit is caring for four different patients. Patient A will be discharged home and is in need of instruction about wound care. Patients B and C have returned from the operating room within an hour of each other, and both require vital signs and monitoring of their intravenous (IV) lines. Patient D is resting following a visit by physical therapy. Which of the following activities by the nurse represent(s) use of clinical decision making for groups of patients? (Select all that apply.)
-Consider how to involve patient A in deciding whether to involve the family caregiver in wound care instruction. -Decide which activities can be combined for patients B and C.
DAME (used to assess risk for falls in older adults)
-D: drug and alcohol use -A: age-related physiologic status -M: medical problems -E: environment
8. The nurse cared for a 14-year-old with renal failure who died near the end of the work shift. The health care team tried for 45 minutes to resuscitate the child with no success. The family was devastated by the loss, and, when the nurse tried to talk with them, the mother said, "You can't make me feel better; you don't know what it's like to lose a child." Which of the following examples of journal entries might best help the nurse reflect and think about this clinical experience? (Select all that apply.)
-Description of the efforts to restore the child's blood pressure, what was used, and questions about the child's response -The meaning the experience had for the nurse with respect to her understanding of dealing with a patient's death -A description of what the nurse said to the mother, the mother's response, and how the nurse might approach the situation differently in the future
TRENDELENBURG POS/headdown
-HOB is lowered. bedframe tilted -inc venous return, and COutput -used for postural drainage, inc sec removal from lungs -inc risk of ICPressure -inc risk of gastric reflux -admonial cavity will compressed diaphragm--dyspnea
SEMI-FOWLER'S POSITION
-HOB is raised 30 deg -foot of bed can be raised--inc venous return -promotes lung expansion -dec risk of gastric reflux
ISBARQ method of patient hand-off (revised)
-I: introduction -S: situation -B:background -A: assessment -R: recommendation -Q: question and answer
closed drainage system
-Jackson-pratt drain -hemovac drain may be connected to an electrical suction or built-in reservoir
NURSE PT RELATIONSHIP FOUR PHASES
-Pre-interaction -orientation -working -termination
color classification of open wounds
-R: red-protect -Y: yellow-cleanse -B: black-debride -mixed wound: contains components of RY&B wounds
sedation scale
-S: sleep, easy to arouse: no action necessary -1: awake and alert; no action needed -2: occasionally drowsy but easy to arouse; no action needed -3: frequently drowsy and drifts off to sleep during conversation; decrease the dose -4: somnolent with minimal or no response to stimuli; discontinue the opioid and consider use of naloxone
THERAPEUTIC COMM GOAL
-TO UDNERSTAND CLIENTS MESSAGE -FACILITATE VERBALIZATION OF FEELINGS -COMM THE NURSES UNDERSTANDING AND ACCEPTANCE -INDENTIFY PROBLEM, GOALS AND OBJECTIVES,
PRONE POS.
-abdomen and chest in their dependent pos--on their faces -aerates sup. part of lungs -inc perfusion of the deep. part of lung -promotes hip extension, post leg amputation-forces leg to go back and stretches the muscle on the from part of thigh
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
ISOTONIC exercises
-active exercises -no shortening of the muscle -ex. holding and carrying a grocery sack -lift up and bring down is active resistive ROM
USE FOR
-acute kidney injury -chronic renal failure -
MECHANICAL SOFT
-adds food w/more texture more appeal -for post op progression -for difficulty chewing or slowing - clear, full and pureed -eggs -pancakes
PUREED
-adds soft solid foods -food is ground or mashed -food thick does provide more calories -
ACTIVE RESISTIVE ROM
-against manual resistance or mechanical resistance (weights, machines w/ counter pressure) -inc muscle strength and maintain joint mobility
ISOMETRIC exercises
-alternately contract and relaxes muscle but not move joint -for muscle strength when joint is immobilized -help alleveiate muscle atrophy -used after client's surgery or on traction pts.
NURSING OUTCOME
-approx balance with fluid intake and output =2500ml/3days
NURSING CONSIDERATIONS
-appy in the morning before client rises -do not apply in skin lesions -must have size correctly and applied -need to be clean, dry, smooth -removed and reapplied as prescribed intervals for skin cleansing -observe for complications such as skin irritation and breakdown, color, temp, sensation, swelling and movement changes -assess circulation
EXTREMITY ELEVATION POS
-arm up on pillows, leg up in traction, -promotes venous return fr extremity -prevents stasis of fluid in extremity -dec risk of thrombus formation
intentional tort
-assault and battery -defamation of character -invasion of privacy -false imprisonment -fraud
GERIATRIC/PEDIATRIC PT
-at risk in fluid imbalances and malnutrition after surgery
CARDIAC CONTRACTION properties
-automaticity-heart beas -irritability-heart contraction from conduction -refractory mechanism-allows ventricles to fill completely before next contraction -conductivity-transmits impulses for contraction to occur -contractility-systole- contracting diastole-resting -extensibility-to stretch, more stretch greater contraction over stretch-contraction dec but heart works harder
FOWLER'S POSITION/head elevated
-bed is raised 45 degrees or more -diaphragm drops -encourages inc. lung expansion -dec gastric reflux bec using gravity esp. when eating or w.NG tube in place -used in nasotracheal suctioning
NURSING CONSIDERATIONS
-breathe in and exhale normally -seal lips around mouthpiece -inhale slowly and deeply -hold breath for at least 3 secs while keeping ball elevated, -exhale take several normal breaths and repeat procedure 4-5 times -do 10-12x repitetions
NURSING CONSIDERATIONS OF FEM ANGIO
-check for hx of allergies -ask pt. allergic to iodine or seafood -administer epinephrine, antihistamines or corticosteroids as ordered
three main activities of the valuing process
-choosing: choosing freely from alternatives after careful consideration of the consequences of each alternative -prizing: involves pride, happiness, and public affirmation acting- combining choice into one's behavior with consistency and regularity on the value
factors affecting body temp
-circadian rhythms -age and gender -physical activity -state of health -environmental temperature
OUTCOME
-client cough after procedure to facilitate secretion removal
CAT
-complementary and alternative therapies -mind, body, and spirit are integrated and contribute to health and illness -health is balance of body systems: mental, social, and spiritual as well as physical -illness is a manifestation of imbalance or disharmony
info contained in incident report
-complete name of person and witnesses -factual acct of incident -date, time, and place of incidence -pertinent characteristics of person involved -any equipment or resources being used -any other important variables -documentation by physician of medical exam of person involved
qualitative
-conducted to gain insight by discovering meanings -based on belief that reality is based on perceptions that differ for each person and change over time
ELDERLY
-dec sympathetic nervous system response-control over heart and pulse -arterial walls thicken> inc systolic pressure -diastolic pressure may not change -BP no increase in HR w/ stress -orthostatic hypotension-dizziness, falls
LOW RESIDUE DIET
-decreases resin of intestinal obstruction -decreases intestinal activity -foods are easily digested
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
PULSE OXIMETRY
-degree of O2 saturation in arterial blood -monitor arterial oxyhemoglobin saturation in arterial blood -use wavelengths of light -4-6 heartbeats PR displays will supply info w/ each heartbeat > 95%
CARDIOVASCULAR SYSTEM
-deliver oxygen, hormones, nutrients, antibodies -removes end products of metabolism -CO2
CHANGING DRESSINGS
-determine type of dressing, -presence of drains -frequency of dressing change -solutions or ointments used -assess skin beneath tape -though hand washing before and after dressing change -wear sterile goes on fresh or pen wound -change dressings when wet -secure dressings with tape, ties and bandages
USED FOR
-diabetes 1 &2 - -
WOUND HEALING DIET
-diet should be high protein, fat carbs, vitamins (ACE) and minerals (esp zinc)
elements of signed consent
-disclosure: nature of procedure, risks involved, alternatives, no guaranteed outcome -comprehension: correctly repeat in own words what they are giving consent for -competence: understands info needed to make decision -voluntariness: signing of their will and understanding
FEMALE CATH INSERTION
-dorsal recumbent position or in Sim's position -2-3 in in urethra, insert additional inch after urine flows,
False BP reading usually
-due to narrow BP cuff
four elements of liability
-duty: one establish nurse-patient relationship -breach of duty: didn't do what supposed to (follow standard of care) -causation: not doing something was the cause for the injury -damages: actual harm
FEMORAL ANGIOGRAM
-dye injected into the arteries and X-rays taken of the vascular system -client feels warmth upon dye infection -
SYMPTOMS OF ALLERGIC RXN
-dyspnea, N&V, sewating, tachcardia, numbness of extremities,
Tx of ALLERGY
-epinephrine -antihsitamines, steroids -assessing femoral -popliteal -posterior tibial -dorsalis pedis pulses
ACTIVE exercises
-ex. walking
patient protection and affordable care act (PPACA) goals
-expand coverage, control health care costs, and improve the health care delivery system -provide Medicaid or subsidized coverage to qualifying people with incomes up to 400% poverty, beginning in 2014 -provide a new way to get health insurance: the health insurance marketplace; designed to help people more easily find health insurance that fits their budget
naturopathy
-first do no harm -physician as teacher -treat the whole person -prevention -healing power of nature -treat the cause
LITHOTOMY POS
-flat position, thighs are flexed-legs are up,legs abducted-so knees are dropped away from center of body -used for bladder cath -exam. of perineum -GYN care-for vaginal access
LOW FAT DIET USE
-for atherosclerosis conditions -coronary heart disease -obesit -cystic fibrosis -lowers total intake of fat and cholesterol
FOR
-for constipation bowel disorders diabetic diet cholesterol-restreicted diet
LOW FAT MENU
-fruit -vegetables -cereals -lean meat -egg whites -olive oil -nonfat frozen yogurt and nondairy desserts -cottage cheese, loft -coffee, tea, skim milk and fruit juice
MODIFIED TRENDELENBURG POS
-head slightly elevated, foot 20 deg elevation -inc venous return -promotes ventilation -no ICPressure nor pressure to diaphragm
allopathic medicine (biomedicine)
-health is the absence of disease -the main causes of illnesses are pathogens -illness occurs in either the mind or body, which are separate entities - traditional medicine based on what doctors use -dominant for about 100 years -spearheaded remarkable advances in biotechnology, surgical interventions, pharmaceutical approach, diagnostic tools
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
ACTIVE ASSIST ROM
-improve circulation and joint mobility -provide support on injured area -or extremity after surgery -pt cannot lift
HIGH PROTEIN DIET
-increases amino acids and protein levels -will build muscle mass -increases immune function
HIGH FIBER DIET
-increases bulk in stools
FOLEY CATHETER
-indwelling lumen cath-used for urinary drainage
wound complications
-infection -hemorrhage -dehiscence(wound separates) and evisceration(protrusion) -fistula formation
FORMATS for DOCUMENTATION
-initial nursing assessment, use agency form for baseline to later comparisons and pt's condition changes -Kardex care plan -Computerized documentation -Plan of nursing care -Progress notes -critical/collaborative pathways -flow sheets -discharge and transfer summary -home healthcare documentation -long term care doc
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)
ORIENTATION
-intro to pt, at bedside upon admission -talk to pt, use verbal and nonverbal comm to ease her fears -present a warm caring manner -close curtain and sit down so pt feels undivided attention -act w/ integrity -pt is confident w/ nurse -recognize and respect pats understanding of her body and condition -express geniuine concern that pt will receive tx she needs
OBESE PT
-less resistance to infection (prone), poor blood supply, increased risk for respiratory, cardiovascular and GI problems
THERAPEUTIC COMM
-listening and understanding client promotes clarification and insight
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
MENU
-low sodium, protein,K foods -use foods have high biologic needs
measurement criteria for standard 7 (ANA standards)/ registered nurse cont.
