Fundamentals Exam 2 Study Guide
What is a sign of inadequate oxygenation in older adults?
1. Restlessness. 2.Confusion
40. Which of the following needs to be corrected in the room for the patient with a visual impairment? 1. The call light is left on the bedside stand. 2. The patient's tissues are on the patient's lap. 3. The path to the bathroom is cleared of equipment. 4. The patient's slippers are on the floor where the patient left them when returning to bed.
1. The call light is left on the bedside stand.
A patient is newly admitted to the hospital and appears to be disoriented. There is a concern for the patient's immediate safety. The nurse is considering the use of restraints to prevent an injury. The nurse recognizes that the use of restraints in a hospital requires: 1. a physician's order. 2. the patient's consent. 3. a family member's consent. 4. agreement among the nursing staff.
1. a physician's order.
What age range is considered adolescence?
12-18
What is a normal respiratory rate?
12-20 breaths/minute, 15-30 children, 25-50 infant
A patient has experienced some respiratory difficulty and is placed on oxygen via nasal cannula. A nurse assists the patient with this form of oxygen delivery by: 1. changing the tubing every 4 hours. 2. assessing the nares for breakdown. 3. inspecting the back of the mouth q8h. 4. securing the cannula to the nose with nonallergic tape.
2. assessing the nares for breakdown.
To prevent plantar flexion, a nurse will obtain: 1. trochanter rolls. 2. foot boots. 3. sandbags. 4. hand splints.
2. foot boots.
While walking through a hallway in the extended care facility, a nurse notices smoke coming from a wastebasket in a patient's room. Upon closer investigation, the nurse identifies that there is a fire that is starting to flare up. The nurse should first: 1. extinguish the fire. 2. remove the patient from the room. 3. contain the fire by closing the door to the room. 4. turn off all of the surrounding electrical equipment.
2. remove the patient from the room.
A patient is being seen in an outpatient medical clinic. A nurse has reviewed the patient's chart and finds that there is a history of a cardiopulmonary abnormality. This is supported by the nurse's assessment of the patient having: 1. scleral jaundice. 2. reddened conjunctivae. 3. symmetrical chest movement. 4. clubbing of the fingertips.
4. clubbing of the fingertips.
How many times do you do every exercise?
5
A patient has just returned to the unit after abdominal surgery. A nurse is planning care for this patient and is considering interventions to specifically pro-mote pulmonary function and prevent complications. The nurse first: 1. teaches the patient leg exercises to perform. 2. asks the physician to order nebulizer treatments. 3. demonstrates the use of a flow-oriented incentive spirometer. 4. informs the patient that his secretions will need to be suctioned.
3. demonstrates the use of a flow-oriented incentive spirometer.
30. An expected physical change for an older adult is: 1. warmer extremities. 2. increased perspiration. 3. reduced adaptation to darkness. 4. generalized erythema.
3. reduced adaptation to darkness.
A Yankauer suction catheter is used for _____________ _____________________ suction.
A Yankauer suction catheter is used for oropharyngeal suctioning.
Thalassemia
A group of diseases involving inadequate production of normal hemoglobin, and therefore decreased erythrocyte production and is due to an absent or reduced globulin protein
Sickle Cell Disease
A group of inherited, autosomal recessive disorders characterized by an abnormal form of hemoglobin in the RBC
Asthma
A heterogenous disease characterized by a combination of clinical manifestations along with reversible expiratory airflow limitation or bronchial hyperresponsiveness
Collapse of alveoli
Atelectasis
For postural drainage for the lower lobes, the patient is best placed in which position? 1. Trendelenburg 2. Prone, horizontal 3. High Fowler's 4. Three-fourths supine
1. Trendelenburg
What is the rate for artificial ventilations with a BVM?
10-12 breaths per minute; one every 5-6 minutes
Which structures protect a client's internal organs, support blood production, and store minerals? 1. Joints 2. Bones 3. Muscles 4. Cartilage
2. Bones
34. Which of the following is a potentially reversible cognitive impairment? 1. Dementia 2. Depression 3. Disengagement 4. Ischemic vascular dementia
2. Depression
A patient who has deep vein thrombosis is at risk for: 1. atelectasis. 2. pulmonary emboli. 3. orthostatic hypotension. 4. hypostatic pneumonia.
2. pulmonary emboli.
For patients at risk of or having cardiopulmonary issues, the target blood pressure for people below 60 years of age is less than: 1. 110/70 2. 120/80 3. 140/90 4. 150/80
3. 140/90
24. Provide an example of a patient who may experience sensory deprivation.
Patients who are more prone to sensory deprivation are those in medical isolation/private rooms, alone in the home, immobilized in hospitals or other facilities, separated from family and friends, and experiencing disabilities that restrict mobility and/or sensory function.
1. Development of cognition
Piaget
Culturally specific timetable for life events to occur
Social Clock
How do newborns respond to discomforts?
by crying
Being able to carry out nursing skills is only part of a nurses role, they must also understand
The rationale/Reason why
Bacteria that are spread through inadequate preparation or storage of food are: 1. Streptococcus 2. Candida 3. Listeria 4. Hepatitis B
3. Listeria
A patient has weakness to the upper and lower extremities and has been on bed rest for several days. Which of the following actions performed by the new staff nurse requires correction? 1. Performing passive range of motion exercises 2. Having the patient do as much of the bath as possible 3. Massaging the lower extremities 4. Assisting the patient to different positions every 11⁄2 hours
3. Massaging the lower extremities
Which is the purpose of encouraging active leg and foot exercises for a client who has had hip surgery? 1. Maintain muscle strength 2. Reduce leg discomfort 3. Prevent clot formation 4. Improve wound healing
3. Prevent clot formation
A nurse is making a home visit to a patient who has emphysema (chronic obstructive pulmonary disease [COPD]). Specific instruction to control exhalation pressure for this patient with an increased residual volume of air should include: 1. coughing. 2. deep breathing. 3. pursed-lip breathing. 4. diaphragmatic breathing.
3. pursed-lip breathing.
The equipment that is used on a bed to assist a patient to raise the torso is a: 1. sandbag. 2. bed board. 3. trapeze bar. 4. wedge pillow.
3. trapeze bar.
What angle is low fowlers position?
30 degrees
The nurse documents the patient's periods of increasing depths of breathing, followed by period of apnea, as: 1. eupnea. 2. bradypnea. 3. ataxic. 4. Cheyne-Stokes.
4. Cheyne-Stokes.
If all of the following are prescribed, the best nursing strategy for the prevention of renal calculi is: 1. administration of diuretics. 2. provision of a high-fiber diet. 3. insertion of a urinary catheter. 4. offering of 2 liters of fluid per day.
4. offering of 2 liters of fluid per day.
A nurse recognizes that the position that is contraindicated for a patient who is at risk for aspiration is: 1. Fowler's. 2. lateral. 3. Sims. 4. supine.
4. supine.
A patient had total hip replacement surgery and requires careful postoperative positioning to maintain the legs in abduction. The nurse will obtain a: 1. foot boot. 2. trapeze bar. 3. bed board. 4. wedge pillow.
4. wedge pillow.
How many taste buds does the average adult have?
9,000
Smell accounts for ______% of taste.
90%
What is the normal SpO2 range?
95%-100%
What produces small water droplets to help prevent drying of the mucous membranes?
A humidifier
Patients who are immobilized in health care facilities require that their psychosocial needs be met along with their physiological needs. A nurse recognizes a patient's psychosocial needs when telling the patient the following: 1. "The staff will limit your visitors so that you will not be bothered." 2. "We will help you get dressed so you can look more presentable." 3. "We can discuss the routine to see if there are any changes that you may want to make." 4. "A roommate can sometimes be a real bother and very distracting. We can move you to a private room."
3. "We can discuss the routine to see if there are any changes that you may want to make."
Aspirin is prescribed on a regular schedule for a client with rheumatoid arthritis. The nurse understands that the medication is being used primarily for which purpose? 1. Analgesic 2. Antipyretic 3. Anti-inflammatory 4. Antiplatelet
3. Anti-inflammatory
Pigeon toes
Internal rotation of forefoot or entire foot; common in infants
During an assessment, a nurse determines that a patient with a high risk for injury is an individual experiencing:
Patients with high risk for injury experience: -impaired mobility -diminished sensation and/or cognition -decreased safety awareness
What is the supine position? Where are the pillows?
The bed is flat and the person is flat in bed facing up. Their head is supported by a pillow.
Signs and symptoms of cardiac pain in women include:
The following signs and symptoms are indicative of cardiac pain in women: epigastric pain, complaints of indigestion, nausea or vomiting, or a choking feeling and dyspnea.
Systemic vascular resistance (SVR)
The force opposing the movement of blood within the blood vessels
What 4 things do you need to make sure you do when transferring someone from a bed to a wheelchair?
The gait belt is on. Their shoes are on. The wheelchair is as close as possible. Wheels are locked.
What structure is the narrowest part of the airway?
The glottis
The nurse is assessing a patient with rib fractures and a chest tube on the right side of the chest. The patient verbalizes stabbing chest pain and extreme shortness of breath and exhibits a profound decrease in the pulse oximeter reading. The nurse auscultates the lungs and finds absent breath sounds on the right side of the chest. What should the nurse prepare to do? 1. Assist the health care provider in removing the chest tube 2. Assist the health care team in performing cardiopulmonary resuscitation (CPR) 3. Assist the health care provider in inserting another chest tube 4. Assist the health care team in inserting an artificial airway
3. Assist the health care provider in inserting another chest tube
Which joint helps in the gliding movement of the wrist? 1. Pivot joint 2. Hinge joint 3. Biaxial joint 4. Ball-and-socket joint
3. Biaxial joint
A patient has a chest tube in place to drain bloody secretions from the chest cavity. When caring for a patient with a chest tube, a nurse should: 1. keep the drainage device above chest level. 2. clamp the chest tube when the patient is ambulating. 3. apply an occlusive dressing if the tubing becomes dislodged. 4. leave trapped fluid in the tubing and estimate the amount.
3. apply an occlusive dressing if the tubing becomes dislodged.
32. A patient has gone to an outpatient obstetric clinic for a routine checkup. The patient asks a nurse what is happening with the baby now that she is in her second trimester. The nurse informs the patient that the: 1. skin thickens and lanugo disappears. 2. body becomes rounder and fuller. 3. brain is undergoing a tremendous growth spurt. 4. organ systems continue basic development and move toward refinement of function.
3. brain is undergoing a tremendous growth spurt.
A restraint that may be used to prevent an adult patient from pulling on and removing tubes or an IV is a(n): 1. vest restraint. 2. jacket restraint. 3. extremity restraint. 4. mummy restraint.
3. extremity restraint.
A nurse is completing admission histories for newly admitted patients to the unit. The nurse is aware that the patient with the greatest risk of injury: 1. is 84 years of age. 2. uses corrective lenses. 3. has a history of falls. 4. has arthritis in the lower extremities.
3. has a history of falls.
30. Parents arrive at the pediatric clinic with their 1 1⁄2-year-old child. The parents ask the nurse if there are signs that may indicate that the child is not able to hear well. The nurse explains to the parents that they should be alert to the child: 1. awakening to loud noises. 2. responding reflexively to sounds. 3. having delayed speech development. 4. remaining calm when unfamiliar people approach.
3. having delayed speech development.
33. The nurse recognizes that there are changes that occur for the patient who has Alzheimer's disease. One of these is agnosia, which the nurse knows is the: 1. loss of language skills. 2. progressive loss of memory. 3. loss of ability to recognize objects. 4. loss of the ability to perform familiar tasks.
3. loss of ability to recognize objects.
A possible complication for a patient who has been prescribed prolonged bed rest is thrombus formation. For the nurse to assess the presence of this serious problem, the nurse should: 1. attempt to elicit Chvostek sign. 2. palpate the temperature of the feet. 3. measure the patient's calf and thigh diameters. 4. observe for hair loss and skin turgor in the lower legs.
3. measure the patient's calf and thigh diameters.
The patient is admitted with a diagnosis of COPD. The appropriate oxygen delivery method for this patient is a: 1. simple face mask with 5-8 L/min (50%) O2. 2. Venturi mask with 8 L/min (35%-40%) O2. 3. nasal cannula with 1-2 L/min (28%) O2. 4. partial nonrebreather mask with 6-10 L/min (80%) O2.
3. nasal cannula with 1-2 L/min (28%) O2.
38. The school nurse recognizes that the most common type of visual disorder in children is: 1. glaucoma. 2. retinal detachment. 3. nearsightedness. 4. macular degeneration.
3. nearsightedness.
