EXAM 1 - NUR1400
What is orthostatic hypotension?
- A drop in blood pressure due to a sudden change of posture (standing) - decreases by 20/10 within 3 minutes - acute or chronic
Nonopioids
- Acetaminophen - Ibuprofen (NSAIDs)
What is hypertension?
- BP GREATER THAN 130/80 - a MAJOR risk for heart disease and stroke - can result in premanent thickening of the blood vessles and myocardium - risk factors: high cholesterol, excessive alcohol, salt, fat, caloric intake
What is hypotension?
- BP LESS THAN 90/60 - results from too much BP meds, diuretics, or dehydration - S/S = dizziness, tachycardia, sweating, nausea, confusion
What could Behavioral/Physiological responses to pain look like?
- Behavioral: moving away from stimuli, crying, restlessness, social isolation, anxiety - Physiological: increased HR and BP, muscle tension, immune system dysfunction, fatigue
Opiods (narcotics)
- Hydromorphone, Oxycodone - Naloxone (Narcan)
what is the upper and lower respiratory tracks composed of?
- Upper: nose, pharynx, layrnx, epiglottis - Lower: trachea, R&L bronchi (main stem, segmental, and terminal)
what are is ventilation, diffusion, and perfusion in the respiratory system?
- Ventilation: inspiration & exhalation - Diffusion: exchange of O2 and CO2 between the alveoli of the lungs and the circulating blood - Perfusion: exchange of O2 and CO2 between the circulating blood and tissue cells
What is atelectasis?
- a collapsed lung or incomplete lung expansion
what is hypothermia?
- abnormally low body temperature - can occur from alcoholism, hypothyroidism, unprotected exposure to cold environments - causes poor coordination, slurred speech, BP drop
Adjuvants
- antidepressants and anticonvulsants - corticosteriods
What is hyperthermia?
- elevated body temperature - due to upward displacement of thermoregulatory set point (from bacteria, viruses, ect) - causes muscles aches, fatigue, increased HR + respiratory rate
What is a POX and when should the nurse use it?
- measures the oxyhemoglobin saturation (SpO2) of artirial blood - used when monitoring pt receiving O2 therapy, at risk for hypoxia, and post-op patients
where is the regulation of the repiratory system?
- medulla: in the brain stem just above the spinal cord - stimulated by chemoreceptors in the aortic arch and carotid bodies
what is a normal respiration rate / respiratory complications? Apnea, Orthopnea, Trachypnea, Bradypnea
- normal rate = 12-20 - an increase of CO2 is the most powerful respiratory stimulant - Apnea: sleep disorder where breathing starts/stops - orthopnea: SOB when lying down - Trachypnea: in response to increased metabolic rate - Bradypnea: can occur from opioid overdose
What is a normal body temperature and how is it regulated?
- normal temp = 96.7-100.5 - the Hypothalamus contains the thermoregulatory center
How is blood pressure measured?
- normal value 120/80 - systolic is the highest pressure during ventricular contraction - diastolic is the lowest pressure in the ventricles in-between beats
what are the 5 bundle practices?
-EBP that have proven positive outcomes when implemented together to prevent infection -hand hygiene -maximun barrier precautions -Chlorhexidine and optimal catheter site selection -daily removal of unnecessary line
Qualitative Reasearch
-Non-Numerical data; -Descriptive -seeing reality not as a fixed entity but as existing in a context -
When should surgical asepsis be used?
-When skin integrity is broken (open wound) -During procedures that involve insertion of catheters or surgical instruments into sterile body cavities
how can a patients self esteem needs become endangered?
-a need to feel good about oneself -illness or death of a spouse, loss of breast, injury, growth spurt
what is 3rd level isolation?
-airborne precautions -gown, gloves, N95 mask -negative pressure room -TB, Chicken Pox, Measles
what is the difference between an antibody and an antigen?
-antibody: immunoglobulin produced by the body in response to an antigen -antigen: foreign material capable of producing an immune response
what is health equity?
-attainment of the highest level of health for all people
when should the nurse perform hand hygiene?
-before touching a patient -before a clean or aseptic procedure -after exposure to bodily fluids -immediately after touching a pt or their surroundings -after removing gloves
what is most responsible fot HAI's
-catheter-associated urinary tract infections (CAUTI) -surgical site infection (SSI) -Central line-associated bloodstream infections (CLABSI) -Ventilator-associated pneumonia (VAP)
what is 1st level isolation?
-contact precautions -no sharing equipment, private room -gowns + gloves -MRSA, CDIFF
What is qualitative data?