-maintains a therapeutic and professional health care consumer-nurse relationship within boundaries -contributes to resolving ethical issues involving health care consumers, colleagues, community groups, systems, and other stakeholders -takes action regarding legal, unethical, or inappropriate behavior that can endanger or jeopardize the best interests of health care consumer or situation -speaks up when appropriate to question practice when necessary for safety and quality improvement -advocates for equitable health care consumer care
PROHIBITED MENU
-marbled meats -avocados -whole milk -bacn -eggyolks -butter -creamed vegetables -potato chips and fried potatoes -cake, ice cream, chocolate
INTAKE AND OUTPUT
-measuring 24H I&O evaluates fluid status
MENU
-milk, yogurt, meat, cheese, lentils, nuts, PB
common modes of value transmission
-modeling: learn from parents what is low or high value; leads to socially acceptable behavior -moralizing: taught complete set of values by parents, church with no room for change -laissez-faire: little or no guidance; leads to confusion -rewarding and punishing: rewarded or punished for acceptable/unacceptable behaviors -responsible choice: encourage to explore competing values and weigh consequences
NURSING CONSIDERTIONS ON WHD
-monitor urinary and bowel elimination -avoid alcohol -manage fluid balance -inform of severity of complications related to severity of malnutrition -
SIDE LYING/LATERAL POSITION
-most of the weight is on the dependent pos, hip and shoulder -allows drainage of oral secretions -encourage aeration of superior lung tissue -side that's up have the ability to expand -increases perfusion of the dependent lung tissue(side that's down gets more blood -increased risk of pressure of ear, shoulder, trochanter and ankle of dependent side
shamanism
-most widely practiced medical system -illness is thought to originate in the spirit world -healing techniques involve native plants and herbs, animals, rituals, ceremonies, purification techniques
CONSENT FORM
-need to be signed and attached to chart
ACTIVE ROM
-no assistance -maintain joint mobility -all extremeties, 5x each joint
EKG nursing considerations
-no smoking or drinking of caffeine beveratges for 24H period to test -leads applied to atomic chest points -lubricating gel on them to inc electric act. conduction -pt lies still during procedure
NON THERAPEUTIC COMM
-not say: advising giving approval- belittling challenging making s stereotyped comments reassuring probing
phases of home visit- Entry
-nurse identifies needs and determines interventions - nurse teaches the patient and caregivers -nurse documents care given in the home
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
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
ayurveda
-originated in Vedic civilization -balance among people, environment, and larger cosmos integral to health -central is patient's basic constitution- dosha -uses nutrition, exercise, herbs, breathing, meditation, massage, aromatherapy, and purification
indications of a concussion
-physical: headache, vomit, problems w/ balance, dazed, fatigue -cognitive: mentally foggy, difficulty concentrating, difficult remembering, confusion, forget recent activities -emotional: irritability, nervousness, very emotional behavior -sleep: drowsiness, difficulty falling asleep, sleep more or less than usual
ELASTIC STOCKINGS
-prevent deep vein thrombosis and pulmonary embolism -prevents phlebitis
BODY MECHANICS
-prevent musculoskeletal injury to nurse and patient -prevents sore muscles and joints in nurse and patient
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
levels of healthcare
-primary health care: treatment of common health problems ex sore throat, flu, diabetes, HTN -secondary health care: treatment of problems requiring more specialized clinical expertise ex MI, CVA - tertiary health care: management of rare and complex disorders ex pituitary tumor
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
DRESSING CHANGE
-promote healing, keep moist, clean and free from debris -for tissue repair and regeneration -manage and and protect wounds and prevent infection -facilitates absorption and measurement of wound drainage
WOUND HEALING DIET
-promotes wound healing -prevents infection -influences balanced diet
FULL LIQUID DIET
-provides more nutrients -progress from clear liq diet -for client w/ difficulty chewing or swallowing -ice cream, yogurt, cream soups,
SITES
-radial-thumb -femoral-groin -carotid-mdial edge of sternocleidomastoid muscle neck -pedal pulse/dorsalis pecs-top of foot -posterior tibial -inner side of ankle -popliteal -back of knee -temporal-lateral of the keys -apical -5th intercostal space at midclavicular
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
LOW FAT DIET
-reduces calories from fat and minimizes cholesterol intake
PULSE SITES
-reflects bounding blood flow and indicate circulation status
TERMINATION
-remind pt termination is near -verify discharge planning occurs -make nec. referrals -ensure smooth transition for pt and health care team
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
PARA SYMPATH
-rest and digest dec HR, atrial force of contraction, velocity of conduction-SA>Anode -minimal effect on ventricular contraction force
RENAL DIET
-restricted sodium protein and K intake -varied based on metabolic needs
MALE CATH INSERTION
-retract foreskin -penis perpendicular to body -insert cath 6-7 in. until urine flows, advance 2 in. more
PRE-INTERACTION
-review pt. data (med or surgical hx and info from family embers) -anticipate concerns or issues that might arise
CLIENTs RIGHTS
-right to privacy -R records -info of PT used for dx and tx only -info about client cant be released w/ others unless w/ permission
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)
NURSING CONSIDERATIONS
-select apporpriate site for sensor -remove nail polish or artificial nails if finger or toes are to be used -assess sensor site for perfusion regularly to prevent skin breakdown -change sides of spring sensors q 2h -adhesive sensors q 4H -protect sensor from bright light with a towel or sheet
measurement of pressure ulcer
-size of wound -depth of wound -presence of undermining, tunneling, or sinus tract(all on wound bed)
chiropractic medicine
-spinal adjustment -heat and ice -electrical stimulation -relax techniques -rehab and general exercise -counseling about diet, weight loss, and other lifestyle factors -dietary supplements
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
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
WORKING
-team building phase bet you patient and entire health care team -encourage pt, to understand her condition, and how to set and accomplish goals -expect pt. to participate in her health care -understand that the patient expects health care needs are met by nurse and health care team -
phases of home visit- pre-entry
-the ref nurse collects patient data - nurse reviews the data and schedules visit -nurse evaluates safety issues
holism
-theory and philosophy that focuses on connections and interactions between parts of the whole -all living organisms, including humans, are continuously connecting and interacting w/ environment -parts of organism are continuously interacting and changing -this continual interaction and change means that the body is not the sum of its parts but it is unified, dynamic whole
FEM ANGIO uses
-to confirm diagnosis of occlusive arterial dis. upon surgery considerations -arteriogram also demonstrate the location of a vascular obstruction or aneurysm
POSTURAL DRAINAGE
-to loosen bronchial secretions by positioning the affected lobe areas -prone/supine/side position head is lower than lower body -do not percuss lung areas -auscultate first and xrays
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)
OUTPUT FLUIDS
-urine, diarrhea, vomitus, gastric scution, and drainage from post surgical wounds and other tubes
measurement criteria for standard 7 (ANA standards)/ the registered nurse
-use code of Ethics for nurses w/ interpretive statements to guide practice -delivers care in a manner that preserves and protects health care consumer autonomy, dignity, rights, values, and beliefs -recognizes the centrality of the health care consumer and family as core members of health care team -upholds health care consumer confidentiality within legal and regulatory parameters -assists health care consumers in self-determination and informed decision making
osha legal regulations
-use of electrical equipment -use of isolation techniques -use of radiation -use of chemicals
ANTI-EMBOLIC STOCKINGS/ELASTIC STOCKINGS
-used to dec thrombus formation by exerting external pressure on lower extremity muscles and superficial leg veins, preventing stasis and promoting venous return in lower extremities.
THERAPEUTIC COMM INTERVENTION
-using silence -using general lead or broad openings, -clarification -reflecting
7 requirements that provide a coherent framework for evaluating ethics of clinical research
-value -scientific validity -fair subject selection -favorable risk-benefit ratio -independent review -informed consent
LOW SODIUM DIET
-varies no added salt 4g/day to severe restriction 500 mg/day -increases excretion of water -prevents HTN -tx of HF, kidney dis, cirrhosis -baked chicken, lettuce, slice tomatoes, apples sauce -no can foods, fired foods, milk products, processed meats
SIDE LYING W/ BENT LEG/SIM'S OR SEMIPRONE POS.
-weight on the anterior ileum, humerus and clavicle -be aware of pressure points -lack of straight spinal position
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
confirming NG feeding tube placement
-xray -measurement of aspirate pH and visual assessment of aspirate -measurement of tube length and tube marking -carbon dioxide monitoring -confirming nasointestinal tube placement
NON THERAPEUTIC COMM
-yes or no comm. not expand on how they feel -verbal responses is cut off comm -non verb behaviors suggest uncaring attitude (legs cross, looking at watch, )implies client not impt, or distracted -insults client (invading body boundaries-too close, looking directly on eye contact-depends on culture); assess cultural belief
A person's normal body temperature can change how much throughout the day?
1 degree F
LPN
1 year program, can do most nursing functions
The body's core temperature is how much higher than surface temperature?
1-2 degrees F
4-8Match the following components of systems theory with the definition of that component
1-Feedback Data related to system functioning 2-Input. Data entering the system 3-Content Product and information obtained from the system 4-Output End product
14. A new graduate nurse is being mentored by a more experi- enced nurse. They are discussing the ways nurses need to remain active professionally. Which of the statements below indicates the new graduate understands ways to remain involved professionally? (Select all that apply.)
1. "I am thinking about joining the health committee at my church." 2. "I need to read newspapers, watch news broadcasts, and search the Internet for information related to health."
13. A nurse is working with a nursing assistive personnel (NAP) on a busy oncology unit. The nurse has instructed the NAP on the tasks that need to be performed, including getting patient A out of bed, collecting a urine specimen from patient B, and checking vital signs on patient C, who is scheduled to go home. Which of the following represent(s) successful delegation? (Select all that apply.)
1. A nurse explains to the NAP the approach to use in getting the patient up and why the patient has activity limitations. 3. The nurse sees the NAP preparing to help a patient out of bed, goes to assist, and thanks the NAP for her efforts to get the patient up early. 4. The nurse is in patient B's room to check an intravenous (IV) line and collects the urine specimen while in the room.
4-4 . While working in a community health clinic, it is important to obtain nursing histories and get to know the patients. Part of history taking is to develop the nurse-patient relationship. Which of the following apply to Peplau's theory when estab- lishing the nurse-patient relationship? (Select all that apply.)
1. An interaction between the nurse and patient must develop. 2. The patient's needs must be clarified and described. 3. The nurse-patient relationship is influenced by patient and nurse preconceptions.
12. Identify behaviors that foster the development of trust. (Select all that apply.)
1. Answer the call light promptly 4. Answer questions honestly. 5. Demonstrate competence when doing treatments
2-10 Which of the following activities performed by the nurse is/ are focused on the patient-centered care principle of physical comfort? (Select all that apply.)
1. Asking the patient what a tolerable level of pain is for him or her following surgery 2. Providing a back rub at bedtime 3.Offering the patient a warm wash cloth for his or her hands before eating 6. Changing the bed linens for a patient who is experiencing diaphoresis
4-13. Which of the following statements apply to theory generation? (Select all that apply.)
1. Builds scientific knowledge base of nursing 2. Discovers relationships of phenomena to practice 4. Identifies observations about a phenomenon
1-7. Contemporary nursing requires that the nurse has knowledge and skills for a variety of professional roles and responsibilities. Which of the following are examples? (Select all that apply.)
1. Caregiver 2. Autonomy and accountability 3. Patient advocate 4. Health promotion
what is a Source-oriented system?
1. Disciplines document in separate sections of the chart 2. Contains a variety of sections 3. Data scattered; may lead to fragmentation
15. When interviewing a Native American patient on admission to the hospital emergency department, which questions are appropriate for the nurse to ask? (Select all that apply.)
1. Do you use any folk remedies? 2. Do you have a family physician? 3. Do you use a Shaman?
4-15 As an art nursing relies on knowledge gained from practice and reflection on past experiences. As a science nursing relies on (select all that apply):
1. Experimental research. 2. Nonexperimental research. 3. Research from other disciplines
10. The patient has a fractured femur that is placed in skeletal traction with a fresh plaster cast applied. The patient experi- ences decreased sensation and a cold feeling in the toes of the affected leg. The nurse observes that the patient's toes have become pale and cold but forgets to document this because one of the nurse's other patients experienced cardiac arrest at the same time. Two days later the patient in skeletal traction has an elevated temperature, and he is prepared for surgery to amputate the leg below the knee. Which of the following state- ments regarding a breach of duty apply to this situation? (Select all that apply.)
1. Failure to document a change in assessment data 5. Failure to notify a health care provider about a change in the patient's condition
4-11 Match the following theories with their definitions.
1. Grand theory-Provides a structural framework for broad concepts about nursing. 2. Middle-range theory-Addresses specific phenomena and reflect practice . 3.Descriptive theory-First level in theory development and describes a phenomenon. 4Prescriptive theory-Linked to outcomes (consequences of specific nursing interventions)
4-12. A nurse is applying Henderson's theory as a basis for theory based-nursing practice. Which other elements are important for theory-based nursing practice? (Select all that apply.)
1. Knowledge of nursing science 2. Knowledge of related sciences 4. Knowledge of standards of practice
1-9. Health care reform will bring changes in the emphasis of care. Which of the following models is expected from health care reform?
1. Moving from an acute illness to a health promotion, illness prevention model
2-8 Which of the following is/are characteristics of managed care systems? (Select all that apply.)
1. Provider receives a predetermined payment for each patient in the program. 4. System tries to reduce costs while keeping patients healthy. 5. Focus of care is on prevention and early intervention.
8. Which of the following actions, if performed by a registered nurse, would result in both criminal and administrative law sanctions against the nurse? (Select all that apply.)
1. Taking or selling controlled substances 4. Applying physical restraints without a written physician's order
9. You are giving a hand-off report to another nurse who will be caring for your patient at the end of your shift. Which of the following pieces of information do you include in the report? (Select all that apply.)
1. The patient's name, age, and admitting diagnosis 2. Allergies to food and medications 5. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol
What are advantages of paper health records?
1. care providers are comfortable with it 2. paper records do not require large databases/secure networks to function 3. relatively inexpensive
What are some advantaged of narrative format?
1. gives us detailed info of client's status, activities, nursing interventions, psychosocial context, and response to treatment 2. tracks client change and progress 3. gives us a time line
What is the importance of standardized language?
1. making nursing visible 2. support nursing research 3. provide standardized terminology for use in EHY systems
What are the 7 purposes of a written record?
1.Communication 2.Continuity of care 3.Quality improvement 4.Planning and evaluation of client outcomes 5.Legal record 6.Professional standards 7.Reimbursement and utilization review
what are four components of problem-oriented record system?
1.database 2.problem list 3.plan of care 4.progress notes
what is an example of a history and physical?
1.detailed summery of the current health problem 2.past medical, surgical, and social history 3.medications taken 4.allergies 5.ROS 6.physical examination data
What is included in the plan of care?
1.prescription 2.nursing care plan
respirations for healthy adult
12 to 20 breaths/min
Normal range respriatory rates adult Men
12-18
What are normal RR?
12-20 breaths/min
Normal blood pressure parameters for adults
120/80
average blood pressure for healthy adult
120/80
What are normal pulse ranges for newborns?
130 (80-180) beats per minute
what is stage 1 hypertension?