In discriminating types of chest pain that a patient may experience, a nurse recognizes that pain associated with inflammation of the pericardial sac is noted by the patient experiencing: 1. knife-like pain to the upper chest. 2. constant, substernal pain. 3. pain with inspiration. 4. pain aggravated by coughing.
3. pain with inspiration.
35. A patient has been diagnosed with glaucoma. The nurse anticipates that the patient will report a history of: 1. severe redness and itching of the eyes. 2. cloudy and blurred vision. 3. painless loss of peripheral vision. 4. dark spaces blocking forward vision and distortion of lines
3. painless loss of peripheral vision.
A patient is admitted to a medical center with a diagnosis of left ventricular congestive heart failure. A nurse is completing the physical assessment and is anticipating finding that the patient has: 1. liver enlargement. 2. peripheral edema. 3. pulmonary congestion. 4. jugular neck vein distention.
3. pulmonary congestion.
28. A nurse is seeking to evaluate the effectiveness of information provided to the parents of an infant. The nurse determines that teaching has been successful when the parents: 1. place small pillows in the infant's crib. 2. position the infant on the stomach for sleeping. 3. purchase a crib with slats that are less than 2 inches apart. 4. prop up a bottle for the infant to suck on while falling asleep.
3. purchase a crib with slats that are less than 2 inches apart.
An older adult patient in the extended care facility has been wandering outside of the room during the late evening hours. The patient has a history of falls. The nurse intervenes initially by: 1. placing an abdominal restraint on the patient during the night. 2. keeping both the light and the television on in the patient's room all night. 3. reassigning the patient to a room close to the nursing station. 4. having the family members check on the patient during the night.
3. reassigning the patient to a room close to the nursing station.
How many stages are in Piaget's stages of Cognitive development?
4
How many exercises are there on the shoulder?
4 Felxion and extension Abduction and adduction Horizontal abduction and adduction Rotation
Oxygen is Humidified at how many liters per minute?
4 Liters per minute
The nurse is performing discharge teaching for a patient with chronic obstructive pulmonary disease (COPD). What statement, made by the patient, indicates the need for more teaching? 1. "Pursed-lip breathing is like exercise for my lungs and will help me strengthen my breathing muscles." 2. "Huff coughing will help me get the mucus up out of my lungs." 3. "I should make sure that I get the influenza vaccine every year." 4. "I should limit my fluid intake to 1 liter per day because I don't want to produce excess sputum."
4. "I should limit my fluid intake to 1 liter per day because I don't want to produce excess sputum."
A parent with three children has gone to the outpatient clinic. The children range in age from 2 1⁄2 to 15 years old. A nurse is discussing safety issues with the parent. The nurse evaluates that further teaching is required if the parent states: 1. "I have spoken to my teenager about safe sex practices." 2. "I make sure that my child wears a helmet when he rides his bicycle." 3. "My 8-year-old is taking swimming classes at the local community center." 4. "Now my 2 1⁄2-year-old can finally sit in the front seat of the car with me."
4. "Now my 2 1⁄2-year-old can finally sit in the front seat of the car with me."
31. An adolescent girl has gone to a family-planning center for information about birth control. The pa-tient asks the nurse what she should use to avoid getting pregnant. The nurse responds: 1. "Are your parents aware of your sexual activity?" 2. "You've been using some kind of protection before, right?" 3. "What are your friends doing to protect them-selves?" 4. "What can you tell me about your past sexual experiences?"
4. "What can you tell me about your past sexual experiences?"
Which term describes synovial joint movement away from the midline of the body? 1. Inversion 2. Extension 3. Pronation 4. Abduction
4. Abduction
Which type of joint permits movement in any direction? 1. Pivot 2. Hinge 3. Biaxial 4. Ball-and-socket
4. Ball-and-socket
The nurse is applying a sequential compression device on the immobilized patient. Which of the following actions is appropriate? 1. Make sure the red light is on so the unit will run. 2. Remove the device after 2-3 days. 3. Check for function after 10 or more complete cycles. 4. Fit two fingers between the patient's leg and the device sleeve.
4. Fit two fingers between the patient's leg and the device sleeve.
32. Which of the following is a priority safety measure in the acute care environment for a patient with a sensory deficit? 1. Encouraging the family to visit the patient 2. Referring the patient to a support group 3. Determining the patient's medical history 4. Orienting the patient to the surroundings
4. Orienting the patient to the surroundings
After a CVA (stroke) a patient is prescribed prolonged bed rest. During assessment, the nurse is especially alert to the presence of: 1. an increased joint ROM. 2. an increased hemoglobin level. 3. an increased muscle mass. 4. a unilateral increase in calf circumference.
4. a unilateral increase in calf circumference.
A nurse manager is evaluating the care that is provided by a new staff nurse during the orientation period. One of the patients requires nasotracheal suctioning, and the nurse manager determines that the appropriate technique is used when the new staff nurse: 1. places the patient in the supine position. 2. prepares for a clean or nonsterile procedure. 3. suctions the oropharyngeal area first, then moves to the nasotracheal area. 4. applies intermittent suction for 10 seconds while the suction catheter is being removed.
4. applies intermittent suction for 10 seconds while the suction catheter is being removed.
A child has ingested a poisonous substance. The parent is instructed by the nurse to: 1. take the child to the hospital immediately. 2. administer 30 mL of emetic. 3. take the child to the pediatrician. 4. call the poison control center.
4. call the poison control center.
A patient has been placed in skeletal traction and will be immobilized for an extended period of time. The nurse recognizes that there is a need to prevent respiratory complications and intervenes by: 1. suctioning the airway every hour. 2. changing the patient's position every 4-8 hours. 3. using oxygen and nebulizer treatments regularly. 4. encouraging deep breathing and coughing every hour.
4. encouraging deep breathing and coughing every hour.
27. A nurse is working with a group of young adults at the community center. There are many discussions about life and health issues. The nurse is aware that a health-related concern for young adults is that: 1. attachment needs must be enhanced. 2. "labeling" may alter their self-perceptions. 3. adaptation to chronic disease is developing. 4. fast-paced lifestyles may place them at risk for illnesses or disabilities.
4. fast-paced lifestyles may place them at risk for illnesses or disabilities.
22. A nurse is assigned to prepare a teaching plan for a group of preschool age children. For this age group, the nurse includes: 1. appropriate use of medications. 2. cooking safety including use of the stove. 3. information on prevention of obesity and hypertension. 4. guidelines for crossing the street or actions to take during a fire.
4. guidelines for crossing the street or actions to take during a fire.
A nurse is instructing a patient on joint range of motion and performance of shoulder extension. The nurse correctly instructs the patient to: 1. raise the arm straight forward. 2. straighten the elbow by lowering the hand. 3. rotate the arm until the thumb is turned inward and toward the back. 4. move the arm behind the body with the elbow straight.
4. move the arm behind the body with the elbow straight.
A patient has been admitted to a medical center with a respiratory condition and dyspnea. A number of medications are prescribed for the patient. For a patient with this difficulty, the nurse should question the order for: 1. steroids. 2. mucolytics. 3. bronchodilators. 4. narcotic analgesics.
4. narcotic analgesics.
33. A responsive patient had eye surgery, and patches have been temporarily placed on both eyes for pro-tection. The evening meal has arrived, and the nurse will be assisting the patient. In this circumstance, the nurse should: 1. feed the patient the entire meal. 2. encourage family members to feed the patient. 3. allow the patient to be totally independent and feed himself. 4. orient the patient to the locations of the foods on the plate and provide the utensils.
4. orient the patient to the locations of the foods on the plate and provide the utensils.
A patient is transferred to a rehabilitation facility from the medical center after a CVA (stroke). The CVA resulted in severe right-sided paralysis, and the patient is very limited in mobility. To prevent the complication of external hip rotation for this patient, the nurse uses a: 1. footboard. 2. bed board. 3. trapeze bar. 4. trochanter roll.
4. trochanter roll.
The average heart rate for an adult is between __-___ beats per minute.
60-100
What is the normal Ph for arterial blood gas?
7.35-7.45
How many stages (crises) of social development does Erikson describe?
8
How many stages are in Erikson's stages of psychosocial development?
8
Inhalation and exhalation that moves air in and out of the body
Ventilation is: -loading of oxygen on to the hemoglobin molecule -inhalation and exhalation that moves air in and out of the body -the exchange of oxygen and carbon dioxide
How is air or blood evacuated from the pleural cavity?
Water- seal chest tube
Identify which of the following are intrinsic factors that contribute to a patient's risk for falling. Select all that apply. a. Age 65 or older. b. Loose electrical cords. c. Liquid spilled on the floor. d. Limited visual acuity. e. Clutter between the bed and bathroom. f. Poor balance. g. Orthostatic hypotension.
a, d, f and g. a. Age 65 or older. d. Limited visual acuity. f. Poor balance. g. Orthostatic hypotension.
a. A restraint is defined as: b. Chemical restraints are:
a. A restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move arms, legs, body, or head freely. b. Chemical restraints are medications such as anxiolytics and sedatives used to manage a patient's behavior.
The nurse enters a patient's room to find the patient unresponsive and the cardiac monitor showing a rhythm of ventricular fibrillation. What is the priority intervention for the nurse to perform? 1. Check a pulse 2. Initiate CPR 3. Administer epinephrine 4. Defibrillate the patient
1. Check a pulse
Which finding in the older adult clients is associated with aging? 1. Decrease in height 2. Decrease in neck rigidity 3. Increase fine-motor dexterity 4. Increased range of motion (ROM)
1. Decrease in height
The nurse is caring for a patient with pneumonia. On entering the room, the nurse finds the patient lying supine in bed, coughing and short of breath, with a pulse oximeter reading of 95%. What should the nurse do first? 1. Elevate the head of the bed to 45 degrees 2. Apply oxygen via nasal cannula at 2 L/minute 3. Encourage the patient to use the incentive spirometer 4. Notify the health care provider
1. Elevate the head of the bed to 45 degrees
For exercise, which of the following is appropriate for an immobilized older adult? 1. Gradual, extended warm-ups 2. Rapid transitions and movements 3. Sustained isometric exercises 4. Increased intensity programs
1. Gradual, extended warm-ups
After a discectomy and fusion surgery, the client wants to attempt walking with assistance for the first time. Upon rising to a standing position, the client reports feeling faint and light headed. Which action would the assisting nurse have the client do upon hearing the client's concern? 1. Have the client sit on the edge of the bed so the nurse can hold the client upright. 2. Have the client slide to the floor with assistance to avoid injuring the client because of a fall. 3. Have the client bend to increase blood flow to the brain. 4. Have the client lie down immediately so the nurse may obtain the client's blood pressure (BP).
1. Have the client sit on the edge of the bed so the nurse can hold the client upright.
The nurse is caring for a patient receiving oxygen therapy via nasal cannula. What interventions should the nurse include in the plan of care? (Select all that apply.) 1. Monitor a pulse oximeter reading. 2. Palpate pedal pulses. 3. Educate the patient about reason for oxygen therapy. 4. Ask the nursing assistive personnel (NAP) to monitor the patient and titrate the oxygen flow rate. 5. Assess the skin around the ears and nares for signs of skin breakdown.
1. Monitor a pulse oximeter reading. 3. Educate the patient about reason for oxygen therapy. 5. Assess the skin around the ears and nares for signs of skin breakdown.
The nurse is caring for a patient with an endotracheal tube. What are reasons to suction this patient? (Select all that apply.) 1. The airway has visible secretions. 2. There is a written order to suction routinely every 4 hours. 3. The patient exhibits excessive coughing. 4. The patient shows a decrease in pulse oximeter reading. 5. The patient has clear bilateral lung sounds.
1. The airway has visible secretions. 2. There is a written order to suction routinely every 4 hours. 3. The patient exhibits excessive coughing. 4. The patient shows a decrease in pulse oximeter reading.
Which joint is an example of a condyloid joint? 1. Wrist joint 2. Elbow joint 3. Shoulder joint 4. Sacroiliac joint
1. Wrist joint
29. When presenting a program for a group of individuals in their middle-aged adult years, a nurse informs the members to expect the following physical change: 1. a decrease in skin turgor. 2. increased breast size. 3. palpable lateral thyroid lobes. 4. a visual acuity that is greater than 20/50.
1. a decrease in skin turgor.
39. Because of the possibility of diminished independence for the patient with sensory losses, an important and specific ethical standard for the nurse to follow is the preservation of: 1. autonomy. 2. fidelity. 3. justice. 4. nonmaleficence
1. autonomy.