-descriptive data that can be observed but not measured -composed of subjective data -emotions, feelings, thoughts, pain
what are the three ways a disease can be transmitted?
-direct contact: through kissing, hugging, sexual intercourse -droplet transmission: cough or sneeze directly on you -airborne transmission: spreads the easiest, organism can attach to dust particles
what is 2nd level isolation?
-droplet precautions -5mm or larger -gowns, gloves, surgical mask -Rubella, mumps, adenovirus (flu)
how do research teams protect human rights?
-having an IRB (institutional review board) -informed consent
what are the types of nursing assessments?
-health history -physical assessment -comprehensive assessment -ongoing partial assessment -focused assessment -emergency assessment
what is the general systems theory
-how parts work together in a system -the whole system is always greater than its parts -i.e. molecules, organs, health
What makes a problem statement in a study?
-identifies the direction that the research project will take -clear & unambiguous -express a relationship between two or more variables -identify the population to be studied -encourage empiric testing
what are examples of primary health promotion
-immunizations, clinics, accident prevention, diet and exercise
What is heart failure characterized by?
-inability to fill with or eject blood efficiently -causes reduced CO -causes increased fluid buildup in the heart + lungs
what are the characteristics of a chronic illness?
-irreversible illness that causes permanent physical impairement -requires long-term care -remission: disease is present but not experiencing symptoms -exacerbation: the symptoms reappear
what is scientific knowledge?
-knowledge based on the scientific method using objective data -is the most reliable
what is Myocardial Ischemia?
-necrosis (death) of myocardial muscle due to lack of oxygen -from reduced or blocked flow through coronary arteries
a nursing instructor is preparing a class to discuss the different types of white blood cells. what would the instructor most likely include as granulocytes?
-neutrophils -esinophils -basophils
What is qunatitative data?
-numerical data, anything that can be counted or measured -composed of objective data
what are examples of tertiary health promotion?
-rehabilitation, PT & OT, diabetes self-monitoring, support groups
what are examples of secondary health promotion?
-screenings for early detection
what are characteristics of an acute illness?
-sudden onset of symptoms -short lived -requires immediate care
what are the characteristics of the nursing process?
-systematic (ordered manner) -dynamic (overlapping of steps, simultaneously) -interpersonal (always patient centered) -outcome oriented (health promotion and illness prevention) -universally applicable in nursing situations
What is Erikson's theory?
-the process of socialization, emphasizing how individuals learn to interact with the world. -the biologic, environmental factors in development
What is Dorothea Orem's theory and what is an example of how a nurse can help meet the needs of a client using that guideline?
-the role of the nurse is to facilitate self-care to sustain life and health, to recover from disease or injury, or to cope with its effects -an example would be arranging an evaluation appointment with a dietitian for a client.
what is the science and art of nursing
-the science of nursing is the knowledge base for the care that is given (A&P, Chem, Mircro, Psych) -the art of nursing is the skilled application of that knowledge to help others achieve maximum health and quality of life (caring, ADPIE)
what is the assessment phase of the nursing process
-the systematic and continuous collection, analysis, validation, and communication of patient data, or info -uses nursing history, patient record, and physical examinations -focuses on patients response to actual or potential health problems -diagnosis was originally considered the logical conclusion of the assessment phase
what is true regarding nursing theory?
-the ultimate outcome is improved client care -it provides rationale for the care that nurses provide -may be descriptive or prescriptive -provides a focus for care that is delivered to clients
how can the nurse best provide love and belonging needs to their patient
-understanding and accepting others and both giving and receiving love -involving family, establishing a nurse-to-patient relationship, support groups
what is the health belief model
-what people perceive or believe to be true about themselves in relation to their health -weighs pros and cons
when should transmission based precautions be used?
-when a patient is suspected of having a disease -in addition to standard precautions
What is a dysrhythmia (arrhythmia)?
-when the electrical signals do not flow as they should , the heart beat becomes too slow/fast/irregular
what is referred pain, transient pain, superficial pain, and phantom pain?
1) Referred pain is perceived in an area distant from its point of origin, whereas 2) transient pain is brief and passes quickly. 3) Superficial pain originates in the skin or subcutaneous tissue. 4) Phantom pain may occur in a person who has had a body part amputated, either surgically or traumatically.
How do you write measurable outcomes when planning in the nursing process?
1) Subject 2) Verb: define, idntify, describe, demonstrate 3) performance criteria 4) target time
what is the pathway of deoxygenated blood?