140-159/90-99
Normal range respriatory rates adult
16-20
Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period?
1700
9. When the nurse takes the patient's nursing history, he or she sits:
18 inches to 4 feet from the patient
normal BMI
18.5-24.9
In what time period did nursing care as we now know it begin?
18th to 19th century
Code for professional nurses
1950
ANA publishes its first standards of nursing practice
1973
ANA publishes the scope of nursing practice
1987
ANA publishes standards of clinical nursing practice
1991
at discharge, the nurse advises a client about a calorie-restricted diet. which is an ideal rate of weight loss?
1lb per week
Lockjaw
1st sign of generalized tetanus
4-9. A patient is admitted to an acute care area. The patient is an active business man who is worried about getting back to work. He has had severe diarrhea and vomiting for the last week. He is weak, and his breathing is labored. Using Maslow's hierarchy of needs, identify this patient's immediate priority.
2. Air, water, and nutrition
5-5. Arrange the following steps of evidence-based practice (EBP) in the appropriate order:
2. Ask the burning clinical question. 6. Collect the most relevant and best evidence. 5. Critically appraise the evidence you gather. 1. Integrate the evidence. 3. Evaluate the practice decision or change. 4. Share the results with others.
13. A precise definition for the word quality is difficult to articulate when it comes to quality of life. Why? (Select all that apply.)
2. Community values are subject to change, and communities influence definitions of "quality." 3. Individual experiences influence perceptions of quality in potentially different ways, making consensus difficult. 4. Placing measurable value on elusive elements such as cognitive skills, ability to perform meaningful work, and relationship to family is challenging.
1-10. Which of the following nursing roles may have prescriptive authority in their practice? (Select all that apply.)
2. Nurse practitioner 3. Certified clinical nurse specialist
23-1.A nurse is caring for a patient who recently had coronary bypass surgery. Which are legal sources of standards of care the nurse uses to deliver safe health care? (Select all that apply.)
2. Policies and procedures of the employing hospital 3. State Nurse Practice Act 4. Regulations identified in The Joint Commission's manual 5. The American Nurses Association standards of nursing practice
2-15. Which of the following are examples of the principle of patient-centered care that is focused on respect, values, prefer- ences, and expressed needs? (Select all that apply.)
2. Pulling the curtain around the patient bed before changing the wound dressing on the patient's leg 3. Allowing the patient to ask questions and express his or her concern about surgery 5. Working with the family to bring in ethnic foods that the patient prefers
14. Your patient has just been told that she has cancer, and she is crying. Which actions facilitate therapeutic communication? (Select all that apply.)
2. Pulling the curtain to provide privacy 3. Offering to discuss information about her condition 5. Sitting quietly by her bed and hold her hand
14. Which of the following explain how health care reform is an ethical issue? (Select all that apply.)
2. Reforms promote the principle of beneficence, a hallmark of health care ethics. 3. Purchasing health care insurance may become an obliga- tion rather than a choice, a potential conflict between autonomy and beneficence. 4. Lack of access to affordable health care causes harm, and nonmaleficence is a basic principal of health care ethics.
2-11. The nursing staff is developing a quality program for the floor. Which of the following are nursing-sensitive indicators from the National Database of Nursing Quality Indicators that the nurses can use to measure patient safety and quality for the unit? (Select all that apply.)
2. Turnover rate of nurses on the unit 3. Incidence of patient falls 4. Number of certified RNs
Code of ethics with interpretive statements accepted by ANA; ANA publishes bill of rights for registered nurses
2001
anuria
24-hour urine output is less than 50mL; complete kidney shut down or renal failure
Overweight BMI
25- 29.9
11. A 67-year-old patient will be discharged from the hospital in the morning. The health care provider has ordered three new medications for her. Place the following steps of the nursing process in the correct order. ____ 1. The nurse returns to the patient's room and asks her to describe the medicines she will be taking at home. ____ 2. The nurse talks with the patient and family about who will be available if the patient has difficulty taking medicines and considers consulting with the health care provider about a home health visit. ____ 3. The nurse asks the patient if she is in pain, feels tired, and is willing to spend the next few minutes learning about her new medicines. ____ 4. The nurse brings the containers of medicines and information leaflets to the bedside and discusses each medication with her. ____ 5. The nurse considers what she learns from the patient and identifies the patient's nursing diagnosis.
3-assessment 5-nursing diagnosis 2-planing 4-intervention 1-evaluation
4-6. To practice in today's health care environment, nurses need a strong scientific knowledge base from nursing and other dis- ciplines such as the physical, social, and behavioral sciences. This statement identifies the need for which of the following?
3. Interdisciplinary theories
23-2. A nurse is sued for failure to monitor a patient appropriately after a procedure. Which of the following statements are correct about this lawsuit? (Select all that apply.)
3. The person filing the lawsuit has the burden of proof. 4. The plaintiff must prove that a breach in the prevailing standard of care caused an injury.
Obese BMI
30 - 39.9
High-Protein Diet
30 grams powdered skim milk and 1 egg in 100 ml of water or Roast beef sandwich with skim milk Common medical problems: burns, infections, hyperthyroidism Purpose: to reestablish anabolism to raise albumin levels Not allowed: soft drinks, "junk" food
what are normal respirations for newborns?
30-60 breaths per minute
LOW-FAT CHOLESTEROLD RESTRICTED
300 MG/DAY CHOLESTEROL -AHA -DEC CALORIES FROM FAT AND CHOLESTEROL - prevention atherosclerosis -fruits,vegetables -milk, chicken no skin
forehead temp
34.4 C, 94.0 F
Normal range oral temperature
35.5-37.5 C (95.5-99.5 F)
axillary temp
36.5 C, 97.7 F
What are normal temperatures for newborns?
36.8C(98.2)
oral temperature for healthy adult
37.0 C, 98.6 F
rectal temp
37.5 C, 99.5 F
tympanic temp
37.5 C, 99.5 F
4-5. Theory-based nursing practice uses a theoretical approach for nursing care. This approach moves nursing forward as a science. This suggests that:
4. Theories will be tested to describe or predict patient outcomes.
In which order should the following steps for putting the first hand into a sterile glove be performed? 1. Carefully open the inner package. Fold open the top flap, then the bottom and sides. 2. Place the inner package on the work surface with the side labeled "cuff end" closest to the body. 3. With the thumb and forefinger of the nondominant hand, grasp the folded cuff of the glove for the dominant hand, touching only the exposed inside of the glove. 4. Keeping the hands above the waistline, lift and hold the glove up and off the inner package with fingers down. 5. Place the sterile glove package on a clean, dry surface at or above your waist. 6. Carefully insert dominant hand palm up into the glove and pull it on. 7. Open the outside wrapper by carefully peeling the top layer back and remove inner package, handling only the outside of it.
5, 7, 2, 1, 3, 4, 6
Normal range of wbc
5,000 - 10, 000/ mm3 if elevated = infection
Whats a normal pulse range?
60-100
pulse rate for healthy adult
60-100 (80 average)
Normal pulse rate for adults
60-80 BPM ( beats per minute)
Whats the average pulse rate?
80 beats per minute
what are normal BP findings for newborns?
80/40
underweight BMI
< 18.5
morbid obese BMI
> 40
What is stage 2 hypertension?
>160/>100
The nurse is evaluating client health. Which client should the nurse determine to be exhibiting the most signs of health?
A client with a leg amputation who performs activities of daily living with a prosthesis
What is a contusion wound?
A closed wound caused by blunt trauma; may be referred to as a bruise or an ecchymotic area.
what is hypothermia?
A core body temperature of less than 95°F
what is stage 3?
A deep crater characterized by full-thickness skin loss with damage or necrosis of subcutaneous tissue. Adipose is visible.
A nurse has applied a blood pressure cuff to a client's upper arm, positioned the stethoscope over the client's brachial artery, inflated the cuff and is now slowly releasing air from the cuff. The nurse should recognize the client's peak blood pressure when what sound is audible?
A faint, clear tapping sound
6. The nurse notes that an advance directive is on a patient's medical record. Which statement represents the best descrip- tion of an advance directive guideline the nurse will follow?
A living will is invoked only when the patient has a terminal condition or is in a persistent vegetative state.
What is an abcess wound?
A localized collection of pus resulting from invasion from a pyogenic bacterium or other pathogen
Which scenario is the best example of a nurse in the role of counselor?
A nurse allowing a crying client to verbalize fears of death
1-5. Evidence-based practice is defined as
A problem-solving approach that integrates best current evidence with clinical practice
What is an abrasion wound?
A scrape of the superficial layers of the skin
malaise
A sense of unease; depression
Neutrophils
A type of white blood cell that engulfs invading microbes and contributes to the nonspecific defenses of the body against disease. increased most in bacterial infections phagocytosis during acute infection
what is crushing wound?
A wound caused by force leading to compression or disruption of tissues.
what is a tunnel wound?
A wound with an entrance and exit site.
RN
AS or BSN degree, completes all nursing skills, specialized training, BSN level looking into evidence-based practice, papers focused on research
ASSESS BEFORE IMPLEMENTING
ASSESS BEFORE IMPLEMENTING
5. A woman who is a Jehovah's Witness has severe life-threatening injuries and is hemorrhaging following a car accident. The health care provider ordered 2 units of packed red blood cells to treat the woman's anemia. The woman's husband refuses to allow the nurse to give his wife the blood. What is the nurse's responsibility?
Abide by the husband's wishes and inform the health care provider
TYPES OF WOUNDS
Abrasion Avulsion Cut Ecchymosis/contusion Hematoma laceration patterned stab
what is clean non granulating tissue?
Absence of granulation tissue
9-4. Which of the following is required in the delivery of culturally congruent care?
Acquiring specific knowledge, skills, and attitudes
What focus charting component reflects the planning and implementation phase of the nursing process?
Action (3rd column)
SOAPIE: interventions
Actions of health care team performed for achieve expected outcomes
9-2. A 46-year-old woman from Bosnia came to the United States 6 years ago. Although she did not celebrate Christmas when she lived in Bosnia, she celebrates Christmas with her family now. This woman has experienced assimilation into the culture of the United States because she:
Adapted to and adopted the American culture.
what are the four types of wound closer?
Adhesive Strips Sutures Surgical Staples Surgical Glue
If client received less than 3 doses of Td
Administer both Td and tetanus immune globulin (TIG)
2-9. Which of the following nursing activities is found in a tertiary health care environment?
Admitting a patient following open heart surgery to the cardiovascular intensive care unit
9-9. Which of the following best represents the dominant values in American society on individual autonomy and self-determination?
Advance directive
1-4. A nurse is caring for a patient with end-stage lung disease. The patient wants to go home on oxygen and be comfortable. The family wants the patient to have a new surgical procedure. The nurse explains the risk and benefits of the surgery to the family and discusses the patient's wishes with the family. The nurse is acting as the patient's:
Advocate
12. A nursing student is taking postoperative vital signs in the postanesthesia care unit. She knows that some ethnic groups are more prone to genetic disorders. Which of the fol- lowing patients is most at risk for developing malignant hypertension?
African American
Tuberculosis
Airborne precautions Wear fit-test respirator mask
Which is an appropriately stated nursing intervention?
Ambulate 30 ft (9 m) twice a day with the assistance of a walker.
Mary Elizabeth Mahoney
America's first African American nurse
The first nursing journal owned, operated, and published by nurses was:
American Journal of Nursing
Which organization has established standards that help the nurse determine which clinical actions fall under the scope of nursing practice?
American Nurses Association
Which nursing group provides a definition and scope of practice for nursing?
American Nurses Association (ANA)
What association includes documentation in many of its standards?
American Nursing Association (ANA)
Which client presents the most significant risk factors for the development of Clostridium difficile infection?
An 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis
what is a Deep Tissue Pressure Injury (DTI)?
An area of skin that is intact but persistently discolored. It might be purplish or deep red, painful, or boggy, or have a blister. Pain and temperature change often come before skin color changes.
what is a puncture wound?
An open wound caused by a sharp object.
what is a penetrating wound?
An open wound in which the agent causing the wound lodges in body tissue.
what is an incision wound?
An open, intentional wound caused by a sharp instrument
4. A nurse has worked on an oncology unit for 3 years. One patient has become visibly weaker and states, "I feel funny." The nurse knows how patients often have behavior changes before developing sepsis when they have cancer. The nurse asks the patient questions to assess thinking skills and notices the patient shivering. The nurse goes to the phone, calls the physi- cian, and begins the conversation by saying, "I believe that your patient is developing sepsis. I want to report symptoms I'm seeing." What examples of critical thinking concepts does the nurse show? (Select all that apply.)
Analyticity Self-confidence
11-1. The nurse is aware that preschoolers often display a develop mental characteristic that makes them treat dolls or stuffed animals as if they have thoughts and feelings. This is an example of:
Animism.
14. Which of the following is unique to the commitment level of critical thinking?
Anticipates when to make choices without others' assistance.
Phases of Pain experience
Anticipatory (fear, anxiety about impending pain) Sensation of pain (mild, moderate, severe) Pain aftermath (weakness, nausea, sweating)
The nurse is caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse?
Apply a nonparticulate (N-95) respirator when entering the room.
droplet precautions
Appropriate for diphtheria Strep Pneumonia Influenza
airborne precautions
Appropriate for: measles Tuberculosis Varicella Disseminated zoster
A client has tested positive for colonization with a multidrug-resistant organism (MDRO) and has been placed on contact precautions. Which actions should be included in this client's care? Select all that apply.