81. Chest tubes have been inserted into a patient after thoracic surgery. In working with this patient, a nurse should: 1. coil and secure excess tubing next to the patient. 2. clamp off the chest tubes except during respiratory assessments. 3. milk or strip the tubing every 15-30 minutes to maintain drainage. 4. remove the tubing from the connection to check for adequate suction.
1. coil and secure excess tubing next to the patient.
After a patient assessment, the nurse suspects hypoxemia. This is based on the nurse finding that the patient is experiencing: 1. restlessness. 2. bradypnea. 3. bradycardia. 4. hypotension.
1. restlessness.
36. A mother is taking her newborn for his first physical examination. She expresses concern because during her pregnancy she may have been exposed to an infectious disease, and the baby's hearing could be affected. The nurse inquires if the patient was exposed to: 1. rubella. 2. pneumonia. 3. tuberculosis. 4. a urinary tract infection.
1. rubella.
A nurse is checking a patient who has a chest tube in place and finds that there is constant bubbling in the water-seal chamber. The nurse should: 1. secure any loose connections. 2. leave the chest tube clamped. 3. raise the tubing above the level of the insertion site. 4. prepare the patient for the removal of the tube.
1. secure any loose connections.
The nurse recognizes the importance of teaching the patient who is using oxygen at home that the leading cause of burns and fires is: 1. smoking. 2. the use of heating blankets. 3. the misuse of the stove. 4. damage to the oxygen tank.
1. smoking.
26. Parents of a 1-year-old are asking about what can be expected of a child this age. A nurse informs the parents that a major milestone for a 1-year-old child is: 1. tripling of the birth weight. 2. sleeping 6-7 hours each day. 3. walking with good balance. 4. playing well with others.
1. tripling of the birth weight.
A patient is being discharged home with an order for oxygen PRN. In preparing to teach the patient and family, a priority for the nurse is to provide information on the: 1. use of the oxygen delivery equipment. 2. physiology of the respiratory system. 3. use of PaO2 levels to determine oxygen demand. 4. length of time that the oxygen is to be used by the patient.
1. use of the oxygen delivery equipment.
31. A nurse is assessing a patient for a potential gustatory impairment. This may be indicated if the patient has a(n): 1. weight loss. 2. blank look or stare. 3. increased sensitivity to odors. 4. period of excessive clumsiness or dizziness
1. weight loss.
A teenager is being discharged with a cast. Which would the nurse recommenced if the client experiences pruritus around the cast edges? 1. 'Scratch the itchy area gently.' 2. 'Put an ice pack on the affected area.' 3. 'Sprinkle a layer of powder around the itchy spots.' 4. 'Ask your doctor for a prescription for an antihistamine.'
2. 'Put an ice pack on the affected area.'
The nurse is performing CPR on an adult patient in cardiac arrest. The nurse knows that the rate of compressions should be how fast? 1. 80 to 100 compressions/minute 2. 100 to 120 compressions/minute 3. 120 to 140 compressions/minute 4. 60 to 80 compressions/minute
2. 100 to 120 compressions/minute
During patient assessment, which of the following is an expected sign of hypoxemia? 1. Pale conjunctivae 2. Central cyanosis 3. Dependent edema 4. Splinter hemorrhages
2. Central cyanosis
Which synovial joint movement is described as turning the sole away from the midline of the body? 1. Pronation 2. Eversion 3. Adduction 4. Supination
2. Eversion
A nurse selects which of the following for maintaining dorsal flexion for the patient? 1. Pillows 2. Foot boots 3. Bed boards 4. Trochanter rolls
2. Foot boots
The nurse is assessing a patient. What data is the nurse likely to find if the patient is experiencing hypoxia? (Select all that apply.) 1. 2 edema in the feet 2. Heart rate of 120 beats/minute 3. Respiratory rate of 24 breaths/minute 4. Shortness of breath 5. Confusion 6. Chest pain
2. Heart rate of 120 beats/minute 3. Respiratory rate of 24 breaths/minute 4. Shortness of breath 5. Confusion
The nurse is developing a plan of care for an older adult with end-stage chronic pulmonary disease with impaired oxygenation. What considerations should be made when developing the plan of care? 1. Older adults present with the classic symptoms of coronary artery disease (CAD). 2. Older adults are more likely to change unhealthy habits than younger adults. 3. Mental status changes are often the first sign of hypoxia or respiratory problems. 4. Cough suppressants should be administered without restrictions.
2. Older adults are more likely to change unhealthy habits than younger adults.
The nurse is preparing to perform nasotracheal suctioning on a patient. Put the following steps in order of performance. 1. Assist patient to semi-Fowler's or high-Fowler's position, if able. 2. Perform hand hygiene. 3. Apply sterile gloves. 4. Lubricate catheter with water-soluble lubricant. 5. Apply suction. 6. Have patient take deep breaths. 7. Advance catheter through nares and into trachea. 8. Withdraw catheter.
2. Perform hand hygiene. 1. Assist patient to semi-Fowler's or high-Fowler's position, if able. 3. Apply sterile gloves. 4. Lubricate catheter with water-soluble lubricant. 6. Have patient take deep breaths. 7. Advance catheter through nares and into trachea. 5. Apply suction. 8. Withdraw catheter.
24. During a clinical rotation a student nurse is observing children in a day care center. The student is asked to assist with the activities for the preschool age children. Children in this age group are usually able to: 1. make detailed drawings. 2. classify objects by size or color. 3. easily hold a pencil and print letters. 4. use a vocabulary of more than 8000 words.
2. classify objects by size or color.
A patient is being instructed to perform dorsal flexion of the foot. The nurse observes the patient's ability to: 1. turn the foot and leg toward the other leg. 2. move the foot so the toes point upward. 3. turn the sole of the foot medially. 4. straighten and spread the toes of the foot.
2. move the foot so the toes point upward.
28. An expected outcome for a patient with an auditory deficit should include: 1. minimizing use of affected sense(s). 2. preventing additional sensory losses. 3. promoting the patient's acceptance of dependency. 4. controlling the environment to reduce sensory stimuli.
2. preventing additional sensory losses.
23. Children who are admitted to a hospital may be afraid about the hospitalization. To reduce the fear of school-age children in an acute care environment, a nurse: 1. restrains them for all assessments and procedures. 2. shows them the equipment that is to be used for procedures. 3. provides in-depth information on how procedures are done. 4. tells them that everything will be all right and the procedures will not hurt.
2. shows them the equipment that is to be used for procedures.
A 65-year-old patient is seen in a physician's office for a routine annual checkup. As part of the physical examination, an ECG is performed. The ECG reveals a normal P wave, P-R interval, and QRS complex and a heart rate of 58 beats per minute. The nurse evaluates this finding as: 1. sinus tachycardia. 2. sinus bradycardia. 3. sinus dysrhythmia. 4. supraventricular bradycardia.
2. sinus bradycardia.
25. Parents of a toddler ask a nurse what their child should be able to do at the age of 2 1⁄2 years old. The nurse identifies that the toddler will be able to: 1. skip and throw a ball. 2. speak in short sentences. 3. solve difficult problems. 4. recognize safety hazards.
2. speak in short sentences.
For a patient who has been placed in a spica (full body) cast, the nurse remains alert to possible changes in the cardiovascular system as a result of immobility. The nurse may find that the patient has: 1. hypertension. 2. tachycardia. 3. hypervolemia. 4. an increased cardiac output.
2. tachycardia.
A patient was prescribed extended bed rest after abdominal surgery. The patient now has an order to be out of bed. The nurse should first: 1. assess respiratory function. 2. take the patient's blood pressure. 3. ask if the patient feels light-headed. 4. assist the patient to the edge of the bed.
2. take the patient's blood pressure.
An older adult patient is being discharged home. The patient will be taking furosemide (Lasix) on a daily basis. A specific consideration for this patient is: 1. exposure to the sun. 2. the location of the bathroom. 3. food consumption when taking the medication. 4. financial considerations for long-term care.
2. the location of the bathroom.
A nurse is instructing a patient on range of motion and performance of forearm supination. The nurse correctly instructs the patient to: 1. move the palm toward the inner aspect of the forearm. 2. turn the lower arm and hand so the palm is up. 3. straighten the elbow by lowering the hand. 4. touch the thumb to each finger of the hand.
2. turn the lower arm and hand so the palm is up.
37. For a patient with a hearing deficit, the best way for the nurse to communicate is to: 1. approach the patient from the side. 2. use visible facial expressions. 3. shout or speak very loudly to the patient. 4. repeat the entire conversation if it is not totally understood.
2. use visible facial expressions.
34. After a cerebrovascular accident (CVA or stroke), a patient is found to have receptive aphasia. The nurse may assist this patient with communication by: 1. obtaining a referral for a speech therapist. 2. using a system of simple gestures and repeated behaviors. 3. providing the patient with a letter chart to use to answer questions. 4. offering the patient a notepad and pen to write down questions and concerns.
2. using a system of simple gestures and repeated behaviors.
A nurse is completing a physical assessment of a patient with a history of a cardiopulmonary abnormality. A finding associated with hyperlipidemia is the patient having: 1. cyanosis. 2. xanthelasma. 3. petechiae. 4. ecchymosis.
2. xanthelasma.
29. A nurse is working with patients at the senior day care center and recognizes that changes in sensory status may influence the older adult's eating patterns. For patients who are experiencing changes in their dietary intake, the nurse will assess for: 1. presbycusis. 2. xerostomia. 3. vestibular ataxia. 4. peripheral neuropathy.
2. xerostomia.
Oxygen makes up what percentage of the earth's atmosphere?
21%
Focused assessment of a patient's breathing pattern includes: Select the best answer for each of the following questions:
A focused assessment of a patient's breathing pattern includes: -Observing breathing pattern. -Observing patient perform activities of daily living. -Observing for use of pursed-lip breathing. -Observing patient ambulating. Determine distance walked without shortness of breath. -Observing patient's breathing patterns in different positions.
What is an Oxygen Concentrator?
A machine that collects and concentrates oxygen from room air and stores it for client use
How is oxygenation affected in the individual who is receiving chemotherapy?
In many patients, chemotherapy kills not only fast-growing cancer cells but also other normal fast- growing cells, such as the blood-forming cells in the bone marrow. With a reduction in RBCs and hemoglobin, the patient can have anemia and reduced oxygenation. This is seen as fatigue in the patient on chemotherapy.
Footdrop
Inability to dorsiflex and invert foot because of peroneal nerve damage
Provide an example of a possible physical hazard that may be found in the home.
Inadequate lighting, clutter, lack of security, fire/ electrical hazards, lack of safety devices, and temperature extremes are examples of physical hazards in the home.
A technique for deep breathing using a calibrated device
Incentive spirometry
Upper Respiratory Tract
Includes nose, mouth, pharynx, epiglottis, larynx, and trachea
Kyphosis
Increased convexity in curvature of thoracic spine
Strawberry tongue is associated with...
Scarlett fever
Concept or mental framework that organizes and interprets information. For example, a sports car is shiny, fast, expensive, and small.
Schema
The three layers of the eye wall are... (outermost to innermost)
Sclera, choroid coat, and retina.
What is the goal of moral reasoning in the preconventional stage?
Self Interest: Act to gain reward or to avoid punishment
What are Piaget's 4 stages of cognitive development?
Sensorimotor, Preoperational, Concrete Operational, Formal Operational
27. How can sensory loss affect an individual's life?
Sensory loss often creates feelings of grief, anger, depression, and loss of self-esteem, social isolation, and withdrawal.
9. Identify a way that a nurse can modify sensory stimulation in the health care environment.
Sensory stimulation may be modified in the acute care environment by: • Increasing the patient's view outside and within the room. • Arranging decorations, plants, photos, greeting cards, and the patient's personal items. • Providing audio books and large-print reading material. • Spending time with the patient; listening to and conversing with the patient. • Playing pleasant music or turning on television shows that the patient enjoys. • Providing attractive meals at the correct temperature. • Providing a variety of textures and aromas to enhance the patient's appetite.
Can be achieved in a few hours or a few days
Short Term Goal
Identify measures to prevent pressure injuries.
The best ways to prevent pressure injuries are to: -change the patient's position at least every 1-2 hours -assess the skin frequently -promote mobility -use pressure sensors and pressure relief devices -keep the skin moist -provide hygienic care
23. The occupational health nurse wants to promote safety for the employees. What general safety measures may be implemented by the nurse in a work environment?
The occupational health nurse will reinforce the use of protective devices, such as eye goggles and earplugs, as well as participate in safety policy development, worker education, and environmental and employee screening.
For a patient who had a cerebrovascular accident (CVA, or stroke) with right-sided hemiplegia, identify how the patient can be involved in performing joint range of motion exercise.