1) superior/inferior vena cava 2) right atrium 3) right ventricle 4) pulmonary artery 5) lungs; here oxygen is picked up and carbon dioxide is released
what is visceral pain, cutaneous pain, and deep somatic pain
1) visceral pain, which is poorly localized and can originate in body organs in the abdomen. 2) Cutaneous pain (superficial pain) usually involves the skin or subcutaneous tissue. A paper cut that produces sharp pain with a burning sensation is an example of cutaneous pain. 3) Deep somatic pain is diffused or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves. Strong pressure on a bone or damage to tissue that occurs with a sprain causes deep somatic pain.
what are the stages of becoming ill?
1. experiencing symptoms 2. assuming the sick role 3. assuming the dependent role 4. recovery and rehab
what are the infection cycles?
1. infection agent 2. reservoir 3. portal of exit 4.means of transmission 5. portals of entry 6. susceptible host
what are the 4 key principles of quality improvement
1. systems and processes 2. being part of a team 3. use of data 4. clients
a nurse in an oncology unit is reviewing laboratory test results of several patients, the nurse identifies that the client with which leukocyte count most likely has an infection?
18,000 cells/mm
what is a healthy WBC count?
5,000-10,000 higher if pt is fighting an infection and lower if their immune system is surpressed
what is a normal pulse rate
60-100bpm -should be brisk and regular -rate, Amplitude, Rhythm
how is oxygen carried in the blood?
97% of oxygen is carried as part of hemoglobin on RBC's
What is hemoglobin?
A redish colored protein in RBC's that carries oxygen. men: 14-17.4 women: 12-16
epidural analgesia
A regional pain-relieving drug is delivered continuously through a catheter into a small space in the lower spine; - morphine, hydromorphone, or fentanyl or local anesthetic - monitoring VS and labs closely
how does the nurse prioritize her patients needs?
ABC's 1. Airway (ineffective airway clearance) 2. Breathing (impaired gas exchange, altered breathing pattern) 3. Circulation (decreased cardiac output, Hypotension)
When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action will the nurse implement first? A. Establish a new nursing diagnosis. B. Note which actions were not implemented. C. Add additional nursing orders to the plan. D. Collaborate with the healthcare provider to make changes.
B) note which actions were not implemented
What are dependent and independent variables?
Independent variable: the variable that is varied or manipulated by the researcher. (to give or to not give BP meds) Dependent variable: the response that is measured. (blood pressure)
what is Angina
Insufficient oxygen to the heart muscle causing sudden, severe substernal pain radiating to the left arm
What does PICOT stand for and what is it used for?
Population of interest Intervention of interest Comparison of interest Outcome of interest Time
what are nursing standards?
THE LEVEL OF PERFORMANCE ACCEPTED by and expected of nursing staff or other health team members
a client has a nursing diagnosis of deficent knowledge related to prescribed antibiotic therapy. which outcome would the nurse identify as most appropriate?
The client will state how to safely take the prescribed antibiotic
What are Nurse Practice Acts?
They are laws established in each state to regulate the practice of nursing.
colonization
a disease is present but no symptoms
what is an example of effective coping for a family?
a ritual of wearing dark clothing and closing the windows for 7 days after a family member's passing.
what is QSEN?
a way to care for patients by prioritizing safety, patient-centered care, informatics, teamwork and collaboration, EBP and quality improvement
which of the following is a medical diagnosis a) Pneumonia b) risk for bleeding c) acute pain d) impaired gas exchange
a) Pneumonia
What is a virulence factor?
ability to cause disease -adhesion, invasion, competition for nutrients, resistance to host immunity, secretion of toxins
parts of a research study
abstract, introduction, method, results, conclusion/discussion
What is the adaptation theory?
adjustment of living matter to other living things and environment
a client is administered to the hospital with TB. What precautions should the nurse take?
airborne transmission -gown, gloves, N95 mask -5mm or smaller -negative pressure room -TB, Measles, Chicken Pox
what qualifies something as a profession?
an occupation that meets specific criteria including a well-defined body of specific and unique knowledge, a code of ethics + standards, ongoing research and autonomy
What does low hemoglobin indicate?
anemia, over-hydration, recent hemorrhage
When should standard precautions be used?
at all times and for all patients regardless of their diagnosis
when should medical asepsis be used?
at all times, when performing a clean procedure
what does patient centered care mean?
based in holistic roots in which the nurse in every clinical encounter assesses how the person is doing and communicates respect, compassion and care
what is discharge planning?
begins at the time of admission with the nurse teaching the client and family the specific skills necessary for self-care behaviors at home
what happens during the incubation period of an illness?
between the invasion of the body and the appearance of symptoms. the organism is growing and multiplying
what is the difference between community-health nursing and community-based nursing
community health nursing involves care for the entire populations whereas community based nursing focuses on individuals and families in that population.