Arrange for the client to be housed in a single room. Use appropriate PPE.
10. The nurse at an outpatient clinic asks a patient who is Chinese American with newly diagnosed hypertension if he is limiting his sodium intake as directed. The patient does not make eye contact with the nurse but nods his head. What should the nurse do next?
Ask the patient how much salt he is consuming each day
8. An example of a nurse caring behavior that families of acutely ill patients perceive as important to patients' well-being is:
Asking permission before performing a procedure on a patient.
The nurse needs to obtain an admission weight for a client diagnosed with end-stage lung cancer. To obtain the client's weight, what should the nurse do first?
Assess the client's ability to stand or sit.
5. What is the best example of the nurse practicing patient advocacy?
Assess the patient's point of view and prepare to articulate it
1-2 An 18-year-old woman is in the emergency department with fever and cough. The nurse obtains her vital signs, auscultates her lung sounds, listens to her heart sounds, determines her level of comfort, and collects blood and sputum samples for analysis. Which standard of practice is performed?
Assessment
The nurse is performing care for a client in the end stage of cancer. How can the nurse best facilitate the client and family's ability to cope? Select all that apply.
Assist the client with activities of daily living (ADLs). Assist the client and family with the preparation for end-of-life. Refer the client and family to hospice services.
2-2. Which activity performed by the nurse is related to maintain- ing competency in nursing practice?
Attending a review course in preparation for the certification examination
When assessing a client's radial pulse, the nurse notes an irregular rhythm with a rate of 62 beats per minute. What intervention should the nurse implement next?
Auscultate the apical pulse for 60 seconds
The nurse has palpated the client's radial artery and identified a heart rate of 88 beats per minute with an irregular rate. What is the nurse's most appropriate action?
Auscultate the client's apical heart rate
A nurse is assessing the respirations of a 60-year-old female client and finds that the client's breaths are so shallow that the respirations cannot be counted. What would be the appropriate initial nursing intervention in this situation?
Auscultate the lung sounds and count respirations.
What are normal vital signs for 6-8 year old children?
BP: 102/56 RR: 20-25 PR: 95 (75-115) Temp: oral 37(98.6)
what are normal vital signs for 10 year old children?
BP: 110/58 RR: 17-22 PR: 90(70-100) TEMP: oral (98.6)
What are normal vital signs for teens?
BP: 110/70 RR: 15-20 PR: 80 (55-105) oral temp: 98.6 (37C)
What are normal vital signs in adults older than 70?
BP: 120/80 up to 160/95 RR: 12-20 PR: 80 (60-100) oral temp: 95-96.8 (35-36)
What are normal vital signs for 1-3 year olds?
BP: 98/64 RR: 20-40 PR: 110(80-150) TEMP: rectal 37.7 (99.9)
What are normal vital signs for adults?
BP: <120/80 RR: 12-20 PR: 80 (60-100) oral temp: 98 (36.7)
9-3. To enhance their cultural awareness, nursing students need to make an in-depth self-examination of their own:
Background, recognizing personal biases and prejudices.
15-9. A nurse has been working on a surgical unit for 3 weeks. A patient requires a Foley catheter to be inserted, so the nurse reads the procedure manual for the institution to review how to insert it. The level of critical thinking the nurse is using is:
Basic critical thinking.
A nurse is completing a health history with a newly admitted client. During the interview, the client presents with an angry affect and states, "If my doctor did a good job, I would not be here right now!" What is the nurse's best response?
Be silent and allow the client to continue speaking when ready.
9. A nurse demonstrates caring by helping family members:
Become active participants in care.
3. A child's immunization may cause discomfort during admin- istration, but the benefits of protection from disease, both for the individual and society, outweigh the temporary discom- forts. Which principle is involved in this situation?
Beneficence
High fowlers
Best position to deep breathe and cough
what is an arterial ulcer?
Blockage of arterial blood to an area
24 Pain Profile = COLDERR
C- Character and intensity- acute/ chronic; mild vs. severe O- onset- sudden or insidious L- Location D- Duration E- Exacerbation R- Radiation R- Relief
afferent nervous system conveys info to the
CNS; going to your brain
15. You are floated to work on a nursing unit where you are given an assignment that is beyond your capability. What is the best nursing action to take first?
Call the nursing supervisor to discuss the situation
What is a disadvantage of charting by expectation? (CBE)
Can lead to omission (that may occur from disagreements) of information and errors in care
4-10 Which of the following is closely aligned with Leininger's theory?
Caring for patients from unique cultures
14. A hospice nurse sits at the bedside of a male patient in the final stages of cancer. He and his parents made the decision that he would move home and they would help him in the final stages of his disease. The family participates in his care, but lately the nurse has increased the amount of time she spends with the family. Whenever she enters the room or approaches the patient to give care, she touches his shoulder and tells him that she is present. This is an example of what type of touch?
Caring touch
Which peripheral pulse site is generally used in emergency situations?
Carotid
what is a venous stasis ulcer?
Caused by incompetent venous valves, deep vein obstruction, or inadequate calf muscle function.
SOAPIER: revision
Changes made to the original care plan
What is the third column in focused charting?
Charting in a DAR format: Data, action, response
GI post op care
Check bowel sounds in 4 quadrants 5 min each Keep NPO until bowel sounds present Provide good mouth care while NPO Provide anitemetics for nausea and vomiting Check for distended ab Check for passage of flatus and stool
Respiratory post op care
Check breath sounds Turn, cough, and deep breathe (NOT if post brain, spinal, or eye surgery) Splint wound Offer pain med Teach incentive spirometer Ge out of bed as soon as possible
Extremities post op care
Check pulses Assess for color, edema, temperature Do not cross legs Keep knee gatch flat Prohibit pillows behind knee Apply TEDs Monitor for Calf pain and swelling Pneumatic compression device
Vitamin E
Chemically functions most clearly as an antioxidant The most important lipid-soluble antioxidant in cell Reduces harmful free radicals to harmless metabolites Deficiencies: a) loss of deep tendon reflexes b) changes in balance and coordination c) muscle weakness, visual disturbances
5. The nurse states, "When you tell me that you're having a hard time living up to expectations, are you talking about your family's expectations?" The nurse is using which therapeutic communication technique?
Clarifying
When preparing to take a client's blood pressure, the nurse notes that the sphygmomanometer is visibly soiled. What is the correct action by the nurse?
Cleanse and disinfect the sphygmomanometer.
The nurse is assessing the client's blood pressure (BP) and heart rate (HR) for orthostatic hypotension. In which step should this nurse intervene because of potential danger?
Client stands at bedside, becomes pale, diaphoretic.
Which client should the nurse determine to be at the greatest risk for hospital-acquired infection (HAI)?
Client with a urinary catheter
DAR: what is response?
Clients response to interventions reflects evaluation phase
13. A nurse caring for a patient on a ventilator electronically docu- ments the head of bed elevated at 20 degrees. Suddenly an alert warning appears on the screen warning the nurse that this patient is at a high risk for aspiration because the head of the bed is not elevated high enough. This warning is known as what type of system?
Clinical decision support system
A nurse is planning to pursue further education in the hopes of becoming an expert in geriatric nursing who carries out direct care. For which expanded career role is the nurse preparing?
Clinical nurse specialist
During an assessment of a newly admitted client the nurse asks the client many questions. The nurse begins the assessment by asking, "How many times have you been hospitalized this year for your back pain?" This is an example of which type of question?
Closed question
what are the most commonly used as slings to immobilize an upper extremity or to hold large abdominal dressings in place?
Cloth bandages
2. Mrs. Jones states that she gets anxious when she thinks about giving herself insulin. How do you use your understanding of intrapersonal communication to help with this?
Coach her to give herself positive messages about her ability to do this
Sodium-Restricted Diet
Cold baked chicken, lettuce with sliced tomatoes, applesauce Common medical problems: Heart failure, hypertension, cirrhosis Purpose: To lower body water and promote excretion Not allowed: Preserved meats, cheese, fried foods, cottage cheese, canned foods, added salt
A client is brought to the emergency department with a head injury following an all-terrain vehicle (ATV) accident. The nurse asks the family members to describe how the accident occurred. The nurse is implementing which ANA standard?
Collaboration
3. A patient on a surgical unit develops sudden shortness of breath and a drop in blood pressure. The staff respond, but the patient dies 30 minutes later. The manager on the nursing unit calls the staff involved in the emergency response together. The staff discusses what occurred over the 30-minute time frame, the actions taken, and whether other steps should have been implemented. The nurses in this situation are:
Conducting reflective practice.
5-12-A nurse is providing care to a patient who is experiencing major abdominal trauma following a car accident. The patient is losing blood quickly and needs a blood transfusion. The nurse finds out that the patient is a Jehovah's Witness and cannot have blood transfusions because of religious beliefs. He or she notifies the patient's health care provider and receives an order to give the patient an alternative to blood products. This is an example of:
Considering the patient's preferences and values while pro-viding care.
6. The surgical unit has initiated the use of a pain-rating scale to assess patients' pain severity during their postoperative recov- ery. The registered nurse (RN) looks at the pain flow sheet to see the pain scores recorded for a patient over the last 24 hours. Use of the pain scale is an example of which intellectual standard?
Consistent
13. A home health nurse notices significant bruising on a 2-year- old patient's head, arms, abdomen, and legs. The patient's mother describes the patient's frequent falls. What is the best nursing action for the home health nurse to take?
Contact a child abuse hotline
The nurse is donning a pair of sterile gloves. The nurse correctly dons the first glove, but inadvertently inserts the thumb and index finger into the thumb hole of the second glove. The glove remains intact. Which action is most appropriate?
Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole.
A student nurse is attempting to improve their communication skills. Which therapeutic communication skill is appropriate?
Control the tone of the voice to avoid hidden messages.
12. Presence involves a person-to-person encounter that:
Conveys a closeness and a sense of caring.
An adults normal internal temperature is called what?
Core temperature
High-Roughage, High-Fiber Diet
Cracked wheat bread, minestrone soup, apple, Brussels sprouts Common medical problems: constipation, large bowel disorders Purpose: to maximize bulk in stools Not allowed: white bread, pies and cakes frm white flour, "white" processed foods
6. Which of the following is a strategy for creating work environments that enable nurses to demonstrate more caring behaviors?
Creating a setting that allows flexibility and autonomy for staff
seborrheic dermatitis = cradle cap
Crusting of infant's scalp due to hyperactive sebaceous glands caused by maternal hormones
14. During their clinical postconference meeting, several nursing students were discussing their patients with their instructor. One student from a middle-class family shared that her patient was homeless. This is an example of caring for a patient from a different:
Culture
DO KAPLAN PRE & POST OP PRACTICE QUESTIONS
DO KAPLAN PRE & POST OP PRACTICE QUESTIONS
What focus charting component reflect the assessment phase of the nursing process?
Data (3rd column)
What are disadvantages of source orient record system?
Data may be fragmented/scattered difficult to track treatments and client outcomes
1-1. You are participating in a clinical care coordination conference for a patient with terminal cancer. You talk with your col- leagues about using the nursing code of ethics for professional registered nurses to guide care decisions. A nonnursing col- league asks about this code. Which of the following statements best describes this code?
Defines the principles of right and wrong to provide patient care
15. Mr. Sakda emigrated from Thailand. When taking care of him, you note that he looks relaxed and smiles but seldom looks at you directly. How do you respond?
Deflect your eyes downward to show respect
Effects of morphine
Depresses CNS, especially respiratory center would cause decreasing or fluctuating of consciousness
5-15. A nurse researcher is developing a research proposal and is in the process of selecting an instrument to measure anxiety. In which part of the research process is this nurse?
Designing the study
What factors influence body temperature?
Developmental level Environment Gender Exercise Emotions/stress Circadian rhythm
4-7. Which of the following theories describe the life processes of an older adult facing chronic illness?
Developmental theories
2-13. A nurse is presenting information to a management class of nursing students on the topic of groups of inpatient hospital services that have a fixed reimbursement amount, with adjust- ments made on the basis of case severity and regional costs. The nurse is presenting information to the class on which topic?
Diagnosis-related groups
2. The nurse sits down to talk with a patient who lost her sister 2 weeks ago. The patient reports she is unable to sleep, feels very fatigued during the day, and is having trouble at work. The nurse asks her to clarify the type of trouble. The patient explains she can't concentrate or even solve simple problems. The nurse records the results of the assessment, describing the patient as having ineffective coping. This is an example of:
Diagnostic reasoning.
2. An 18monthold child is noted by the parents to be "angry" about any change in routine. This child's temperament is most likely to be described as:
Difficult.
The new nursing graduate is concerned about some of the critical changes that will be occuring in nursing. What changes does the nurse anticipate will impact nursing care?
Difficulty for nurses to remain current in a rapidly changing medical and technology
The nurse is setting up a sterile field to perform a catheterization when the client touches the end of the sterile field. What would be the nurse's next appropriate action?
Discard the sterile field and the supplies and start over.
6. When action is taken on one's prejudices:
Discrimination occurs.
12. You are the night shift nurse and are caring for a newly admitted patient who appears to be confused. The family asks to see the patient's medical record. What is the first nursing action to take?
Discuss the issues that concern the family with them
Which best exemplifies the role of the nurse as educator?
Discussing side effects of a medication with a client
The nurse has finished caring for a client on contact precautions. Which nursing action regarding the stethoscope used to auscultate this client's lungs and bowel sounds is appropriate?
Disinfect it with alcohol swabs.