The patient can perform passive range of motion to the right side and active range of motion with the left side. Participation in activities of daily living (ADLs), to the extent the patient is able, will also provide joint mobility.
Positioning for the patient with right-sided atelectasis will be on the left or right side?
The patient should be positioned with the right side up, so he/she would be lying on the left side (healthy lung down).
Individuals have gone to the health fair to receive their free influenza vaccine. The nurse briefly discusses the medical backgrounds of the patients. The influenza vaccine will be withheld from the following individuals: Select all that apply. a. Three-month-old child b. Older adult woman c. Man with chronic arthritis d. Woman with a severe hypersensitivity to eggs e. A woman with a history of Guillain-Barré syndrome
The patients who should not receive the flu vaccination are: a, d, and e. a. Three-month-old child d. Woman with a severe hypersensitivity to eggs e. A woman with a history of Guillain-Barré syndrome
The parents of an adolescent are concerned about possible substance abuse. What signs, symptoms, and behaviors are indicative of this problem?
The presence of drug-oriented magazines, beer and liquor bottles, drug paraphernalia, blood spots on clothing, and the continual wearing of long-sleeved shirts in hot weather and dark glasses indoors. Psychosocial clues include failing grades, change in dress, increased absenteeism from school, isolation, increased aggressiveness, and changes in interpersonal relationships.
Oxygenation
The process of obtaining O2 from the atmospheric air and making it available to the organs and tissues in the body
Tuberculosis (TB)
An infectious disease caused by Mycobacterium - usually involves the lungs, but any organ can be infected, including brain, kidneys, and bones.
A restraint is indicated for a patient in the hospital. Which of the following are correct for the use of restraints? Select all that apply. a. Obtain renewals for restraint orders every 72 hours b. Evaluate the patient at least every 1-2 hours. c. Pad the skin under the restraint. d. Keep the restraint in place for 8 hours. e. At least two fingers should fit under the secured restraint. f. Tie the restraint ends with a knot. g. Attach the restraint ties to the side rails.
b, c, and e. b. Evaluate the patient at least every 1-2 hours. c. Pad the skin under the restraint. e. At least two fingers should fit under the secured restraint.
Which of the following pathophysiological changes occur with immobility? Select all that apply. a. Increased basal metabolic rate b. Decreased gastrointestinal motility c. Orthostatic hypotension d. Increased appetite e. Increased oxygen availability f. Hypercalcemia g. Increased lung expansion h. Decreased cardiac output i. Increased dependent edema j. Decreased stressors k. Increased urinary stasis l. Decreased passive behaviors
b, c, f, h, i, and k. b. Decreased gastrointestinal motility c. Orthostatic hypotension f. Hypercalcemia h. Decreased cardiac output i. Increased dependent edema k. Increased urinary stasis
Put the following steps in order for preparing to move the patient in bed. a. Raise the level of the bed to a comfortable working height. b. Close the door to the room. c. Determine the number of people needed to assist. d. Perform hand hygiene. e. Explain the procedure to the patient. f. Obtain equipment.
c, f, d, e, b, a (Step d may be done third or fifth; both are acceptable) c. Determine the number of people needed to assist. f. Obtain equipment d. Perform hand hygiene e. Explain the procedure to the patient. b. Close the door to the room. a. Raise the level of the bed to a comfortable working height.
The Centers for Medicare and Medicaid Services (CMS) have identified that payment will be denied for events that are not present on admission but occur during hospitalization. Which of the following are included in the CMS listing of these occurrences? Select all that apply. a. Air embolism b. Blood transfusion c. Patient falls d. Wrong medication administered e. Surgical site infection f. Stage III pressure ulcer
a, c, e, and f. a. Air embolism c. Patient falls e. Surgical site infection f. Stage III pressure ulcer
Which of the following actions are correct for the use of a sequential compression device? Select all that apply. a. The back of the patient's ankle and knee are aligned with markings on the sleeve. b. A hand width is left between the sleeve and the patient's skin. c. The sleeve and device are removed once daily. d. The unit is observed through one complete cycle after application. e. A small amount of powder or cornstarch can be applied to the legs if not sensitive. f. Allow patient to ambulate with SCD or MCD.
a, d, and e a. The back of the patient's ankle and knee are aligned with markings on the sleeve. d. The unit is observed through one complete cycle after application. e. A small amount of powder or cornstarch can be applied to the legs if not sensitive.
a. The patient has a reddened area on the coccyx/ buttocks. The nurse considers positioning the patient in: b. For the patient with acute respiratory distress, the best position is: c. The patient is too weak to cough. What will be necessary to maintain the airway? d. For the chair-bound patient, the patient should move:
a. 30-degree lateral position b. High Fowler's c. Oral or nasotracheal suctioning may be indicated. d. Position should be changed every 1 hour or less, with weight shifts every 15-20 minutes.
Identify for each of the following illustrations what range-of-joint-motion (ROJM) exercise is being performed: A. Roll head in circle B. Point foot up and down C. Turn palms facing up and down D. Rotate arm in complete circle E. Kick leg back
a. Rotation of the neck (roll head in circle) b. Dorsiflexion of the foot (point foot up/down) c. Supination of the forearm (turn palms up/down) d. Circumduction of the arm (rotate in complete circle) e. Hyperextension of the hip (kick leg back)
What was the concluding statement of Harlow's study regarding attachment styles in monkeys?
"Nourishment is not the prime motivator"
Consequences of Immobility: Urinary System
-Renal calculi -Urinary stasis -Infection
Back and Spine Conditions: Examples
-Spinal cord injury -Herniated disk -Intervertebral disk disease -Low back pain (acute/chronic) -Scoliosis -Spinal stenosis
Joint and Connective Tissue Conditions: Example
-Sprains Tendonitis -Joint dislocation -Osteoarthritis -Rheumatoid arthritis -Juvenile idiopathic arthritis -Gout
What is included in thromboprophylaxis?
-adherence to prescribed anticoagulants -proper positioning -safe use of antiembolic stockings.
Rheumatoid Arthritis (RA)
-autoimmune disease & inflammatory process in joint & other body tissues -joint inflammation leads to erosion -pain, swelling, & joint deformity -1% of population -impairment in mobility can result
Juvenile Idiopathic Arthritis (JIA)
-chronic inflammation of joints from autoimmune conditions -can cause significant disability, w/ joint deformity -affects children younger than 16, w/ peak onset between ages 1-2, girl affects 2x more than boys -estimated 294,000 children under age of 18 -mobility impairments & physical disability
Spinal Cord Injury (SCI)
-depending on degree of injury, SCI may result in temporary or permanent neurologic impairment & mobility -primary cause is traumatic motor vehicle accidents, falls, sports, or personal violence -can occur at any age, but males 15-40 are the highest percentage affected
Osteoarthritis (OA)
-inflammation & breakdown of the joint (cartilage, joint lining, ligaments, bone) -affecting weight-bearing joints (hips, knees, vertebrae) & hands -pain, swelling, & reduced mobility -33% of adults -reduced mobility of joint
Parkinson Disease (PD)
-neurologic disorder w/ loss of dopamine production to brain -muscular tremor, rigidity of extremities & trunk, slowness of movement, & impaired coordination & balance -mobility impairment increases w/ disease progression -typically affects >50 y.o., w/ higher incidence in men than women
Low Back Pain
-one of the most common conditions affecting mobility -caused by muscle, bone, or nerve irritation from a variety of conditions -conditions causing pain: muscle strain/spasm, degenerative conditions (arthritis) & trauma -common symptom in late-term pregnancy -most common in ages 30-50
Bone fractures
-partial or complete disruption of bone -occur mostly from traumatic injury, but spontaneous factor can occur in the presence of bone disease (osteoporosis) -usually during infancy -most occur in children, adolescents & adults >65 y.o. (wrist & hip as a result of falls) -reduction or loss in movement
For the following patient scenario, identify the assessment findings that the nurse should focus on to prevent patient injuries. Upon entering the patient's home, the visiting nurse observed that the patient was wearing slippers with no back slip-ons. The patient stated that she seemed to always leave her glasses somewhere. There were piles of newspapers and other items cluttering the floor around the living room chairs. The lighting in the stairway was less than 60, watts and there were throw rugs on the wood floors in the halls. When looking through the medicine cabinet with the patient, the nurse noted that some medications were expired. The patient admitted to falling once when getting up during the night to go to the bathroom.
-slippers with no back -always leave her glasses somewhere -piles of newspapers and other items cluttering the floor around the living room chairs -lighting in the stairway was less than 60 watts -throw rugs on the wood floors -medications were expired -admitted to falling once when getting up during the night to go to the bathroom The patient should be wearing slippers that fit well and will not slide off and cause the patient to trip. The patient's glasses should be kept close by in a case or on a necklace so that there is she has better vision. Clutter around chairs, poor lighting, and throw rugs can all cause the patient to fall. Expired medications can be ineffective and dangerous to keep around. Nocturia is a concern, as is the admission of a prior fall.
The nurse documents that the patient has lordosis because which of the following was observed? 1. An exaggeration of the anterior convex curve of the lumbar spine 2. An increased convexity in the curvature of the thoracic spine 3. Inclining of the head to the affected side where the sternocleidomastoid muscle is contracted 4. Lateral S-or C-shaped spinal column with vertebral rotation and unequal heights of the hips and shoulders
1. An exaggeration of the anterior convex curve of the lumbar spine
What areas are included in a focused patient assessment of overall mobility?
A focused assessment includes: -mobility -pain -endurance -activity.
The process of thinking with a purpose
Critical thinking
Lower Respiratory Tract
Consists of the bronchi, bronchioles, alveolar ducts, and alveoli
During which life stage do women experience menopause and men experience a slowing of hormone production?
Middle Adulthood
When reviewing lab results of an older patient with an infection, you would expect to find
Minimal Leukocytosis
Capacity to maneuver around freely
Mobility
How many pillows do you use for prone position and where?
One under face, one under pelvis and one under feet (3)
Contributes to BP regulation by controlling sodium excretion and extracellular fluid (ECF) volume
Kidneys
4. Moral development
Kohlberg
Tachypnea pattern of breathing associated with metabolic acidosis
Kussmaul respiration
During which stage do people begin to experience the stages of death and dying?
Late Adulthood
Short term memory is normally the first to decline during which of the life stages?
Late Adulthood
What life stage is considered pre-adolescents?
Late Childhood
During which life stage does hair become dull and thin?
Late adulthood
During which stage do emotions begin to slowly become under control?
Late childhood
During which stage are you prone to infections and accidents?
Late childhood and late adulthood
Scoliosis
Lateral S or C shaped spinal column with vertebral rotation; unequal heights of hips and shoulders
What should you do if the person begins getting sweaty, short of breath and is in any pain?
Lay them back down and report it to the charge nurse.
Knock-knee (genu valgum)Legs curved inward so that knees come together as person walks
Legs curved inward so that knees come together as person walks
What disease is caused by a dimming or distortion of vision and it occurs with age and what disease is caused by excessive intraocular pressure?
Macular degeneration and Glaucoma
Decreased phagocytosis of bacteria
Malignant disorders that arise from granulocytic cells in the bone marrow will have the primary effect of causing this
3. Based on human needs
Maslow
Physiologic needs, safety needs, love and belonging, esteem, self actualiztion
Maslows Hierarchy of Needs
What do CNA's use when they can not physically lift a person?
Mechanical Lift
Pneumonia, diabetes, congestive heart failure, hypertension...
Medical diagnoses
Written secondary data
Medical record
What is a disease that affects the semicircular canals and can cause nausea and dizziness?
Meniere's disease
19. What are the signs and symptoms associated with Ménierè's disease?
Meniere's disease is characterized by progressive low-frequency hearing loss, vertigo, tinnitus, and a full feeling or pressure in the affected ear.
Using clinical judgement the nurse can assign one of these three results as the outcome
Met, partially met, not met
The primary symptom is exertional dyspnea caused by reduced lung compliance
Mitral stenosis
GERD
More common in people with Asthma than in general population. May worsen asthma symptoms as reflux may trigger bronchoconstriction and cause aspiration
Reflex when arms reach out when feeling "dropped"
Moro reflex
Left-sided heart failure
Most common form results from the inability of the left ventricle to 1) empty adequately during systole or 2) fill adequately during diastole
What are the leading causes of falls in the home?
Most falls occur within the home, specifically in the bedroom, bathroom, and kitchen -Environmental factors such as broken stairs, icy sidewalks, inadequate lighting, throw rugs, and exposed electrical cords cause many accidents. -Older adults typically fall while transferring from beds, chairs, and toilets; getting into or out of bathtubs; tripping over carpet edges or doorway thresholds; and slipping on wet surfaces or descending stairs.