What did Erik Erikson do?
created an 8-stage theory of Psychosocial development
What is hypoxia?
deficiency in the amount of oxygen reaching the tissues - often caused by hypoventilation - Deoxygenation is a LATE SIGN of a respiratory complication
what is pulse pressure
difference between systolic and diastolic pressure (40)
what is the difference between disease and illness
disease is physiologic changes in a persons body while illness is the response of a person to a disease
the two main form of communication in nursing are reporting and a) bossing b) apologizing c) documenting d) complaining
documenting
when is an infection most infectious yet patient displays only vague S/S?
during the prodromal stage
a nurse is assessing a family and identifying where the familty is in the family life cycle. during the assessment, the nurse applies duvall's theory. which theory forms the basis for duvalls theory?
ericksons theory of psychosocial development
the amount of something that is more than necessary, permitted or desirable
excess
where does authoritative knowledge come from?
from an expert in the field and is accepted as truth based on the persons perceived expertise
a nurse is caring for a patient dianosed with influenza and otis media. which effective action by the nurse can teach the clients family to prevent the spread of the infection?
hand hygiene
How can the nurse best assess a patients safety and security needs?
hand washing, using equipment properly, administering medications, ambulating patients
what kind of assessment is completed by the student nurse during clinicals?
head to toe assessment during shift change
what is health disparity?
health difference that is closely linked with social, economic, and/or environmental disadvantage
what is the difference between health and wellness?
health is the state of optimal functioning or wellbeing, while wellness is the active state of progressing towards maximum possible potential regardless of health
when providing care to a client, the nurse integrates knowledge that a clients beliefs and action are related and influenced by the clients personal expectations in relation to health and illness. the nurse is demonstrating and understanding of which health model?
health-belief model
a 47-year old women is traveling overseas with her husband. He has a sore throat and has been diagnosed with Strep. The women is considered the:
host -a person who may be at risk for, or is susceptible to illness
in the evaluation phase we assess:
how the patient responded to interventions
weakened or damaged (a function or capability)
impaired
with verbal communication, the nurse most uses which method? a) judgement b) informing c) silence d) reflecting
informing
physical exam techniques
inspection: what you can observe (color, size, location, odor, sounds) palpation: pressing onto body surface to feel organs or tissues auscultation: listening to bowl, heart, lungs, or diaphragm
what are signs that a person's self-actualization needs are being met?
interest in others, respect for all people, able to descern between bad and good, creative problem solving
in which phase of the interview do you introduce yourself, explain your purpose, and build rapport with the patient?
introductory
what is the purpose of ongoing planning?
it is conducted by any nurse caring for the client and is meant to keep the plan up to date
what is nursing criteria
measurable qualities or characteristics that identify skill or knowledge of health status.
what is a complete blood count?
measures the amount, size, and shape of WBC, RBC, platelets, and hemoglobin/hematocrit levels
what is a healthy RBC count?
men: 4.5-5.5 million women: 4.0-5.0 million
What is morbidity and mortality?
morbidity: the rate at which a disease occurs mortality: the number of deaths caused by a certain disease
a nurse is caring for a patient who became very ill after ingesting seafood. How will the nurse document this condition?
noncommunicable disease. -caused by food or environmental toxin
my facial expressions and attitude send what kind of message to those around me? verbal or nonverbal
nonverbal
what theory describes, explains, predicts, and controls outcomes in nursing practice?
nursing theory
what is objective data?
observable and measurable -vital signs -head to toe assessment data -blood work and imaging
what is comprehensive planning?
occurs from the time of admission to the time of discharge and includes initial, ongoing, and discharge planning
what is subjective data?
only perceived by affected person, going by what the patient says -S/S -feelings, emotions -personal information -pain
what is an example of a physiologic need?
oxygen, water, food, elimination, physical activity, rest, sexuality
where does traditional knowledge come from?
passed down from generations
PCA
patient-controlled anesthesia - fentanyl, hydromorphone IV or epidural - reversal agents need to be readily available
What does hematocrit measure?
percentage of red blood cells in a blood sample men: 42%-52% women:36%-48%
a nurse is recovering from a mild upper respiratory infection with no fever. The nurse is assigned to care for four clients. What is the appropriate nursing action to prevent the clients from getting the infection?
perform meticulous hand hygiene and don a new mask with each client encounter. -people with respiratory infections need to wear a mask until their symptoms have subsided.