PIE- Evaluation
Document the patient's response to interventions and treatments
10. You are supervising a beginning nursing student who is docu- menting patient care. Which of the following actions requires you to intervene? The nursing student:
Documented medication given by another nursing student.
Nurses wear personal protective equipment (PPE) to protect themselves and clients from infectious materials. Which examples accurately represent the proper use of personal protective equipment in a health care agency? Select all that apply.
During some care activities for an individual client, nurses may need to change gloves more than once. Nurses should remove PPE at the doorway or in an anteroom, except for the respirator. To remove a gown, nurses should unfasten ties, if at the neck and back, and allow the gown to fall away from shoulders.
Which statement describes diastolic blood pressure?
During ventricular relaxation, blood pressure is due to elastic recoil of the vessels.
The nurse is performing an extensive dressing change on a client with burns. The nurse explains each step as it is being performed. The nurse is acting in which role by providing explanation of each step?
Educator
What is is an EHR?
Electronic Health record
8. On the nursing unit you are able to access a patient's medical record and review the education that other nurses provided to the patient during an initial hospitalization and three sub- sequent clinic visits. This type of feature is most common in what type of record system?
Electronic health record
11. A homeless man enters the emergency department seeking health care. The health care provider indicates that the patient needs to be transferred to the City Hospital for care. This action is most likely a violation of which of the following laws?
Emergency Medical Treatment and Active Labor Act (EMTALA)
4. Helping a new mother through the birthing experience demonstrates which of Swanson's five caring processes?
Enabling
8. You are caring for a recently retired man who appears with drawn and says he is "bored with life." Applying the work of Havinghurst, you would help this individual find meaning in life by:
Encouraging him to explore new roles.
9-1. A 6-month-old child from Guatemala was adopted by an American family in Indiana. The child's socialization into the American midwestern culture is best described as:
Enculturation.
metabolism uses what to produce heat?
Energy
What are 5 advantaged of electronic health records?
Enhanced communication and collaboration improved access to information time saving improved quality of care information is private and safe
26-1 A manager who is reviewing the nurses' notes in a patient's medical record finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following directions does the manager give to the staff nurse who entered the note?
Enter only objective and factual information about the patient.
A prospective student is interested in alternate emerging pathways to the nursing profession instead of the traditional programs. What pathways should the student be advised to research? Select all that apply.
Entry level master's degree programs RN completion programs for LPNs
7-2. Of the five caring processes described by Swanson, which describes "knowing the patient"?
Establishing an understanding of a specific patient
The nursing process includes step(s)? Select all that apply.
Evaluate Plan Assess Implement
10. A patient had hip surgery 16 hours ago. During the previous shift the patient had 40 mL of drainage in the surgical drainage collection device for an 8-hour period. The nurse refers to the written plan of care, noting that the health care provider is to be notified when drainage in the device exceeds 100 mL for the day. On entering the room, the nurse looks at the device and carefully notes the amount of drainage currently in it. This is an example of:
Evaluation.
While assessing a client, the nurse notices that the client seems to be distracted from the questions being asked. The nurse attempts to identify factors that may be affecting the communication. What would the nurse identify as an internal influencing factor?
Experience
4-2. A theory is a set of concepts, definitions, relationships, and assumptions that:
Explain a phenomenon.
11. A female Jamaican immigrant has been late to her last two clinic visits, which in turn had to be rescheduled. The best action that the nurse could take to prevent the patient from being late to her next appointment is:
Explore what has prevented her from being at the clinic in time for her appointment
A client is distraught because a recent computed tomography (CT) scan shows that the client's colon cancer has metastasized to the lungs. Which nursing aim should the nurse prioritize in the immediate care of this client?
Facilitating coping
A person's core body temperature is highest in the early morning and lowest in the late afternoon.
False
True or False: piloerection is an important heat conserving mechenism
False
true or false Nursing process terminology is the same as SOAP terminology
False
True or False the POR system doesn't require a cooperative spirit and diligence among health providers
False The POR system does require cooperative spirit and diligence
Vitamin A
Fat-soluble vitamin Sources: a) derived from beta carotene b) Carotene-containing foods are most important: liver, butter, milk and cheese, and egg yolk: yellow orange, and some green vegetables Deficiencies: a) night blindness, corneal desiccation and ulceration, xerophthalmia b) bronchorespiratory epithelium changes from mucus secretion to keratinization c) Keratinization and xerosis of the skin d) Genitourinary calculi e) Sweat gland atrophy f) Increased cerebral spinal fluid pressure and pseudotumor cerebri g) impaired smell and taste secondary to keratinization h) Defective remodeling of bone i) Degeneration of testes and gonadal resorption j) Deficiency enhances carcinogenicity in lab animals Toxicity a) CNS - lethargy, headache, and papilledema b) Skin - dry and pruritic skin, desquamation, and erythema c) GI - fatty liver, hepatic cirrhosis, and portal hypertension d) Myalgia - gingivitis and cheilosis e) Tender hyperostoses f) Hypercalcemia, hypoprothrombinemia Therapeutic uses: a) Deficiencies b) Dermatologic disease
Low-Phenylalanine Diet
Fats, fruits, jams, low-phenylalanine milk Common medical problems: Phenylketonuria (PKU) Purpose: Low-protein diet to prevent brain damage from imbalance of amino acids Not allowed: meats, eggs, beans, bread
24-1. The nurse summarizes the conversation with the patient to determine if the patient has understood him or her. This is what element of the communication process?
Feedback
3. Nineyearold Brian has a difficult time making friends at school and being chosen to play on the team. He also has trouble completing his homework and, as a result, receives little positive feedback from his parents or teacher. According to Erikson's theory, failure at this stage of development results in:
Feelings of inferiority.
what causes fever?
Fever occurs in response to pyrogens
4. When a nurse assesses a patient for pain and offers a plan to manage the pain, which principal is used to encourage the nurse to monitor the patient's response to the pain?
Fidelity
Which mask should the nurse don when caring for a client with tuberculosis?
Filtered respirator
The nurse is documenting the client's response to a medication. This action reflects a practice that was started by which key figure in nursing's history?
Florence Nightingale
The registered nurse is performing a nutritional assessment to ensure that the client's diet is optimal for wound healing. The nurse's intervention can be traced back to which key contributor to nursing?
Florence Nightingale
who established the first training school for nurses and wrote books about healthcare and nursing education?
Florence Nightingale
FACT documentation
Flow sheet assessment concise, integrated notes and flow sheets timely entries
what is the second column in focused charting?
Focus or problem being addressed
what is the proliferation phase?
Formation of the granulation tissue - vascular endothelial cells proliferate and then collagen will later deposit
Meperidine HCl/ Demerol side effects
Frequent dizziness Tremors Uncoordinated muscle movements Constipation Urinary retention Bradycardia Confusion in older adults
Low-Fat, Cholesterol-Restricted Diet
Fruit, vegetables, cereals, lean meat Common medical problems: Atherosclerosis, cystic fibrosis (CF) Purpose: To reduce calories from fat and minimize cholesterol intake Not allowed: Marbled meats, avocados, milk, bacon, egg yolks, butter
What is a stage 4 pressure ulcer?
Full thickness skin loss, exposed bone, tendon, or muscle, slough or eschar, and tunneling
1-8 Advanced practice registered nurses generally:
Function independently
A nurse is caring for a client with ringworm. Which microorganism causes ringworm in a client?
Fungi
aspirin/ salicylates prolonged usage
GI bleeding, blood dyscrasia, and acid- base disturbances
7-3. A Muslim woman enters the clinic to have a woman's health examination for the first time. Which nursing behavior applies Swanson's caring process of "knowing the patient?"
Gaining an understanding of what a woman's health examination means to the patient
9. Ethical dilemmas often arise over a conflict of opinion. What is the critical first step in negotiating the difference of opinion?
Gather all relevant information regarding the clinical, social, and spiritual aspects of the dilemma.
Clear liquid Diet
Gelatin dessert, popsicle, tea with lemon, ginger ale, bouillon, fruit juice with no pulp Common medical problems: postoperative; acute vomiting or diarrhea Purpose: To maintain fluid balance Not allowed: Fruit juices with pulp, milk
List five factors that affect body temperature
Gender exercise environment age stress
2. A new graduate nurse is providing a telephone report to a patient's health care provider and accepting telephone orders from the provider. Which of the following actions requires the new nurse's preceptor to intervene? The new nurse:
Gives a newly ordered medication before entering the order in the patient's medical record
the most frequently used type of bandage is....
Guaze
4. You are reviewing Health Insurance Portability and Account- ability Act (HIPAA) regulations with your patient during the admission process. The patient states, "I've heard a lot about these HIPAA regulations in the news lately. How will they affect my care?" Which of the following is the best response?
HIPAA provides you with greater control over your personal health care information.
7. A nurse notes that the health care unit keeps a listing of the patient names at the front desk in easy view for health care providers to more efficiently locate the patient. The nurse talks with the nursing manager because this action is a violation of which act?
Health Insurance Portability and Accountability Act (HIPAA)
How Is Heat Exchanged Between the Body and the Environment? (hint: it's like diffusion)
Heat moves from an area of higher to an area of lower temperature
What is focused charting?
Highlights the client's concerns, problems, or strengths in three columns uses assessment data to evaluate patient
5-9-A nurse researcher decides to complete a study to evaluate how Florence Nightingale improved patient outcomes in the Crimean War. This is an example of what type of research?
Historical
A nurse follows surgical asepsis techniques for inserting an indwelling urinary catheter in a client. What is an accurate guideline for using this technique?
Hold sterile objects above waist level to prevent inadvertent contamination.
Motrin
Ibuprofen
Nonsteroidal antiinflammatory drugs (NSAIDs)
Ibuprofen = Motrin Naproxen = Anaprox and Naprosyn Ketoorolac = Toradol
Preventive approach to pain
If pain is expected to occur throughout most of a 24 hour period, a regular schedule is better than prn
What is an example of continuity of care?
If you are concerned that the client is at high risk of infection, you can include a nursing diagnosis of Risk for Infection on the written/electronic care plan. You would then initiate nursing prescriptions for other nurses to observe for a document signs of infection.
11. Allison, age 15 years, calls her best friend Laura and is crying. She has a date with John, someone she has been hoping to date for months, but now she has a pimple on her forehead. Laura firmly believes that John and everyone else will notice the blemish right away. This is an example of the:
Imaginary audience
5-8. The nurses on a medical unit have seen an increase in the number of pressure ulcers that develop in their patients. They decide to initiate a quality improvement project using the PDSA model. Which of the following is an example of "Do" from that model?
Implement the new skin care protocol on all medicine units.
1-3. A patient in the emergency department has developed wheez-ing and shortness of breath. The nurse gives the ordered medi- cated nebulizer treatment now and in 4 hours. Which standard of practice is performed?
Implementation
1-15. Nurses at a community hospital are in an education program to learn how to use a new pressure relieving device for patients at risk for pressure ulcers. This is which type of education?
In-service education
A nurse manager is teaching staff how to use a new piece of hospital equipment. Which educational setting would be most appropriate for this process?
In-service education
vital signs for patient in pain
Increase BP increase HR Rapid, irregular respirations Decreased skin temperature
When seniors in the hypothalamus detect cold, they send out impulses to do what?
Increase heat production and reduce heat loss
responses to pain stimuli
Increased BP and HR (allow increased blood flow to brain and muscles) Rapid, irregular RR (increased O2 to brain and muscles) Increased papillary diameter = increased eye accommodation to light Increased perspiration = decreased temperature Increased muscle tension, leads to neuromuscular responsiveness Aroused apprehension, anxiety, irritability Verbalized pain
5. A patient asks for a copy of her medical record. The best response by the nurse is to:
Indicate that she has the right to read her record
A nurse is assessing an adult client's blood pressure. How should the nurse estimate the client's systolic blood pressure (SBP)?
Inflate the blood pressure cuff while palpating the client's brachial artery.
The nurse identifies the auscultatory gap while taking the client's blood pressure. What should the nurse do next?
Inflate the cuff about 30 mm Hg above the auscultatory gap.
A nursing student is manually taking the client's blood pressure. Which step will demonstrate the correct way of inflating the blood pressure cuff?
Inflate the cuff to 30 mm Hg above reading where brachial pulse disappeared.
7. A nursing student is doing a community health rotation in an inner-city public health department. The student investigates sociodemographic and health data of the people served by the health department, and detects disparities in health outcomes between the rich and poor. This is an example of a(n):
Influence of socioeconomic factors in morbidity and mortality.
1-11 A critical care nurse is using a computerized decision support system to correctly position her ventilated patients to reduce pneumonia caused by accumulated respiratory secretions. This is an example of which Quality and Safety in the Education of Nurses (QSEN) competency?
Informatics
5-6. When recruiting subjects to participate in a study about the effects of an exercise program on balance, the researcher pro- vides full and complete information about the purpose of the study and gives the subjects the choice to participate or not participate in the study. This is an example of:
Informed consent.
4. The nurse teaches parents how to have their children learn impulse control and cooperative behaviors. This would be during which of Erickson's stages of development?
Initiative versus guilt
The nurse places the client on a hypothermia blanket to manage the client's temperature. Which action does the nurse take?
Insert a rectal thermometer probe and secure it in place.
7. When a nurse helps a patient find the meaning of cancer by supporting beliefs about life, this is an example of:
Instilling hope and faith.
15. Which is the best method of negotiating or processing difficult ethical situations?
Institutional ethics committees help to ensure that all par- ticipants involved in the ethical dilemma get a fair hearing and an opportunity to express values, feelings, and opinions as a way to find consensus.