What is the uvula?
Muscular projection from the soft plate composed of muscle and connective tissue. (bonus: what does it do?)
The standardized language for nursing interventions
NIC- Nursing Interventions Classification
The standardized and organized structure to name and measure outcomes
NOC- Nursing Outcomes Classification
The most effective positioning for a patient with cardiopulmonary disease is:
The most effective positioning for a patient is 45-degree semi-Fowler's
What is oxygenation? -the movement of air in and out of the body - the exchange of O2 and CO2 -the movement of oxygen onto the hemoglobin molecule
The movement of oxygen onto the hemoglobin molecule
Indicate at least three examples of health education in the community for prevention or identification of cardiopulmonary disease.
The nurse can provide patient education on topics such as regular blood pressure checkups and taking blood pressure medication as prescribed, following the DASH Diet, a proper caloric diet, and the importance and benefits of a pneumococcal vaccine and annual influenza vaccine, smoking cessation, and avoiding secondhand smoke exposure.
Where should a nurse check for edema in an immobilized patient?
The nurse checks for edema in the immobilized patient at the: -sacrum -hips -legs -feet
10. A nurse may communicate with a hearing-impaired patient by:
The nurse may communicate with a hearing-impaired patient by: • Making sure that a hearing aid, if needed, is in place and in working order. • Approaching the patient from the front to get his or her attention. • Facing the patient on the same level, with adequate lighting. • Making sure that glasses, if needed, are worn and are clean. • Speaking slowly and articulating clearly, using a normal tone of voice. • Rephrasing, rather than repeating information that is not heard. • Using visible expressions and gestures. • Talking toward the patient's better ear. • Using written information to reinforce spoken words, such as letter/word or dry erase board. • Not restricting the hands of deaf patients. • Avoiding eating, chewing, or smoking while speaking with the patient. • Avoiding speaking while walking away, in another room, or from behind the patient.
The patient becomes breathless and tired during the physical exam. The nurse should:
The nurse should complete the assessment in short sections to allow the patient to rest and recover. If the patient is breathless or fatigued, ask closed-ended questions, with "yes" or "no" answers. Focus the initial assessment on the patient's immediate problems.
The nurse notices that the plug for the infusion pump makes a spark when it is plugged into the wall socket. The nurse should:
The nurse should report any equipment that does not appear to work properly to the agency's maintenance, safety, or facilities department.
The objectives or advantages of bed rest are:
The objectives of bed rest are to decrease physical activity and oxygen needs, allow the ill/debilitated patient to rest, and prevent further injury.
What sends impulses to cerebellum to help balance; contains endolymph fluid?
semicircular canals
An older adult patient who often forgets to take medication or does not remember if it was taken may benefit from a(n):
the use of a medication organizer device or system and/or timer
The Virchow triad is related to __________________ ______________________, and the three associated problems are: _______________________________
thrombus formation three associated problems are: (1) blood stasis resulting from decreased blood flow and increased viscosity (2) hypercoagulability due to a change in clotting factors or increased platelet activity (3) vessel trauma.
The eardrum separates the outer ear and the middle ear; it is also known as the...
tympanic membrane
Laboratory tests
used to provide various types of information about the functional state of muscles, bones, or joints. Types of tests include blood tests (e.g., alkaline phosphatase, calcium, phosphorus, uric acid, creatine kinase, blood urea nitrogen, creatinine, and myoglobinuria), analysis of joint fluids, and pathologic analysis of biopsied tissue (e.g., a muscle biopsy or bone biopsy)
Magnetic resonance imaging (MRI)
uses radio waves and magnetic fields to provide an image of soft tissue. This is used most efficiently to evaluate soft tissues, such as a vertebral disk, tumor, ligaments, and cartilage
Arthrography (arthrogram)
visualization of a joint by the injection of a radiopaque substance into the joint cavity, allowing for the evaluation of bones, cartilage, and ligaments. This is most commonly performed on the knee and shoulder joints, but it also can be done on hips, ankles, and wrists
Wells scoring system for DVT:
−2 to 0, low probability -1 to 2 points, moderate probability -3 to 8 points, high probability
During inspiration, what organ contracts and moves downward?
Diaphragm
Temporary decrease in blood supply to an organ or tissue
Ischemia
Need to sit upright to breathe easier
Orthopnea
Lordosis
exaggeration of anterior convex curve of lumbar spine
Time during development where a skill or characteristic is believed to be readily acquired
Critical Period
Who studied cognitive development?
Jean Piaget
Positioning is encouraged to prevent...
Pressure Ulcers
Consequences of Immobility: Integumentary System
Skin breakdown
Signs and symptoms that an abdominal aortic aneurysm (AAA) has ruptured
Sudden, severe low back pain and bruising along the flank
What does the walker have to be aligned with?
The patients hips
Clubfoot
-95%: Medial deviation and plantar flexion of foot (equinovarus) -5%: Lateral deviation and dorsiflexion (calcaneovalgus)
Skeletal Conditions: Examples
-Amputation -Fracture -Fibrosarcoma -Osteochondroma -Osteosarcoma -Osteomalacia -Osteomyelitis -Osteoporosis -Osteogenesis imperfecta -Rickets
Neuromuscular Dysfunction: Examples
-Amyotrophic lateral sclerosis -Cerebral palsy -Guillain—Barré syndrome -Huntington disease -Multiple sclerosis -Muscular dystrophy -Myasthenia gravis -Parkinson disease
Caution is used when administering oxygen to patients with chronic lung disease because:
-Caution is used when administering oxygen to a patient with chronic lung disease because patients with COPD and hypercapnia (high carbon dioxide levels) have adapted to the higher carbon dioxide level. The carbon dioxide-sensitive chemoreceptors are no longer sensitive to increased carbon dioxide as a stimulus to breath. Their stimulus to breathe is a decreased PaO2. -When you administer excessive oxygen to patients with COPD, this satisfies the body's oxygen requirement and negates the stimulus to breathe.
Congenital Defects: Examples
-Club foot -Developmental dysplasia of the hip -Metatarsus adductus -Spina bifida -Syndactyly
Muscle Conditions: Examples
-Disuse atrophy -Fibromyalgia -Myotonia -Myositis -Rhabdomyoma -Rhabdomyosarcoma
Pain can interfere with a patient's activity. How would you assess a patient's pain and observe for signs of pain?
-Do you have any pain or discomfort on movement? -Ask patient to rate pain on a 0-10 pain scale. -Please tell me about your pain. When did it start? How long does it last? Can you get relief? -Would you like your pain medication before I help you walk? -Observe for objective signs of pain such as grimacing; moaning; increasing respiratory rate, pulse, and blood pressure. -Inspect joints for redness or swelling, indicating potential inflammatory process. Watch if patient favors one leg or knee when walking, sitting, or changing position. -Use appropriate pain scale for patients who cannot verbalize their pain.
Identify a nursing diagnosis for a patient who is immobilized.
-Insufficient airway clearance -Potential constipation -Potential disuse syndrome -Potential falls -Altered physical mobility -Potential skin integrity impairment -Potential ECV deficit -Potential urinary stasis
Alternatives to restraints:
-Orient patients and family members to the environment; explain all procedures and treatments. -Provide companionship and supervision; use trained sitters; adjust staffing and involve family. -Offer diversionary activities such as music, puzzles, crocheting, activity aprons, and folding towels. Enlist ideas and support from family. -Assign confused or disoriented patients to rooms near nurses' stations and observe them frequently. -Use calm, simple statements and physical cues as needed. -Use de-escalation, time-out, and other verbal intervention techniques when managing aggressive behaviors. -Provide appropriate visual and auditory stimuli (e.g., family pictures, clock, calendar). -Remove cues that promote leaving the room (e.g., close doors to block view of stairs, do not wear street clothes). -Promote relaxation techniques and normal sleep patterns. -Institute exercise and ambulation schedules as allowed by patient's condition; consult physical therapist for mobility and exercise program. -Attend frequently to needs for toileting, food and liquid, and pain management. -Camouflage IV lines with clothing, stockinette, or Kling dressing. -Evaluate all medications and ensure timely and effective pain management. -Eliminate bothersome treatments as soon as possible. For example, discontinue tube feedings and begin oral feedings as quickly as patient's condition allows. -Use protective devices such as hip pads, helmet, skid-proof slippers, and nonskid strips near bed.
Classic conditions causing immobility:
-Osteoarthritis (OA) -Rheumatoid Arthritis (RA) -Juvenile Idiopathic Arthritis (JIA) -Bone Fracture -Parkinson Disease (PD) -Spinal Cord Injury (SCI) -Low Back Pain
Consequences of Immobility: Cardiovascular system
-Reduced cardiac capacity -Decreased cardiac output -Orthostatic hypotension -Venous stasis -Deep vein thrombosis
Consequences of Immobility: Respiratory System
-Reduced lung expansion -Atelectasis -Pooling of respiratory secretions
Consequences of Immobility: Gastrointestinal System
-Reduced peristaltic mobility -Constipation
Consequences of Immobility: Musculoskeletal System
-Reduction in muscle mass and atrophy -Contracture of joints -Bone demineralization
17. Identify at least one rationale for why a patient may not use his or her hearing aid.
A patient may not use his/her hearing aid because of its appearance, a denial of its need, fit, the difficulty in manipulating a small object, cost, or a lack of understanding of its use. If tactile sense is decreased,zippers or Velcro strips, pullover sweaters or blouses, and elasticized waists are easier for a patient to use. If a patient has a partial paralysis, you dress the af-fected side first. Some patients also need assistance with basic grooming such as brushing, combing, shaving, and shampooing hair. Touch therapy helps to stimulate existing function. If the patient is willing to be touched, hair brushing and combing, a backrub, passive range of motion, and touching the arms or shoulders increase tactile contact. Turning and posi-tioning also improve the quality of tactile sensation. Make referrals to and collaborate with physical and/ or occupational therapy to ensure that patients are able to function at an optimal level.
Hypercalcemia
A patient with multiple myeloma becomes confused and lethargic. The nurse would expect that these clinical manifestations may be explained by diagnostic results that indicate
A premature infant has a deficiency of ________ and is at risk for hyaline membrane disease.
A premature infant may have a deficiency of surfactant.
Chronic Obstructive Pulmonary Disease
A preventable and treatable disease characterized by persistent airflow limitation that is usually progressive
Prinzmetal's Angina
A rare form of angina that often occurs at rest and not with increased physical demand
Continuous bubbling in the chest tube water-seal chamber indicates:
Continuous bubbling in the chest tube water-seal chamber indicates an air leak.
What is the most convenient type of oxygen source for an ambulatory client? A.)Liquid Oxygen Unit B.) Wall Outlet C.) Portable Tank
A. Liquid Oxygen tank- are small lightweight portable units
When transferring the person to bed, a chair, or the wheelchair A. The strong side moves first B. The weak side moves first C. Pillows are used for support D. The transfer belt is removed
A. The strong side moves first
An example of a controllable risk factor for cardiopulmonary disease is
Controllable risk factors include smoking, substance abuse, poor nutrition, lack of exercise, and stress.
Your patient from Texas flew in two days ago and reports respiratory distress after a sleepless night. Crackles and cough present on exam. Diagnosis and treatment.
O2, descent, nifedipine
Even though smoking marijuana would reduce the pain associated with her chronic medical condition, Juanita believes it would be morally wrong because it is prohibited by the law of her state. She is demonstrating ___ morality.
Conventional
Flail Chest
Results from the fracture of several consecutive ribs, in two or more separate places, causing an unstable segment. the resultant instability of the chest wall causes parodoxical movement
If the goal is not met the nurse will...
Revise the careplan
An acute inflammatory disease of the heart potentially involving all layers
Rheumatic fever (RF)
An inflammation in the nose with congestion drainage and sneezing.
Rhinnitis
When ambulating a patient with a weak right side you should stand
Right side
Biographical data is collected to help identify potential
Risk Factors
Reflects a problem that does not yet exist
Risk diagnosis
Male patient: CBC: WBC 6.5 x 10/ul/ul, Hgb 13.4 g/dL, Hct 40%, platelets 50 x 10/UL. What are you most concerned about?
Risk for bleeding
What technique can assist in removing a complete foreign body obstruction
Abdominal thrusts (Heimlich maneuver) Chest compressions if unresponsive
Adapting current schemas to incorporate new information
Accommodation
Adenocarcinoma
Accounts for 30% to 40% of lung cancers and is most common lung cancer in people who have not smoked
Immunity that occurs as a result of injection of a small amount of weakened or dead organisms and modified toxins is called:
Active immunity is obtained through the injection of weakened or dead organisms and modified toxins.