The focus of nursing is always on which of the four common concepts in nursing theory?
person
what are the five major areas of the family function
physical, economic, reproductive, affective coping and socialization
What are Maslow's hierarchy of needs?
physiologic, safety/security, love & belonging, self-esteem, and self-actualization
what does a HIGH hemoglobin indicate?
polycythemia, dehydration, COPD
what are the phases of an interview?
pre-introductory: looking up data before going into room introductory: setting up trust working: assessment, asking questions -summary/closing
a nurse is educating clients on the need for calcium intake to prevent bone loss. What level of prevention does this represent?
primary prevention
what are the parts of a nursing dianosis?
problem (assess your patient) etiology (R/T): factors believed to cause the problem Defining characteristics (AEB): subjective and objective data that signal the existence of a health problem; pain, clutching wrist diagnosis: acute pain R/T wrist fracture AEB patient grimacing and crying, holding wrist, states pain is 10/10
what is bradycardia?
pulse rate BELOW 60 -results in decreased tissue perfusion -can occur from hypothermia, sleep, MI
what is tachycardia?
pulse rate OVER 100 -decreases cardiac filling time which decreases SV & CO -can use an inhaled albuterol sulfate
what is the process called for allowing a nurse to practice in another state?
reciprocity
What is the convalescent period?
recovery from the infection
what is the goal of PET (practice question, evidence, translation)
recruiting an interprofessional team, developing and refining EBP, conducting internal and external searches for evidence
what are the signs of an imflammatory response?
redness, pain, heat, swelling, loss of function
which of the following is a nursing diagnosis a) pneumonia b) risk for infection c) CHF d) heart disease
risk for infection
what is the format for a "Risk For" and a nursing diagnosis?
risk for only has R/T diagnosis has R/T and AEB
which function of the family does dietary considerations, worship practices, attitudes and values represent?
socialization
a nurse is planning to insert an indwelling catheter into a client should utilize which technique?
surgical asepsis
Which model is most useful in examining the cause of disease in an individual, based upon external factors?
the agent-host-environment model
what is cardiac output?
the amount of blood pumped per minute - a healthy reading is 3.5-8/L per minute
what is the etiology?
the cause of the client health problem.
what is a nursing diagnosis?
the diagnosis and treatment of unhealthy responses to actual or potential health problems
a client with Crohn's disease in remission is admitted to the nursing unit for follow-up care. the remission state is characterized by
the disappearance of signs and symptoms associated with the disease.
what happens during the implementation phase of the nursing process?
the evidence based nursing actions planned in the assessment & diagnostic steps are carried out
increased emphasis on nursing knowledge as the foundation for EBP has lead to
the growth of nursing as a professional discipline
what is an inference
the judgement you reach about the cue
a nurse is educating about sterile field, which action by a new nurse would indicate further teaching is required?
the new nurse touches 1.5 in. (4cm) from the outer edges
what forms the foundation of the nurses decision making?
the nursing process
what is the primary source of patient data?
the patient
what does the nursing concepts focus around
the patient as the central theme
which is an example of patient objective data?
the patient says they are
which of the following patient situations is an example of subjective data
the patient says they are cold
what are the nursing competencies
the promote health, to prevent illness, to restore health, to facilitate coping with disability or death
what does stroke volume measure?
the quantity of blood forced out of the left ventricle with each contraction -healthy volume = 60-120mL per beat
when evaluating a clients outcome acheivements, what three options does the nurse have
the terminate, modify, or continue
if an organism enters the body through the blood, how will it exit the body?
though the blood
why was the nursing theory developed?
to describe nursing -for improved patient care, rational nursing interventions, organization, to identify and define interrelated concepts and in simple and concise terminology
what are protocols and standing orders meant to do?
to expand the scope of nursing practice in certain, clearly defined situations. i.e. standing orders for narcotics, overdose, rapid response
a complete nursing diagnosis consists of the problem, the etology, and the defining characteristics
true
assessment is the continuous collection, analysis and documentation of patient data. true or false
true
defining characteristics are the subjective and/or objective data that signal the existance of that problem
true
etiology is the suspected cause of the nursing diagnosis
true
the patients family can help me collect data during the assessment phase. true or false
true
when do you have to validate data?
when there is a discrepancy between what the patient says and what you observe, or when the data lacks objectivity