The nurse preparing a lecture on the history of nursing should include which international organization as the first for professional nurses?
International Council of Nurses
10. Listening is not only "taking in" what a patient says; it also includes:
Interpreting and understanding what the patient means.
DAR: what is Action?
Interventions performed reflects planning and implementation.
What is an unstageable pressure ulcer?
Involves full-thickness skin loss.
4-14. Which of the following statements about theory-based nursing practice is incorrect?
Is not linked to nursing outcomes
A client monitoring his BP at home notices that his BP is higher in one arm than the other. He calls his health care provider for guidance. What is the most appropriate information for the nurse to give this client?
It has been found that most people have differences in BP between arms and that he should use the arm that gives him the highest reading for accurate results.
14. Dave reports being happy and satisfied with his life. What do we know about Dave?
It is difficult to determine Dave's developmental stage since most people report overall satisfaction with their lives in all stages.
A nurse educator is discussing the role of nursing based on the American Nurses Association (ANA). Which statement best describes this role?
It is the role of nursing to provide a caring relationship that facilitates health and healing.
22-1. The patient for whom you are caring needs a liver transplant to survive. This patient has been out of work for several months and doesn't have health insurance or enough cash. What principles would be a priority in a discussion about ethics?
Justice because the first and greatest question in this situation is how to determine the just distribution of resources
A nurse has been exposed to urine while changing the linens of a client's bed. Which guideline is followed for performing hand hygiene after this client encounter?
Keep hands lower than elbows to allow water to flow toward fingertips.
12. The nurse asks a patient how she feels about her impending surgery for breast cancer. Before the discussion the nurse reviewed the description of loss and grief and therapeutic communication principles in his textbook. The critical thinking component involved in the nurse's review of the literature is:
Knowledge application.
5-7. Nurses on a pediatric nursing unit are discussing ways to improve patient care. One nurse asks a colleague, "I wonder how best to measure pain in a child who has sickle cell disease?" This question is an example of a/an:
Knowledge-focused trigger.
LOOK UP DIFFERENT DRAINS
LOOK UP DIFFERENT DRAINS
LOOK UP LUNG SOUNDS
LOOK UP LUNG SOUNDS
HemoVac Drain
Large portable would self-suction device with reservoir common after mastectomy
primary lesions
Lesions that are a different color than the color of the skin, and/or lesions that are raised above the surface of the skin.
Percocet* and Percodan side effects
Light headedness Dizziness Sedation Nausea Constipation Pruritus Administer with milk after meals
The nurse is assessing the apical pulse of a client using auscultation. What action would the nurse perform after placing the diaphragm over the apex of the heart?
Listen for heart sounds.
Morphine sulfate side effects
Liver damage Dizziness and weakness Sedation or paradoxic excitement Nausea Sweating Respiratory depression Decreased cough reflex Constipation Hypotension
what is stage 1?
Localized area of intact skin with nonblanchable redness, usually over a bony prominence but not maroon or purple discoloration.
what is a pressure injury?
Localized injury to the skin and underlying tissue usually over a bony prominence
medical assessment
Looking for pathological conditions to make a sx i.e. HTN, appendicitis, CHF, determines the medical tx that will be ordered, surgery, meds, tx
The nurse must assign a room for a client admitted with endocarditis and methicillin-resistant Staphylococcus aureus (MRSA) in the blood. A client with which diagnosis can share a room with this client?
MRSA in the wound
what do you look for in a periwound?
Maceration Undermining (tunneling) Crepitus (gas trapped under the skin) Erythema, swelling, or other signs of irritation Epiboly (closed or rolled wound edges) Slough Eschar
2-6 Which of the following statements is true regarding Magnet status recognition for a hospital?
Magnet is a special designation for hospitals that achieve excellence in nursing practice
The nurse offers a client two possible times to ambulate, as prescribed by the health care provider. The nurse is acting in which nursing role?
Manager and coordinator
What are examples of quality improvement?
Manual chart audits run reports to analyze data
A nurse wishes to pursue a degree as a nurse practitioner. What is the minimal degree needed by the nurse?
Master's
Full liquid Diet
Milkshakes, soups, custard, all clear liquids Common medical problems: GI upset (diet progression after surgery) Purpose: Nutrition without chewing Not allowed: Jam, fruit, solid foods, nuts
Genitourinary post op care
Monitor I and O Encourage to void Notify provider if unable to void within 8 hours Catheterize if necessary
7. You are caring for an 80-year-old woman, and you ask her a question while you are across the room washing your hands. She does not answer. What is your next action?
Move to her bedside, get her attention, and repeat the ques- tion while facing her
lengthy note taking is a disadvantage of what nursing documentation format?
Narrative format
what is a diabetic foot ulcer?
Narrowing of the arteries, reduced oxygenation to the feet result in delayed wound healing and tissue necrosis.
What is eschar?
Necrotic tissue
11. When an ethical dilemma occurs on your unit, can you resolve the dilemma by taking a vote?
No because an ethical dilemma involves the resolution of conflicting values and principals rather than simply the identification of what people want to do
10. The ANA code of nursing ethics articulates that the nurse "promotes, advocates for, and strives to protect the health, safety, and rights of the patient." This includes the protection of patient privacy. On the basis of this principal, if you partici- pate in a public online social network such as Facebook, could you post images of a patient's x-ray film if you deleted all patient identifiers?
No because, even though patient identifiers are removed, someone could identify the patient based on other com- ments that you make online about his or her condition and your place of work
A nurse needs to measure the blood pressure of a client with an electronic manometer. Which of the following advantages does an electronic manometer provide over an aneroid manometer or mercury manometer?
No stethoscope is required.
2. The point of the ethical principal to "do no harm" is an agree- ment to reassure the public that in all ways the health care team not only works to heal patients but agree to do this in the least painful and harmful way possible. Which principle describes this agreement?
Nonmaleficence
Serum creatinine level
Normal = 0.5-1.5 mg/ dL measures renal function elevated in acute kidney injury and chronic kidney disease
5-10-A group of nurses on the research council of a local hospital are measuring nursing-sensitive outcomes. Which of the following is a nursing-sensitive outcome that the nurses need to consider measuring?
Number of patients who fall and experience subsequent injury on the evening shift
1-14. The nurses on an acute care medical floor notice an increase in pressure ulcer formation in their patients. A nurse consultant decides to compare two types of treatment. The first is the procedure currently used to assess for pressure ulcer risk. The second uses a new assessment instrument to identify at risk patients. Given this information, the nurse consultant exemplifies which career?
Nurse researcher
8. In most ethical dilemmas in health care, the solution to the dilemma requires negotiation among members of the health care team. Why is the nurse's point of view valuable?
Nurses develop a relationship to the patient that is unique among all professional health care providers.
2-14. When a nurse uses information and technology to com- municate, locate and use knowledge, reduce and eliminate errors, and help make decisions, the nurse is working in which area?
Nursing informatics
The client's plan of care is created by the nurse using which guideline for nursing practice?
Nursing process
5. When Ryan was 3 months old, he had a toy train; when his view of the train was blocked, he did not search for it. Now that he is 9 months old, he looks for it, reflecting the presence of:
Object permanence.
The nurse is caring for a client who has an intravenous (IV) catheter in place with a saline lock. The nurse is preparing to change the dressing to the IV site. After reviewing the image, what should the nurse do next?
Obtain a new intravenous dressing change kit
What might a nurse need to do to ensure the continuation of his or her nursing license?
Obtain continuing education credits.
SOAP: Objective data
Obtained by observation, physical examination, and laboratory and diagnostic tests
SOAP: Subjective data
Obtained from the patient/family member
13. A patient with limited English proficiency is going to be dis- charged on new medication. How does the nurse complete the discharge teaching?
Obtains an interpreter to facilitate communication of medication information
9. Place the following stages of Freud's psychosexual develop ment in the proper order by age progression.
Oral Anal Latency Oedipal Genital
ELEVATED BODY TEMP
Oral body temp 101F/37.4C febrile Rectal 100.4F/38 C febrile
4-3 A patient with diabetes is controlling the disease with insulin and diet. The nursing health care provider is focusing efforts to teach the patient self-management. Which of the following nursing theories is useful in promoting self management?
Orem
A home care nurse discusses with a client when visits will occur and how long they will last. In what phase of the nurse-client relationship is this type of agreement established?
Orientation phase
The nursing instructor is discussing communication with a student. The student identifies that a contract is made with the client during which phase of the nurse-client relationship?
Orientation phase
When caring for a psychiatric client, a formal contract is made with the client during which phase of the nurse-client relationship?
Orientation phase
Acetaminophen/ Tylenol side effects
Overdosage may be fatal Liver toxicity Rare GI side effects
PICO
P- patient, population, or problem of interest I- intervention of interest C- comparison of interest O- outcome of interest
5th vital sign
Pain
sources for obtaining information on an assessment
Patient is number one source, family and significant others, patient record, other health care professionals, nursing and healthcare literature
2-5 Nurses on a nursing unit are discussing the processes that led up to a near-miss error on the clinical unit. They are outlining strategies that will prevent this in the future. This is an example of nurses working on what issue in the health care system?
Patient safety
6. Which of the following charting entries is most accurate?
Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise.
2-12. The nurse is providing restorative care to a patient following an extended hospitalization for an acute illness. Which of the following is an appropriate goal for restorative care?
Patient will be able to walk 200 feet without shortness of breath
5-2. A nurse who works in a newborn nursery asks, "I wonder if the moms who breastfeed their babies would be able to breast- feed more successfully if we played peaceful music while they were breastfeeding." In this example of a PICOT question, the I is:
Peaceful music.
Oxycodone and acetaminophen
Percocet
oxycodone and aspirin
Percodan
When accessing a client's central line, a drop of the client's blood falls on the nurse's gloved hand. What is the appropriate action by the nurse?
Perform hand hygiene after removing the glove
what is granulation tissue?
Pink to red moist tissue
The nurse is caring for a client who has active tuberculosis and is under airborne precautions. The health care provider prescribes a computed tomography (CT) examination of the chest. Which action by the nurse is appropriate?
Place a surgical mask on the client and transport to the CT department at the specified time.
15. What is an appropriate way for a nurse to dispose of printed patient information?
Place in a secure canister marked for shredding
Jackson- Pratt (JP) drain
Portable wound self-suction device with reservoir
7. A 35yearold woman is speaking with you about her recent diagnosis of a chronic illness. She is concerned about her treat ment options in relation to her ability to continue to care for her family. As she considers the options and alternatives, she incorporates information, her values, and emotions to decide which plan will be the best fit for her. She is using which form of cognitive development?
Postformal thought
9. The nurse received a hand-off report at the change of shift in the conference room from the night shift nurse. The nursing student assigned to the nurse asks to review the medical records of the patients assigned to them. The nurse begins assessing the assigned patients and lists the nursing care information for each patient on each individual patient's message board in the patient rooms. The nurse also lists the patients' medical diagnoses on the message board. Later in the day the nurse discusses the plan of care for a patient who is dying with the patient's family. Which of these actions describes a violation of the Health Insurance Portability and Account- ability Act (HIPAA)?
Posting medical information about the patient on a message board in the patient's room
6. When preparing a 4yearold child for a procedure, which method is developmentally most appropriate for the nurse to use?
Preparing the child through play with a doll and toy medical equipment
what are the phases of a nursing- interview
Prepatory phase-read current and past records Introduction-introduce self, give title and purpose of interview Working Phase- data gathering Clarify and verify- ask additional questions about conditions, meds, anything that is unclear, if they have been seen for this condition, any tx or meds currently being used prescription or otc Termination- Is there anything else you would like us to know that will help us plan your care
What is the primary goal of the observable action associated with the removal of contaminated gloves?
Prevent contamination of ungloved hand
15-1. While assessing a patient, the nurse observes that the patient's intravenous (IV) line is not infusing at the ordered rate. The nurse assesses the patient for pain at the IV site, checks the flow regulator on the tubing, looks to see if the patient is lying on the tubing, checks the point of connection between the tubing and the IV catheter, and then checks the condition of the site where the intravenous catheter enters the patient's skin. After the nurse readjusts the flow rate, the infusion begins at the correct rate. This is an example of:
Problem solving
ANA
Professional organization for RN's in the US. Publicizes standards of Practice to ensure knowledgeable, safe, comprehensive, nursing care by those who will receive a license
1-6. The examination for registered nurse licensure is exactly the same in every state in the United States. This examination:
Provides a minimal standard of knowledge for a registered nurse in practice
2-4. Which of the following is an example of the nurse participat- ing in primary care activities?
Providing prenatal teaching on nutrition to a pregnant woman during the first trimester
What is the "Gold Standard" for obtaining core temperature?
Pulmonary artery temperature
A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse?
Pulse is felt with difficulty and disappears with slight pressure.
5-13. A group of staff educators are reading a research study together at a journal club meeting. While reviewing the study, one of the nurses states that it evaluates if newly graduated nurses progress through orientation more effectively when they participate in patient simulation exercises. Which part of the research process is reflected in this nurse's statement?
Purpose statement
CONFIDENTIALITY
Puts right to privacy code of ethics
5-1 A nurse researcher interviews parents of children who have diabetes and asks them to describe how they deal with their child's illness. The analysis of the interviews yields common themes and stories describing the parents' coping strategies. This is an example of which type of study?