Bathing, dressing, eating
Activities of daily living
During which life stage do people learn to make decisions and accept responsibility?
Adolescents
During which stage do people have not fluent muscle coordination which can lead to clumsiness and awkwardness in movements?
Adolescents
During which stage do people need reassurance, support, and understanding?
Adolescents
During which stage do people spend less time with family and more with friends?
Adolescents
During which stage do you find people to be more stormy and conflicted?
Adolescents
Resistance of ejection of blood from the left ventricle
Afterload
Tension Pneumothorax
Air in pleural space that does not escape s/s cyanosis, air hunger, extreme agitation, tracheal deviation away from affected side, subcutaneous emphysema, neck vein distention, hyperresonance
Your patient presents with wheezing and dyspnea after exposure to the cold air. What is your diagnosis and approach to treatment?
Albuterol, nebulizer albuterol/ipratropium, IV steroids, magnesium
Cystic Fibrosis
An autosomal recessive, multisystem disease characterized by altered transport of sodium and chloride ions in and out of epithelial cells
An example of a common behavioral change that may be observed in an immobilized patient is:
An immobilized patient may react to the experience by exhibiting hostility, belligerence, inappropriate moods, altered sleeping patterns, withdrawal, confusion, anxiety, sadness, hopelessness, and depression.
A method to encourage voluntary deep breathing for a postoperative patient is the use of a(n):
An incentive spirometer will encourage the postoperative patient to breathe deeply
Your patient was stung by a bee and is now having rash, swelling of tongue, and dyspnea. What is the diagnosis and intervention
Anaphylaxis; ABCs, epinephrine, antihistamines, steroids, H2 blocker (pepcid)
Prevent the conversion of angiotensin I to angiotensin II and reduce angiotensin II (A-II)-mediated vasoconstriction and sodium and water retention.
Angiotensin-converting enzyme (ACE) inhibitors
The effects of immobility on the cardiac system include which findings? (Select all that apply.) 1. Thrombus formation 2. Increased cardiac workload 3. Weak peripheral pulses 4. Orthostatic hypotension 5. Increased stroke volume
Answer: 1, 2, 4 1. Thrombus formation 2. Increased cardiac workload 4. Orthostatic hypotension (occurs when patients experience a drop in blood pressure on rising to an upright position and is associated with symptoms of light-headedness or dizziness) The three major changes are orthostatic hypotension, increased cardiac workload, and thrombus formation.
Which of the following activities reflect a culture of safety within a health care agency? (Select all that apply.) 1. A hospital purchases a new bar-code system to check patient identification during medication administration. 2. A hospital requires nurse managers to submit an annual safety plan for high-risk patients. 3. A nurse commits an error while administering a high-risk medication and is released from her position. 4. A hospital enforces routine monthly checks of electrical equipment. 5. A nurse is treated unfairly after reporting a medication error.
Answer: 1, 2, 4. 1. A hospital purchases a new bar-code system to check patient identification during medication administration. 2. A hospital requires nurse managers to submit an annual safety plan for high-risk patients. 4. A hospital enforces routine monthly checks of electrical equipment. A culture of safety includes a commitment that acknowledges the high-risk nature of the activities of an organization (i.e., manager's safety plan, the determination to achieve consistently safe operations [check of electrical equipment], and an organizational commitment to resources [purchase bar-code system]).
A patient is receiving 5000 units of heparin subcutaneously every 12 hours to prevent venous thromboembolism while on prolonged bed rest. Because bleeding is a potential side effect of this medication, the nurse should continually assess the patient for which findings? (Select all that apply.) 1. Increased bruising 2. Pale yellow urine 3. Bleeding gums 4. Guaiac-positive stools 5. Skin turgor
Answer: 1, 3, 4 1. Increased bruising 3. Bleeding gums 4. Guaiac-positive stools Because bleeding is a potential side effect of these medications, continually assess the patient for signs of bleeding such as hematuria, bruising, coffee ground-like vomitus or gastrointestinal aspirate, guaiac-positive stools (test for hidden blood, + = blood, - = no blood), and bleeding gums.
Which of the following patients are at risk for falls because of intrinsic factors? (Select all that apply.) 1. A patient with a tendency to have postural hypotension 2. A patient whose hospital room has a bedside commode and suction machine blocking the path to the bathroom 3. A patient who has bathroom floor mats that are thin and frayed 4. A patient who has dementia and has cataracts 5. A patient whose bed is placed in the highest position
Answer: 1, 4. 1. A patient with a tendency to have postural hypotension 4. A patient who has dementia and has cataracts Intrinsic fall factors are physiological conditions such as postural hypotension that causes poor balance, dementia, and visual deficits (cataracts).
A young mother asks the nurse in the outpatient clinic what causes toddlers to often have accidents. Which of the following statements made by the nurse best answers the mother's question? 1. "Toddlers are curious about their surrounding environment." 2. "The toddler's environment expands." 3. "Toddlers take risks frequently." 4. "Many toddlers are exposed to stress in their daily activities."
Answer: 1. 1. "Toddlers are curious about their surrounding environment." Toddlers begin to explore because of curiosity about their environment.
The nurse is caring for a patient whose calcium intake must increase because of high-risk factors for osteoporosis. The nurse would recommend which of the following menus? 1. Cream of broccoli soup with whole wheat crackers, cheese, and tapioca for dessert 2. Hot dog on whole wheat bun with a side salad and an apple for dessert 3. Low-fat turkey chili with sour cream with a side salad and fresh pears for dessert 4. Turkey salad on toast with tomato and lettuce and honey bun for dessert
Answer: 1. 1. Cream of broccoli soup with whole wheat crackers, cheese, and tapioca for dessert Teach patient and/or caregiver the current recommended dietary allowances for calcium and review foods high in calcium (e.g., milk fortified with vitamin D, leafy green vegetables, yogurt, and cheese).
A patient has been on bed rest for a prolonged period of time. On assessment, the nurse recognizes which finding as a sign associated with immobility? 1. Decreased peristalsis 2. Decreased heart rate 3. Increased blood pressure 4. Increased urinary output
Answer: 1. 1. Decreased peristalsis Immobility disrupts normal metabolic functioning: decreasing the metabolic rate; altering the metabolism of carbohydrates, fats, and proteins; causing fluid, electrolyte, and calcium imbalances; and causing gastrointestinal disturbances such as decreased appetite and slowing of peristalsis.
22. Identify community resources where a patient with a sensory impairment may be referred.
Examples of available community resources are the American Foundation for the Blind, American Red Cross, Canine Companions, Lions Club, and public health/visiting nurse services.
The nurse observes the NAP apply and monitor a patient's sequential compression device (SCD) appropriately when the following is observed. 1. Initial patient measurement is made around the calves. 2. NAP verifies fit of SCD by placing two fingers between patient's leg and SCD sleeve. 3. Sleeves are wrapped directly over the leg from ankle to knee. 4. NAP removes SCD sleeves every 2 hours during placement.
Answer: 2 2. NAP verifies fit of SCD by placing two fingers between patient's leg and SCD sleeve. The appropriate way to check the fit of an SCD is by placing two fingers between a patient's leg and the sleeve. Arrange SCD sleeve under patient's leg according to leg position indicated on inner lining of sleeve. Place patient's leg on SCD sleeve. The back of the ankle should line up with ankle marking on inner lining of sleeve. Position the back of the knee with popliteal opening on inner sleeve.
An older adult has limited mobility as a result of a total knee replacement. During assessment you note that the patient has difficulty breathing while lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (Select all that apply.) 1. Blood pressure 128/84 mm Hg 2. Respirations 26 per minute on room air 3. Heart rate 114 beats/min 4. Crackles heard on auscultation 5. Pain reported as 3 on scale of 0 to 10 after medication
Answer: 2, 3, 4 2. Respirations 26 per minute on room air 3. Heart rate 114 beats/min 4. Crackles heard on auscultation Patients who are immobile are at high risk for developing pulmonary complications. The most common respiratory complications are atelectasis (collapse of alveoli) and hypostatic pneumonia (inflammation of the lung from stasis or pooling of secretions). Ultimately the distribution of mucus in the bronchi increases, particularly when the patient is in the supine, prone, or lateral position.
A 72-year-old male patient is scheduled for elective surgery. A review of his history shows that he takes six medicines daily. He is generally healthy but has an enlarged prostate that causes him to go to the bathroom frequently. He had a low-grade fever the night before surgery but is afebrile at 7 a.m. Which factors place him at a fall risk? (Select all that apply.) 1. Low-grade fever 2. Multiple medications 3. Elective surgery 4. Urinary frequency 5. Patient age
Answer: 2, 4, 5. 2. Multiple medications 4. Urinary frequency 5. Patient age Patients with multiple medications, patients with urinary frequency, and patients 65 years of age and older are at increased risk for falls.
Identify the order in which elastic stockings should be applied. 1. Evaluate skin integrity and circulation. 2. Identify patient using at least two identifiers. 3. Pull the remainder of the stocking over the patient's heel and on up the leg. 4. Turn the stocking inside out holding heel. 5. Slide stocking over patient's foot, making sure that toes are covered. 6. Assess condition of patient's skin. 7. Use tape measure to measure patient's legs to determine proper stocking size.
Answer: 2,6,7,4,5,3,1. 2. Identify patient using at least two identifiers. 6. Assess condition of patient's skin. 7. Use tape measure to measure patient's legs to determine proper stocking size. 4. Turn the stocking inside out holding heel. 5. Slide stocking over patient's foot, making sure that toes are covered. 3. Pull the remainder of the stocking over the patient's heel and on up the leg. 1. Evaluate skin integrity and circulation.
To prevent complications of immobility, what would be the most effective activity for a 55-year-old patient who has had abdominal surgery on the first postoperative day? 1. Turn, cough, and deep breathe every 30 minutes while awake 2. Ambulate patient from the bed to a bedside chair 3. Passive range of motion four times a day 4. Immobility is not a concern the first postoperative day
Answer: 2. 2. Ambulate patient from the bed to a bedside chair Ambulation is the most effective activity in this case. When the patient becomes immobilized, prevention of complications of immobility is critical.
A nursing team conference is being held to discuss a 72-year-old patient who wanders frequently. The patient gets lost on the nursing unit and goes into other patients' rooms. The nursing team selects a set of interventions. Which of the actions suggested by the NAP requires the nurse to intervene? 1. Arranging to have the patient work on a puzzle in her room 2. Confronting the patient and immediately removing her from the room when she becomes aggressive with other patients 3. Relocating the patient to a room near the nurses' station 4. Asking the patient's family to bring pictures of grandchildren to place in the patient's room
Answer: 2. 2. Confronting the patient and immediately removing her from the room when she becomes aggressive with other patients The proper way to deal with aggressive behavior is de-escalation and time-out.
A nurse discovers an electrical fire in a patient's room. Which action should the nurse take first? 1. Turn off the oxygen to the wall unit 2. Evacuate any patients/visitors in immediate danger 3. Close all doors and windows 4. Use water from the sink in the patient room to extinguish fire
Answer: 2. 2. Evacuate any patients/visitors in immediate danger Following RACE, the first action is to rescue and remove all patients in immediate danger.
Place the following steps for applying a wrist restraint in the correct order. 1. Pad the skin overlying the wrist. 2. Insert two fingers under secured restraint to be sure that it is not too tight. 3. Be sure that patient is comfortable and in correct anatomical alignment. 4. Secure restraint straps to bedframe with quick-release buckle. 5. Wrap limb restraint around wrist or ankle with soft part toward skin and secure snugly.
Answer: 3, 1, 5, 2, 4. 3. Be sure that patient is comfortable and in correct anatomical alignment. 1. Pad the skin overlying the wrist. 5. Wrap limb restraint around wrist or ankle with soft part toward skin and secure snugly. 2. Insert two fingers under secured restraint to be sure that it is not too tight. 4. Secure restraint straps to bedframe with quick-release buckle.
Place the steps for conducting a timed "get up and go" test in the proper order. 1. Turn around. 2. Stand still and then walk 10 feet. 3. Stand up from chair. 4. Sit down. 5. Turn around and walk back to chair.
Answer: 3, 2, 5, 1, 4. 3. Stand up from chair. 2. Stand still and then walk 10 feet. 5. Turn around and walk back to chair. 1. Turn around. 4. Sit down.
Identify at least three pathologies that reduce chest wall expansion.
Examples of pathologies that can reduce chest wall expansion are: -Musculoskeletal abnormalities, such as pectus excavatum and kyphosis -Muscle diseases, such as muscular dystrophy -Nervous system diseases, such as myasthenia gravis, Guillain-Barré syndrome, and poliomyelitis -Disease or trauma involving the medulla oblongata and spinal cord -Trauma to the chest wall, such as multiple rib fractures, chest wall, or upper abdominal incisions
What is the process of breathing out?
Expiration
The nurse finds a 68-year-old woman wandering in the hallway and exhibiting confused behavior. The patient says that she is looking for the bathroom. Which interventions are appropriate to ensure the safety of the patient? (Select all that apply.) 1. Ask the physician or health care provider to order a restraint. 2. Insert a urinary catheter. 3. Provide scheduled toileting rounds every 2 to 3 hours. 4. Consult with the health care provider about ordering an antianxiety medication. 5. Keep the bed in low position with the side rails down. 6. Keep the pathway from the bed to the bathroom clear.
Answer: 3, 5, 6. 3. Provide scheduled toileting rounds every 2 to 3 hours. 5. Keep the bed in low position with the side rails down. 6. Keep the pathway from the bed to the bathroom clear. Safety measures include checking on patients often and providing for toileting needs, keeping a bed in low position with side rails down to allow for easy exit, and keeping walking pathways clear.
A home health nurse is visiting a patient and begins a discussion with the family caregiver about food safety. Which of the following statements made by the caregiver suggests that he or she requires further instruction? 1. "When I prepare a salad, I need to rinse the lettuce and mushrooms thoroughly." 2. "I always wash my hands before I start to make a meal." 3. "When I make fried chicken, I use the cutting board to cut up the chicken pieces, and then later chop up greens for a salad on the same board." 4. "I always cook my husband's pork chops well done."
Answer: 3. 3. "When I make fried chicken, I use the cutting board to cut up the chicken pieces, and then later chop up greens for a salad on the same board." One should always use separate cutting boards for vegetables, poultry, and meat to reduce the risk of food contamination.
A patient on prolonged bed rest is at an increased risk to develop this common complication of immobility if preventive measures are not taken. 1. Myoclonus 2. Pathological fractures 3. Pressure injuries 4. Pruritus
Answer: 3. 3. Pressure injuries Immobility is a major risk factor for pressure injuries. Any break in the integrity of the skin is difficult to heal. Preventing a pressure injury is much less expensive than treating one; therefore preventive nursing interventions are imperative. Pressure injuries can be prevented or minimized with the use of turning and positioning techniques and devices, maintenance of optimal nutritional status, and wound management.
The nurse applies elastic stockings on a patient after major abdominal surgery. The nurse teaches the patient that the stockings are used after a surgical procedure to promote __________________________.
Answer: Venous return to the heart. Elastic stockings (sometimes called antiembolic stockings) aid in maintaining external pressure on the muscles of the lower extremities and thus promote venous return. Increase in venous return helps reduce the stasis of blood thereby reducing the risk for DVT in the lower extremities.
What are anthropometric measurements and how often are they assessed?
Anthropometric measurements include: -mid upper arm circumference -triceps skin-fold measurements *assessed every 2-4 weeks *dietitian or physical therapist may be responsible to taking these measurements
Identify the appropriate care for a patient with a closed chest tube drainage system in place. Select all that apply. a. Clamp the chest tube when the patient ambulates. b. Milk the tube for the patient who has just had thoracic surgery, if necessary. c. Instruct the patient to inhale if the tube disconnects. d. Report over 100 mL of sanguinous drainage after the patient is more than 8 hours postoperative. e. Keep the drainage unit upright.
Appropriate care for the patient with a chest tube includes: d & e. d. Report over 100 mL of sanguinous drainage after the patient is more than 8 hours postoperative. e. Keep the drainage unit upright. -Assessment of respiratory status and system integrity: Observation for air leaks, kinked tubes -Proper positioning of the patient with chest tubes to facilitate chest tube drainage and optimal functioning of the system -Careful ambulation and transfers -Identifying and reporting any changes in vital signs, level of comfort, SpO2, or excessive bubbling in water-seal chamber -Immediately managing/reporting if there is a disconnection of the system, change in type and amount of drainage, bleeding, or sudden cessation of bubbling
What measures the partial pressure of oxygen dissolved in plasma?
Arterial blood gas
You are a CNA and your charge nurse instructs you to perform ROM on Ms. Adam's left side. When you go into the room, Ms. Adams asks you to do the right side too. What do you do?
Ask the charge nurse if you are able to do it.
Even while carrying out interventions, the nurse is aware this process is continually ongoing
Assessment
6. How can a nurse evaluate a patient's vision and hearing during routine interactions or care?
Assessment of vision and hearing: • Ask the patient to read • Observe the performance of ADLs (activities of daily living) • Observe the patient's use of glasses, magnifiers, or hearing aids • Observe patient's conversation/interaction with others
Interpreting new experiences in terms of existing schemas
Assimilation
What is the disease characterized by an irregular curvature of the cornea or lens and what is the medical name for a sty?
Astigmatism and hordeolum
Collapse of alveoli, preventing exchange of oxygen
Atelectasis
Is the major cause of Coronary Artery Disease
Atherosclerosis
The nurse anticipates that atrial fibrillation will be treated with:
Atrial fibrillation is treated with cardioversion, rate control medication therapy, such as calcium channel blockers or beta-blockers, interventions based on the underlying cause, and blood thinners such as warfarin (Coumadin).
What are the three parenting styles?
Authoritarian, Permissive, Authoritative
Which specialized cells help you see when it is dark and which ones are responsible for seeing in bright light and seeing colors?
Rods are for seeing in dark conditions and Cones are for seeing in bright light and they perceive color
Reflex where you scale the bottom of a baby's foot and the toes will curl and fan
Babinski reflex
How should you enter an elevator when using a wheelchair?
Backwards
What device can be used to provide artificial ventilations after a patient has stopped breathing?
Bag-Valve Mask
Nurses must remember to check this area for skin breakdown for clients who use a nasal cannula for oxygen therapy
Behind the ears
Antihistamines
Bind with H1 receptors on target cells, blocking histamine binding
Cyanosis
Bluish discoloration of skin and mucous membranes may be caused by reduced Hgb, excessive concentration of deoxyhemoglobin in blood
What medication is contraindicated for a patient with asthma?
Bronchodilators and other ephedrine containing products are contraindicated for patients with asthma
20. The nurse is caring for a patient with a hearing aid. What is included in the care for this patient and the assistive device?
Care for a hearing aid includes: • Making sure your fingers are dry and clean before handling hearing aids. • Inserting and removing the hearing aid over a soft surface. • Placing the battery in hearing aid when it is turned off. • Removing the hearing aid battery when not in use and storing it in a marked container in a safe place. • Protecting hearing aids from water and excessive heat or cold. • Using a soft dry cloth to wipe hearing aids and a soft brush to clean difficult to reach areas.
Chest movement is affected by what conditions?
Conditions that may affect chest wall movement include pregnancy, obesity, musculoskeletal abnormalities, abnormal structural configuration, trauma, muscle diseases, and nervous system diseases.
What is the thin membrane that lines the eyelids and becomes inflamed when you have pink eye?
Conjunctiva
These have the primary effects of 1) systemic vasodilation with decreased SVR, 2) decreased myocardial contractility, 3) coronary vasodilation, and 4) decreased HR
Calcium Channel Blockers
Epistaxis
Can be caused by trauma, hypertension, low humidity, upper respiratory infections, allergies, sinusitis, foreign bodies, chemical irritants, tumors, anatomic malformation, etc.
Cardiac dysrhythmias may be caused by:
Cardiac dysrhythmias may be caused by ischemia, valvular abnormality, anxiety, drug toxicity, caffeine, alcohol, tobacco use, cardiothoracic surgery, or as a complication of acid-base or electrolyte imbalance.
Cardiac output is the result of the stroke volume x _____.
Cardiac output is the result of stroke volume x heart rate.
Occurs when O2 and nutrients supplied to the tissues are inadequate because of severe LV failure, papillary muscle rupture, ventricular septal rupture, LV free wall rupture or right ventricular infarc
Cardiogenic Shock
Provide examples of dietary risks that may influence cardiopulmonary status and oxygenation.
Cardiopulmonary status may be influenced by the intake of a diet high in fat, cholesterol, salt, and calories, and low in iron and essential nutrients
A child understands that changing the form of a substance or object does not change its amount, overall volume, or mass. This is called ____.
Conservation
What is the disease that is characterized by a cloudy lens?
Cataracts
Which of the following pathophysiological changes in the heart and lungs occur with aging? Select all that apply. a. Thinning of the ventricular wall of the heart b. SA node becoming fibrotic from calcification c. Increased elastin in the arterial vessel walls d. Increased chest wall compliance and elastic recoil e. Decreased alveolar surface area f. Increased responsiveness of central and peripheral chemoreceptors g. Decreased number of cilia h. Increased respiratory drive
Changes that occur in the cardiopulmonary system as a result of aging include: b, e, & g. b. SA node becoming fibrotic from calcification e. Decreased alveolar surface area g. Decreased number of cilia
Bronchiectasis
Characterized by permanent, abnormal dilation of medium-sized bronchi that is a result of inflammatory changes that destroy elastic and muscular structures supporting the bronchial wall
What is a nursing priority for an older adult client who uses an oxygen mask that recently lost weight?
Check the fit of the mask for an adequate seal
What triggers us to breathe if we try to hold our breath too long?
Chemoreceptors that measure carbon dioxide in the blood. If the carbon dioxide level gets too high, the body is signaled to breath more quickly and deeply
What is the spiral shaped organ of hearing filled with fluid that vibrates when sound waves hit, and what are the hairlike cells that surround it?
Cochlea and organ of corti
Emphasizes fruits, vegetables, fat-free or low-fat milk and milk products, whole grains, fish, poultry, beans, seeds, and nuts
DASH diet
Name one sign of inadequate oxygenation?
Decreased energy, restlessness, rapid shallow breathing, rapid heart rate, sitting up to breath, nasal flaring, confusion, sleepiness, hypertension
Defibrillation is recommended within _____ (time) for an out-of-hospital sudden cardiac arrest and within _____(time) for an inpatient.
Defibrillation is recommended within 5 minutes outside of a hospital/medical center and 3 minutes for an in-hospital victim.
These tell us more specific information about a nursing diagnosis label, what we would refer to if we were unsure if a diagnosis was right for our patient
Defining Characteristics
They increase the force of cardiac contraction (inotropic action) and decrease the HR (chronotropic action)
Digitalis preparations
Aplastic Anemia
Disease in which the patient has peripheral blood pancytopneia and hypocellular bone marrow
Charactered by bone resorption
Disuse osteoporosis
Increased urine excretion
Diuresis
An example of a fluid and electrolyte imbalance that may occur with prolonged immobility is:
Diuresis occurs as a result of the increased blood flow to the kidneys. Diuresis causes the body to lose electrolytes such as potassium and sodium and reduces serum calcium levels. Immobility increases calcium resorption from the bones, causing a release of excess calcium into the circulation or hypercalcemia.
16. A patient has gone to the local walk-in emergency center with flu-like symptoms. After seeing the phy-sician, the patient shows the nurse the prescriptions the physician has written. The patient should be in-formed that ototoxicity may occur with the adminis-tration of which of the following medications? Select all that apply. a. Furosemide b. Vitamin C c. Acetaminophen d. Vancomycin e. Cough suppressant with codeine f. Aspirin
Drugs that may cause ototoxicity are: a. Furosemide d. Vancomycin f. Aspirin
Difficulty breathing, sensation of breathlessness
Dyspnea
What technique can be used to create a good mask seal for BVM use?
E-C clamp, two rescuers with one sealing the mask
Name 3 advanced airways that are available to prehospital EMTs?
ET tube, Combitube, Laryngeal mask airway, King LT, cricothyrotomy
During what stage do people often find a partner and start a family?
Early Adulthood
During which stage do people look to further their education?
Early Adulthood
During which stage do the decisions made shape the rest of our lives?
Early Adulthood
During which life stage have most primary teeth developed?
Early Childhood
What are the two milestones of the preoperational stage?
Egocentrism, Pretend Play
Before using a cane, walker or crutches, the CNA should make sure the canes have
Rubber tips and handles
All goals should follow a ___________ format
SMART
In addition to pulse oximetry, what tool can be used to assess a patient's respiratory status?
End-tidal CO2 (capnography)
You have a burn that is red, swollen, and has blisters. What layer(s) of the skin were damaged?
Epidermis and dermis
What are the three layers of the skin?