Qualitative
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
5-3. A nurse researcher conducts a study that randomly assigns 100 patients who smoke and attend a wellness clinic into two groups. One group receives the standard smoking cessation handouts; the other group takes part in a new educational program that includes a smoking cessation support group. The nurse plans to compare the effectiveness of the standard treatment with the educational program. What type of a research study is this?
Randomized controlled trial
5-11. A group of staff nurses notice an increased incidence of medication errors on their unit. After further investigation it is determined that the nurses are not consistently identifying the patient correctly. A change is needed quickly. What type of quality improvement method would be most appropriate?
Rapid-improvement event
A nurse is caring for an adult with fever. The nurse determines that which site is most ideal for obtaining the client's core body temperature?
Rectum
When heat sensors in the hypothalamus are stimulated they send out impulses to do what?
Reduce body temperature
Which nursing intervention would be most appropriate for a new mother that calls the nursery for help with breastfeeding?
Refer the mother for a home care visit.
what is epithelial tissue?
Regenerating epidermis
7. The philosophy sometimes called the ethics of care suggests that ethical dilemmas can best be solved by attention to which of the following?
Relationships
Which action is the best example of a nurse donning/removing protective equipment properly?
Removing respirator after leaving client's room
What focus charting component reflects the evaluation phase of the nursing process?
Response
what is laboratory data?
Results from diagnosing testing
What are disadvantages of paper health records?
Retrieving info may be slow access may be delayed documentation is time consuming there is a relatively high risk for patient care error storage of paper records is expensive confidentiality is difficult to protect
Low-Residue Diet
Roast lamb, buttered rice, sponge cake, "white" processed foods Common medical problems: temporary GI/elimination problem s (lower bowel surgery) Purpose: To minimize intestinal activity Not allowed: Whole wheat, corn, bran
1-12 A nurse is caring for an older adult couple in a community- based assisted living facility. During the family assessment he notes that the couple has many expired medications and multiple medications for their respective chronic illnesses. They note that they go to two different health care providers. The nurse begins to work with the couple to determine what they know about their medications and helps them decide on one care provider rather than two. This is an example of which Quality and Safety in the Education of Nurses (QSEN) competency?
Safety
Codeine side effects
Same as morphine Constipation High dosage = restlessness and excitement less potent than morphine
pediculosis/ lice
Scalp: white eggs (nits) on hair shaft with itchy scalp Body : macules and papules Pubis: red macules
Hydromorphone/ Dilaudid
Sedation Hypotension Urine retention
13. Teaching an older adult how to use email to communicate with a grandchild who lives in another state is an example of ____________, which aids cognitive performance by using new approaches.
Selective optimization with compensation
12. Elizabeth, who is having unprotected sex with her boyfriend, comments to her friends, "Did you hear about Kathy? You know, she fools around so much; I heard she was pregnant. That would never happen to me!" This is an example of adolescent:
Sense of invulnerability.
5-4. A group of nurses have implemented an evidence-based practice (EBP) change and have evaluated the effectiveness of the change. Their next step is to:
Share the findings with others.
A client who has been taught to monitor her pulse calls the nurse because she is having difficulty feeling it strongly enough to count. She states that she takes her pulse before taking her cardiac medication. She sits down with her nondominant arm on a firm service, palm up. She uses her three fingers to feel just below the wrist on the side closest to the body. She does not press hard and she has a watch with a second hand to use to count it, but she has a very difficult time feeling it. What does the nurse recognize that she is doing wrong?
She should place her three fingers just below the wrist on the outside of the arm with the palm
13. A community health nurse is making a healthy baby visit to a new mother who recently emigrated to the United States from Ghana. When discussing contraceptives with the new mom, the mother states that she won't have to worry about getting pregnant for the time being. The nurse understands that the mom most likely made this statement because:
She won't resume sexual relations until her baby is weaned.
10. When working with an older adult, the nurse remembers to avoid:
Shifting quickly from subject to subject.
aspirin/ salicylates side effects
Short term GI bleeding Heartburn Nausea Long term Salicylism Metabolic acidosis Respiratory alkalosis Dehydration Tinnitus
why do older adults have trouble maintaining body heat?
Slow metabolism decreased vasomotor control loss of subcutaneous tissue
11-15. You are working in a clinic that provides services for homeless people. The current local regulations prohibit providing a service that you believe is needed by your patients. You adhere to the regulations but at the same time are involved in influ encing authorities to change the regulation. This action repre sents which stage of moral development?
Social contract orientation
what is sloughing?
Soft, moist, devitalized (necrotic) tissue
Vitamin D
Source: a) Primary - sunlight b) Secondary - fish oils, fortified dairy products Deficiencies: a) Rickets i) Uncalcified areas of bone are softened ii) Deformities of bones from physiological and gravitational stresses on soft sections of bone b) Growth retardation and weakness in infants and children Toxicity: a) Hypercalcemia b) Demineralization of bones c) Renal calculi and metastatic calcifications of soft tissues
Thiamin (B1)
Sources: a) Beef, liver, whole grains, legumes are good sources b) Eggs, fish, are fair sources Deficiencies: a) Gastrointestinal - indigestion, appetite loss b) Nervous system - nerve irritation and deadening sensations c) Cardiovascular - cardiac failure, edema Toxicity: a) shock Therapeutic uses: a) During high energy requirements such as postsurgery b) During pregnancy and lactation c) During growth spurts d) In chronic alcoholism
Vitamin C
Sources: a) Citrus fruit and tomatoes Deficiencies: a) Scurvy i. Sore gums ii. Hemorrhages iii. Anemia Toxicity: oxalate hypersensitivity Therapeutic uses: a) Postsurgical bleeding b) Fevers and infections c) Stress d) Growth
Riboflavin (B2)
Sources: a) Milk is most important source b) Organ meats c) Enriched foods Deficiencies: a) Wound aggravation - poor healing b) Glossitis of the tongue c) Cheilosis of the mouth Toxicity: not common Therapeutic uses: a) After surgery, trayma, and burns b) Growth periods
Vitamin K
Sources: a) chloroplasts of most plant species b) synthesized by many intestinal bacteria Deficiencies: a) bleeding tendency Toxicity: a) acute intravenous vitamin K toxicity causes: chest pain, flushing, and occasionally death b) Large parenteral doses may cause: anemia, hepatic and renal damage, and hemolysis, particularly in clients with glucose-6-phosphate deficiency Therapeutic uses: a) Given for inadequate intake b) Given for inadequate absorption c) Given for inadequate utilization
Niacin
Sources: a) meat b) peanuts, beans Deficiencies: a) Weakness b) Lassitude c) Loss of appetite Toxicity: a) Vasodilation b) Flushing Therapeutic uses: a) Surgery, trauma, burns b) Hypermetabolic states
Pyridoxine (B6)
Sources: a) Yeast, liver, and kidney are good sources b) Egg yolks are fair sources Deficiencies: a) Anemia b) CNS disturbance - seizures Toxicity: peripheral neuropathy Therapeutic uses: a) In high-protein diets and during isoiazid (INH) therapy b) Greater requirement during oral contraceptive use and early pregnancy
Folic acid and cyanocobalamin (B12)
Sources: a) liver and kidney are best Deficiencies: a) anemias i. folic acid - megaloblastic anemia (large, immature RBC) ii. B12 - Pernicious anemia (intrinsic factor needed for intestinal absorption of B12) Toxicity: not common Therapeutic uses: a) Intestinal sprue b) Mixed anemias
The client recently immigrated from Mumbai, India. The client was just admitted to the nurse's unit postoperatively following gallstone removal. The client does not speak the dominant language. When using the hospital's interpretive services, which is most important?
Speak directly to the client.
5. A patient is fearful of upcoming surgery and a possible cancer diagnosis. He discusses his love for the Bible with his nurse, who recommends a favorite Bible verse. Another nurse tells the patient's nurse that there is no place in nursing for spiritual caring. The patient's nurse replies:
Spiritual, mind, and body connections can affect health."
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
pressure ulcer stages
Stage 1: non-blanchable redness Stage 2: partial thickness loss Stage 3: full thickness loss, w/o undermining, see fat Stage 4: 3+ undermining, see tendon, muscle
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
Electronic entry
Streamlines processes Moves documentation to the bedside Decision-making processes are immediate
8. Culture strongly influences pain expression and need for pain medication. However, cultural pain is:
Suffered by a patient whose valued way of life is disregarded by practitioners.
4. A nurse is planning care for a patient going to surgery. Who is responsible for informing the patient about the surgery along with possible risks, complications, and benefits?
Surgeon
A client is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure?
Surgical asepsis technique
what is an ideal wound closure method for skin tears?
Surgical glue
what are three signs of internal hemorrhage?
Swelling of the affected body part pain changes in vital signs
True or false throughout the day, temperature can fluctuate 1°F to 2°F and is usually lowest in the early morning hours and highest in late afternoon or early evening.
TRUE
true or false The average BP for men is slightly higher than that for women of comparable age
TRUE
true or false A moderate fever is the body's natural defense against infection
TRUE (up to 103 F)
4. You are caring for Mr. Smith, who is facing amputation of his leg. During the orientation phase of the relationship, what would you do?
Talk with him about his favorite hobbies
13. A nurse enters a patient's room, arranges the supplies for a Foley catheter insertion, and explains the procedure to the patient. She tells the patient what to expect; just before inserting the catheter, she tells the patient to relax and that, once the catheter is in place, she will not feel the bladder pressure. The nurse then proceeds to skillfully insert the Foley catheter. This is an example of what type of touch?
Task-oriented touch
Which nursing actions demonstrate the aim of nursing to facilitate coping? Select all that apply.
Teaching a client and her family how to live with diabetes Assisting a client and his family to prepare for death Providing counseling for the family of a teenager with an eating disorder
3. A nurse stops to help in an emergency at the scene of an acci- dent. The injured party files a suit, and the nurse's employing institution insurance does not cover the nurse. What would probably cover the nurse in this situation?
The Good Samaritan laws, which grant immunity from suit if there is no gross negligence
What is an example of an external accrediting agency that reviews written and electronic care plans to ensure delivery of quality care and public safety?
The Joint Commission
The nurse conducts a home safety assessment for a client. Which statement best explains the standard of care being implemented?
The RN promotes a safe environment.
What is documentation?
The act of recording client assessments and care in written or electronic form
what system regulates the heart rate?
The autonomic nervous system
how does skeletal muscle influence body temperature?
The breakdown (catabolism) of fats and carbohydrates in muscle produces energy and (get this) heat.
The nurse is checking the client's temperature. The client feels warm to touch. However, the client's temperature is 98.8°F (37.1°C). Which statement could explain this?
The client is covered with a couple of thick blankets.
A nurse is providing care for clients in a long-term care facility. What should be the central focus of this care?
The client receiving the care
A nurse has been caring for a client who suffered a myocardial infarction 2 days ago. During the morning assessment, the nurse asks the client how he feels. Which scenario warrants further investigation?
The client stares at the floor and states, "I feel fine."
When administering beta blocker medications, the physician adds an order to hold medication when the client is bradycardic. Which statement explains this order?
The client's pulse rate is below 60 beats per minute.
where is the blood warmed in the body?
The core
what is body temp?
The degree of heat maintained by the body
What is internal respiration?
The exchange of these gases between the capillaries and body tissue cells
steatorrhea
The excretion of abnormal quantities of fat with the feces owing to reduced absorption of fat by the intestine.
dental caries
The formation of cavities in the teeth by the action of bacteria; tooth decay.
What is inflammation?
The inflammatory reaction is characterized by edema, erythema, pain, temperature elevation, and migration of white blood cells into the wound tissues.
The nurse is teaching a new nurse about preparing a sterile field. Which action made by the new nurse would indicate further teaching is required?
The new nurse touches 1.5 in. (4 cm) from the outer edges.
Which is the best example of a client-centered approach to care?
The nurse asks the client about health goals.
A nurse is following medical asepsis when caring for clients in a critical care unit. Which nursing actions follow these principles? Select all that apply.
The nurse carries soiled items away from the body. The nurse moves soiled equipment away from the body when cleaning it. The nurse cleans least soiled areas first and then moves to more soiled ones.
The American Nurses Association (ANA) Standards of Professional Nursing Practice provides standard of care for all nurses. Which statement on the assessment of the nursing process is accurate?
The nurse collects comprehensive data pertinent to the client's health or situation.
15. In which of the following examples is the nurse not applying critical thinking skills in practice?
The nurse explains the procedure for giving a tube feeding to a second nurse who has floated to the unit to assist with care
A nurse who is caring for newborn infants delivers care by utilizing the sense that is most highly developed at birth. Which example of nursing care achieves this goal?
The nurse gently strokes the baby's cheek to facilitate breastfeeding.
2-1. Which of the following is an example of the principle of patient-centered care focused on continuity and transition?
The nurse is teaching the patient how to change the wound dressing at home
11. A nurse is caring for an older adult who needs to enter an assisted-living facility following discharge from the hospital. Which of the following is an example of listening that displays caring?
The nurse listens to the patient's story while sitting on the side of the bed and then summarizes the story.
A nurse is caring for a client who is diagnosed with tuberculosis. Which nursing intervention promotes infection control based on nursing practice standards for safety?
The nurse places the client in a private room with monitored negative air pressure.
A nurse and an older adult client with chronic back pain are beginning to communicate. What activity should the nurse focus on at this point?
The nurse will be sensitive to the client's emotional barriers.
14. While reviewing the pulmonary section of a patient's electronic chart, the physician notices blank spaces since the initial assessment the previous day when the nurse docu- mented that the lung assessment was within normal limits. There also are no progress notes about the patient's respiratory status in the nurse's notes. The most likely reason for this is because:
The nurses were charting by exception
What is a health record system?
The overall process by which all client records are created, stored, and retrieved in an organization.
3. The nurse has a patient who is short of breath and calls the health care provider using SBAR (Situation-Background- Assessment-Recommendation) to help with the communica- tion. What does the nurse first address?
The patient is short of breath.
3. As you enter the patient's room, you notice that he is anxious to say something. He quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the fol- lowing is the most appropriate documentation of the patient's emotional status?
The patient stated that he felt frustrated by the lack of information he received regarding his tests.
4-1. Which of the following are components of the paradigm of nursing?
The person, health, environment/situation, and nursing
11. The statement that best explains the role of collaboration with others for the patient's plan of care is which of the following?
The professional nurse works with colleagues and the patient's family to provide combined expertise in planning care.
A nurse is explaining to a nursing student why blood pressure is a frequently used assessment parameter in a wide variety of care settings. What can be inferred from an assessment of a client's blood pressure?
The resistance that the client's heart must overcome when pumping blood
What is an laceration wound?
The skin or mucous membranes are torn open
Which client's blood pressure best describes the condition called hypotension?
The systolic reading is below 100 and diastolic reading is below 60.
Lymphocytes
The two types of white blood cells that are part of the body's immune system: B lymphocytes form in the bone marrow and release antibodies that fight bacterial infections; T lymphocytes form in the thymus and other lymphatic tissue and attack cancer cells, viruses, and foreign substances. Increased in chickenpox, mumps, measles, infectious mononucleosis, viral hepatitis important in immune response
6. Successful ethical discussion depends on people who have a clear sense of personal values. When a group of people share many of the same values, it may be possible to refer for guid- ance to philosophical principals of utilitarianism. This phi- losophy proposes which of the following?
The value of something is determined by its usefulness to society.
A nurse is assessing the blood pressure of a client using the Korotkoff sound technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record?
There is an auscultatory gap.
A registered nurse wishes to work as a nurse researcher. Which is true regarding nurse researchers?
They are responsible for the continued development and advancement of nursing.
When increasing the body temp, what happens to the blood vessels?
They constrict to conserve heat bay shunting blood away from the periphery (where heat is lost) to the core of the body, where the blood is warmed.
When decreasing the body temp, what happens to the blood vessels?
They increase in diameter to divert core-warmed blood to the body surface, where heat can be transferred to the surrounding environment.
2-3. The patient tells the nurse that she is enrolled in a preferred provider organization (PPO) but does not understand what this is. What is the nurse's best explanation of a PPO?
This health plan provides you with a preferred list of physicians, hospitals, and providers from which you can choose
What is the first column in focused charting?
Time and date
12. Resolution of an ethical dilemma involves discussion with the patient, the patient's family, and participants from all health care disciplines. Which of the following describes the role of the nurse in the resolution of ethical dilemmas?
To articulate his or her unique point of view, includ- ing knowledge based on clinical and psychosocial observations
What is quality improvement?
To improve quality of care (duh)
A 62-year-old female client being treated for hypertension did not take her daily BP medication over the weekend because she was out of medication and the pharmacy was closed. Her average home blood pressure monitoring (HBPM) reading has been 130/82. Today her BP has been 138/90, 135/85, and 142/86. She calls the on-call nurse for her health care provider. What is the most appropriate thing for this nurse to advise this client?
To take the recommended daily dose of medication and call the health care provider if the average of her HBPM readings increase/decrease by 10, or if she has any other concerns.
7-1. A nurse hears a colleague tell a nursing student that she never touches a patient unless she is performing a procedure or doing an assessment. The nurse tells the student that from a caring perspective:
Touch forms a connection between nurse and patient.
During measurement of a rectal temperature, the thermometer probe should be inserted about 1.5 inches (3.8 cm) in an adult and 0.5 inches (1.3 cm) in an infant.
True
True or False A baseline is important for evaluating a change in the client's physiological status. Such a change may be caused by disease state, the effect of therapies, or changes in physical activity or environment
True
True or False nurses spend up to 25% less time using EHRs?
True
True or false CBE assumes that all standards have been met and the client has responded normally, unless a separate entry is made (an exception).
True
True or false In POR, as the patients condition changes, the database is updated to reflect his current status
True
True or false In court the health record is legal evidence of the care given to a patient and is used to judge whether the interventions were timely and appropriate
True
true or false infants lose about 30% of their body heat through their head thus putting them at risk for decreased body temperature
True
true or false Body temperature is lower when progesterone levels are low and increases as progesterone levels increase.
True
endotracheostomy
Tube through windpipe. Facilitates breathing.
Kidney Diet
Unsalted vegetables, white rice, canned fruits, sweets Common medical problems: chronic renal failure Purpose: To keep protein, potassium, and sodium low Not allowed: beans, cereals, citrus fruits
The nurse is preparing to apply a prescription ointment to the client's wound. After reviewing the image, what is the most important step for the nurse to take?
Use a sterile cotton-tipped applicator to apply the prescription to the site
Neutropenic precautions
Used for clients at increased risk for infection ie immunosuppressed Absolute neutrophil count < 1000 mm3 No fresh fruit or flowers meticulous body hygiene no staff or visitors with cold or sore throat
What is the Braden Scale used for?
Used to predict risk of patient getting a pressure ulcer
PIE: problem
Uses data from your original assessment to identify appropriate diagnosis
5-14. A research study is investigating the following research ques- tion: What is the effect of the diagnosis of breast cancer on the roles of the family? In this study "the diagnosis of breast cancer" and "family roles" are examples of:
Variables
A nurse is providing care to a client who has Salmonella food poisoning. The nurse understands that this pathogen was transmitted by which mechanism?
Vehicle
herpes zoster/ shingles
Vesicular erruption along nerve distribution Pain, tenderness, and pruritus over affected region Primarily seen on face, thorax, trunk caused by reactivation of chickenpox virus/ varicella or decreased immunity Analgesics Compress Oatmeal bath Systemic corticosteroids to diminish severity
Cardiovascular post op care
Vital signs Q 15 min times 4; q 30 min times 2; q 1 h times 2; then as needed Monitor I and O Check K level Monitor CVP
The RN is working with hospital administrators to transform care at their facility. Which nursing competency will be critical for the nurse to utilize?
Work effectively in interdisciplinary teams
A 70-year-old client is taking his own pulse at home. He is following the instructions provided by the nurse. He counts his pulse 62 times in one minute. What should he do next?
Write it down
10. According to Piaget's cognitive theory, a 12yearold child is most likely to engage in which of the following activities?
Writing a story about a clown who wants to leave the circus
Documentation can be done in what two forms?
Written and electronic (or both)
What is narrative format?
Written in source oriented and problem oriented chars. It tells the story of the client's experience in the order it happen
Does charting by exception reduce the amount of time it takes to fill out documentation?
Yes it does
Can CBE lead to errors because nurses may conclude care has bee completed when in reality I was not done?
Yes. this system required you to be carefully assess and validate care provided
yin and yang
Yin: cool, moist, dark Yang: hot, dry, light
12. You are helping to design a new patient discharge teaching sheet that will go home with patients who are discharged to home from your unit. Which of the following do you need to remember when designing the teaching sheet?
You need to use words the patients can understand when writing the directions.
sitz bath
a bath used to apply heat to the pelvic area.
wound
a break or disruption in the normal integrity of the skin and tissues
sinus tract
a cavity or channel underneath the wound that has the potential for infection
the nurse understands which describes psoriasis
a chronic autoimmune reaction
What is the problem list?
a concise listing of problem IDENTIFIED from the database
narcolepsy
a condition characterized by an uncontrollable desire to sleep
hypersomnia
a condition characterized by excessive sleep particularly during the day
sleep apnea
a condition in which a person experiences the absence of breathing (apnea) or diminished breathing efforts (hypopnea) during sleep between snoring intervals
rest
a condition in which the body is in a decreased state of activity, with the consequent feeling of being refreshed
inflammation
a condition resulting from irritation in any body part, marked by pain, heat, redness, and swelling.
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
care transition
a continuous process in which a patients care shifts from being provided in one setting of care to another
strabismus
a deviation of the eye; squint. (Convergent strabismus is called cross-eye; divergent strabismus is called exotropia or walleye. Other types include cyclotropia ,esotropia, hypertropia, and hypotropia.)
incentive spirometer
a device used to force the client to concentrate on inspiration and promote full inflation of the lungs, while providing immediate feedback; used particularly after surgery and in lung disorders.
chronic disease
a disease of long duration that generally manifests itself in an individual as recurring problems that tend to worsen in severity over time.
secondary disease
a disease that directly results from or depends on another disease.
primary disease
a disease that occurs independently, not related to another disease.
risk factor
a factor that increases a person's likelihood of developing a certain disease.
What is hyperpyrexia?
a fever above 105.8°F
egg crate mattress
a foam pad, shaped like an egg carton, which is used on top of a regular bed mattress to provide comfort and to pre-vent pressure areas.
embolus
a foreign substance, blood clot, fat globule, piece of tissue, or air bubble carried in a blood vessel, which partially or completely obstructs blood flow (embolism; pl. emboli)
conduction block
a form of regional anesthesia, also known as conduction block.
bed cradle
a frame used to prevent bedclothes from touching all or part of a person's body.
interview
a goal-directed conversation in which one person seeks information from the other.
induration
a hardened place, a lump, as in the skin in a positive reaction to a tuberculin test.
A nurse records a pulse rate of 170 beats/min on a client's electronic health record. For which client would this be considered a normal assessment finding?
a healthy newborn infant
dialysis
a mechanical way of filtering waste from the blood
endorphins
a naturally occurring analgesic that the body produces in response to exercise and other stimuli
Harriet Tubman
a nurse and abolitionist; active in underground railroad movement before joining union army during civil war
bradykinin
a powerful vasodilator that increases capillary permeability and constricts smooth muscle
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
guided imagery
a process through which the client receives a suggestion that helps control his or her pain or disease. The person learns to visualize himself or herself as powerful and able to conquer pain or disease.
pivot joint
a ring-like structure that turns on a pivot; movement limited to rotation; vertebrae (atlas and axis)
process
a series of actions, changes, or functions intended to bring about a desired result
pustule
a small elevation of the skin filled with pus or lymph.
wheal
a smooth, slightly elevated skin area, usually pale in the center with are ddened periphery, often accompanied by severe itching when caused by an allergic reaction; small elevation caused by injection of an intra-dermal medication, such as the PPD test for tuberculosis or other skin test
community
a specific population or group of people living in the same geographic area under similar regulations and having common values, interests, and needs
hinge joint
a spool-like (rounded) surface of one bone fits into a concave surface of another bone; elbow, knee, ankle joint
law
a standard or rule of conduct established and enforced by the government that is intended chiefly to protect the rights of the public
health
a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity
sleep
a state of rest accompanied by altered consciousness and relative inactivity
specific gravity
a substance's weight, as compared with another. Fluids, such as urine, are compared to (pure water, which has a specific gravity of 1.000) and (Urine 1.010-1.025)
ethics
a systematic study of principles of right and wrong conduct, virtue and vice, and good and evil as they relate to conduct and human flourishing
Clients demonstrating apnea have what?
a temporary cessation of breathing
Hemoccult
a test for occult (hidden) blood in stool or body secretions
Hematest
a test for occult (hidden) blood in stool or body secretions.
Homans' sign
a test for thrombophlebitis in which pain occurs behind the knee when the foot is hyper flexed upward (dorsiflexion).
biofilm
a thick grouping of microorganisms
assault
a threat or attempt to make bodily contact w/ another person w/o that persons consent
Risk for Infection is an appropriate diagnosis if the patient has
a traumatic wound or is immunosuppressed, undernourished, or immobile.
endoscope
a tube-shaped, lighted device used to visualize or operate on hollow organs or within body cavities. Specialized endoscopes include the gastroscope, broncho-scope, and proctoscope. (Process of visualization using this tool is called endoscopy.)
phenazopyridine (pyridium)
a urinary tract analgesic, can cause orange or orange-red urine
Qi
a vital energy or life force that circulates in the body through a system of pathways called meridians
emaciation
a wasting away of the flesh, causing extreme leanness, starvation. (adj: emaciated).
wheeze
a whistling respiratory sound, typical of asthma.
tort
a wrong committed by a person against another person or that persons property; tried in civil court
macule
a flat discolored spot on the skin (also, macule); a dense scar of the cornea that can be seen without optical aids.
Kardex
a flip file with card slots or a notebook for each client on a unit or nursing care team; a system for recording background information and care related to a client's treatment.
ROMs
abduction, adduction, flexion, extension, inersion, eversion, pronation, supination,internal and external rotation, drosiflxion, plantar flexion
cognitive function
ability to think and reason.
diarrhea
abnormal frequency and fluidity of discharge from the bowels
herniation
abnormal protrusion of an organ or tissue through the structure usually containing it, as an inguinal hernia or hiatal hernia; rupture; condition is called herniation.
bradycardia
abnormally slow heart; slow pulse
pallor
absence of skin pigment; paleness.
paralysis
absence of strength secondary to nervous impairment
concept
abstract impressions organized into symbols of reality- conceptual framework or model
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
how are progress notes organized?
according to the problem list labeled according to problem number
fecal impaction
accumulation of hardened stool in the rectum.
Tylenol
acetaminophen
integrity
acting according to code of ethics and standards of practice