Epidermis, dermis, and subcutaneous
Activates B2-adrenergic receptors in peripheral arterioles of skeletal muscle, causing vasodilation
Epinephrine
5. Psychosocial development
Erikson
Making judgments about the patient's progress toward desired health outcomes and the effectiveness of the nursing care plan
Evaluation
Represents the time between ventricular depolarization and repolarization (diastole)
ST Segment
A person can bear some weight but needs weight-bearing help to transfer. The person's functional status for transfer is A. Independent B. Limited Assistance C. Extensive Assistance D. Total Depende
Extensive Assitance
What are the contraindications to NPA insertion?
Facial trauma, suspected basal skull fracture.
What factors contribute to respiratory problems in infants and young children?
Factors contributing to respiratory problems in infants and children are prematurity (surfactant deficiency, respiratory syncytial virus [RSV] infection), frequent exposure to other children, exposure to secondhand smoke, and airway obstruction from foreign objects.
Side rails may be used at any time to keep a patient in bed. True or False
False
True or False: Oxygen is safe to use around open flames
False
True or false: Adhesive nasal strips are not used to improve oxygenation
False, They can be used to improve oxygenation by reducing nasal airway resistance and improving ventilation
True or false. Canes provide support.
False, it aids in providing balance.
What are the medical terms for: farsighted and nearsighted?
Farsighted: hyperopia, nearsighted: myopia
An early sign that the patient's chronic cardiopulmonary disease is worsening is:
Fatigue is an early sign.
Excessive alcohol consumption during pregnancy that causes physical and cognitive abnormalities is called _____ _____ syndrome.
Fetal Alcohol Syndrome (FAS)
Adventitious breath sounds
Fine crackles course crackles, wheezes, stridor, and pleural friction rub
What is used to regulate the amount of oxygen delivered to the client and it is attached to the oxygen source?
Flowmeter
What is the goal of moral reasoning in the conventional stage?
Follow the rules or social acceptance: approval from friends or obey the law
Permanent plantar flexion
Footdrop
For continuous positive airway pressure (CPAP): a. CPAP is used for: b. The usual pressure setting is: c. A disadvantage of CPAP is: d. How is BiPAP different from CPAP?
For CPAP: a. Sleep apnea, and improvement of ventilation for heart, neuromuscular, and pulmonary diseases b. 5-20 cm H2O c. Hypercapnea, gastric distention, discomfort, risk for skin irritation, noise d. BiPAP (Bilevel positive airway pressure) works by providing assistance during inspiration and preventing airway closure during expiration. It provides two levels of pressure: inspiratory positive airway pressure (IPAP) and a lower expiratory positive airway pressure.
For chest percussion, vibration, and postural drainage: a. Chest percussion is contraindicated for a patient with: b. Chest percussion may be done over multiple layers of clothing. True or False c. Vibration is used only during: d. Briefly explain high-frequency chest wall compression (HFCWC) and identify the patients who may benefit most from its use.
For chest percussion, vibration, and postural drainage: a. Bleeding disorders, osteoporosis, fractured ribs b. False c. Exhalation d. High-frequency chest wall compression (HF-CWC) consists of an inflatable vest that is attached to an air-pulse generator. The vest airway clearance system helps to loosen and remove secretions from the airway by delivering high-frequency, small-volume expiratory pulses to a patient's external chest wall. This therapy is beneficial for patients with neuromuscular disorders, cystic fibrosis, or ineffective cough and airway clearance, i.e., with patients who produce 25-30 ml of sputum per day.
For the nursing diagnosis Insufficient airway clearance related to the presence of tracheobronchial secretions, identify a patient outcome and a nursing intervention to assist the patient to meet the outcome.
For the nursing diagnosis Insufficient airway clearance related to the presence of tracheobronchial secretions, possible patient outcomes and nursing interventions are: Patient outcomes: -Sputum will be clear within 24-36 hours -No adventitious lung sounds auscultated -Respiratory rate of 16-24 breaths per minute -Coughing and clearing airway within 24 hours Nursing interventions: -Instruct patient on coughing and deep breathing -Assist with position changes and ambulation -Provide 2000-2500 mL of fluid, if not contraindicated -Monitor vital signs -Suction as necessary -Provide chest physiotherapy or postural drainage, if indicated
The patient has oxygen via a nasal cannula. What specific nursing care should be provided for this patient?
For the patient with a nasal cannula: -Verify setting on flowmeter and oxygen source for proper setup and prescribed flow rate. -Check cannula every 8 hours or as agency policy indicates. Keep humidification container filled at all times. -Post "Oxygen in use" signs on wall behind bed and at entrance to room. -Monitor patient's response to changes in oxygen flow rate with SpO2. Note: Monitor ABGs when ordered; however, obtaining ABG measurement is an invasive procedure, and ABGs are not measured frequently. -Auscultate lung sounds; observe chest excursion; inspect color of skin; and observe for decreased anxiety, improved LOC and cognitive abilities, decreased fatigue, and absence of dizziness. Measure vital signs. -Check adequacy of oxygen flow each shift or as agency policy dictates. -Observe patient's external ears, bridge of nose, nares, and nasal mucous membranes for evidence of skin breakdown. Teach back: Use the principles of teach back to evaluate patient/ family caregiver learning. "I want to be sure I explained how oxygen will help you. Tell me one benefit of oxygen therapy." Revise your instruction now or develop a plan for revised patient teaching if patient is not able to teach back correctly.
Identify the following for tuberculin (Mantoux) testing: a. A skin test is administered on a patient's: b. The test is read after _____ hours. c. A reddened, flat area is a(n) _________ reaction. d. The patient received a Bacille Calmette-Guerin (BCG) vaccination, so the tuberculin skin test will most likely be: Positive or Negative
For tuberculin (Mantoux) testing: a. Inner surface of the forearm b. 48-72 hours c. Negative reaction d. Positive
Identify what should be done if the hospitalized patient's monitor is showing ventricular fibrillation.
For ventricular fibrillation, -Start CPR and defibrillate, preferably with biphasic defibrillator. -Prepare to administer IV/IO epinephrine every 3-5 min.
Clients with Hypoxia are seated in which position?
Fowler
2. Psychosexual focus
Freud
What is a contraindication to insertion of an oropharyngeal airway?
Gag reflex
What supplies do you need? (4)
Gait belt, assistive device, robe, slippers or shoes
An inflammation of the tongue.
Glossitis
These explain the changes in health status you hope to see
Goals
To reduce extension of the fingers and abduction of the thumb, the nurse should use _______________ ____________________ when positioning the patient.
Hand splints or hand rolls
Which researcher studied attachment styles in monkeys?
Harry Harlow
Animals bonding to the first living thing they see after birth is called _____. This was studied by ______.
Imprinting; Konrad Lorenz
Identify at least two environmental or occupational hazards that may affect an individual's cardiopulmonary functioning:
Hazards include: Environmental: Air pollution, smog, and allergens (e.g., pollen) Occupational: Exposure to asbestos, talcum powder, dust, and airborne fibers
Name two techniques for opening a patient airway.
Head-tilt chin lift Jaw thrust
Bloody sputum
Hemoptysis
Collection of blood in the pleural space
Hemothorax
Can be caused by RV failure in which liver becomes congested with venous blood
Hepatomegaly
Pertussis
Highly contagious infection of the respiratory tract caused by a gram-negative bacillus. The bacteria attach to the cilia of the respiratory tract and release toxins that damage the cilia
Congenital hip dysplasia
Hip instability with limited abduction of hips and occasionally adduction contractures (head of femur does not articulate with acetabulum because of abnormal shallowness of acetabulum)
For disaster management, hospitals are required to have what resources in place?
Hospitals are required to have an emergency management plan that addresses identifying possible emergency situations and their probable impact, maintaining an adequate amount of supplies, and having a formal response plan.
Which of the following may cause hyperventilation? Select all that apply. a. Anxiety b. Fever c. Severe atelectasis d. Head injury e. Excessive administration of oxygen
Hyperventilation may be caused by: a, b, and d. a. Anxiety b. Fever d. Head injury
Lung inflammation from stasis or pooling of secretions
Hypostatic pneumonia
Moro reflex
Hypothetical and Abstract Thinking
Inadequate tissue oxygenation
Hypoxia
Erikson believes adolescents are dealing with which crisis?
Identity vs. Role Confusion
After suctioning, the patient has a decrease in overall cardiopulmonary status as evidenced by decreased SpO2, increased EtCO2, continued tachypnea, continued straining to breathe, bronchospasm, and cardiac dysrhythmia. What should the nurse do?
If the patient exhibits these signs, the nurse should: -Limit length of suctioning. -Determine need for more frequent suctioning, possibly of shorter duration. -Determine need for supplemental or increase in supplemental oxygen. Supply oxygen between suctioning passes. -Notify health care provider.
26. Which individuals are at the highest risk for occupational hearing loss?
Individuals who are at high risk of hearing loss are those who work in areas with high noise levels, such as airports, construction sites, farms, factories, stadiums/arenas, etc.
Infection of the innermost layer of the heart
Infective endocarditis
What is the process of breathing in?
Inspiration
Joseph, an 80-year-old, looks back on his life with joy and pride. He has successfully achieved a sense of ___ according to Erikson.
Integrity
The classic symptom of lower extremity PAD
Intermittent claudication
Aortic regurgitation
Is generally the result of rheumatic heart disease, a congenital bicuspid aortic valve, syphilis, or chronic rheumatic conditions, such as ankylosing,spondylitis or reactive arthritis
Explain the "Speak Up" campaign.
It is designed to encourage patients to take a role in preventing health care errors by becoming active, involved, and informed participants in their health care. -For example: patients are encouraged to ask health care workers if they have washed their hands before providing care.
Show how to perform the hip rotation (yes, actually do the skill)
Keeping the leg straight, turn the leg inward and then outward.
Caused by a ;nonocclusive thrombus and does not cause ST segment elevation on the 12-lead ECG
NSTEMI
What is the appropriate oxygen delivery device for low concentrations of oxygen
Nasal cannula: 1-6 L/min
What separates the nose into right and left?
Nasal septum
Nebulization is used in the administration of what types of medications?
Nebulization is used for the administration of bronchodilators and mucolytic agents.
a. A medication that is used to reduce the risk of thrombophlebitis is: b. It is usually given every _____ hours by the _____ route
Newer Low Molecular Weight (LMW) heparins (anticoagulant) are usually given every 12 hours by the subcutaneous route.
How long should an EMT suction an airway?
No longer than 15 seconds.
The nurse is aware that a major difference between Hodgkin's lymphoma and non-Hodgkin's lymphoma is
Non-Hodgkin's lymphoma can manifest in multiple organs
Care provided that helps to meet goals that is within the nursing scope of practice
Nursing Interventions
Prescribed activities that may be done independently by the nurse
Nursing Order
Identify an example of a nursing intervention for promotion of each of the following: a. Dyspnea management b. Patent airway c. Lung expansion d. Mobilization of secretions
Nursing interventions to achieve the following include: a. Dyspnea management: Administration of medications (e.g., bronchodilators), supervision of oxygen therapy, and instruction in breathing and coughing techniques and relaxation measures b. Patent airway: Instruction in coughing techniques, suctioning, and airway placement c. Lung expansion: Positioning, administering chest physiotherapy, instruction in the use of incentive spirometry, and management of chest tubes, if indicated d. Mobilization of secretions: Hydration of the patient, humidification/nebulization of oxygen therapy, postural drainage, and administration of chest physiotherapy
Oxyhemoglobin
O2 bound hemoglobin that is responsible for giving arterial blood its bright red appearance
Information about chemical substances in the health care workplace can be found in:
Safety Data Sheets (SDS)
A child's ability to understand that objects still exist after they are no longer in sight
Object Permanence
Bowlegs (genu varum)
One or both legs bent outward at knee, which is normal until 2-3 years of age
Name two potential chest wall findings that may indicate a dangerous respiratory emergency
Open pneumothorax, Flail chest
8. Orientation to the environment for a patient with a sensory deficit should include:
Orientation to the environment should include: • Keeping your name tag visible, addressing the patient by name, explaining the patient's location, and frequently identifying the time and date in conversations. • Offering short and simple, repeated explanations and reassurance. • Encouraging family and friends not to argue with or contradict a confused patient but to explain calmly their location, identity, and time of day. • Walking the patient through a room to feel the walls and establish a sense of direction. • Approaching a visually impaired patient from the front. • Explaining the location of objects within the room, such as chairs or equipment. • Keeping all objects in the same place and position and describing the location of key items. • Placing necessary objects such as the call light, patient-controlled analgesia (PCA) button, glasses, water, or facial tissue in front of patients. • Asking the patient how to arrange objects so ambulation is easier. • Removing clutter and unnecessary equipment and keeping the path to the bathroom clear.
What are the three bones called that are in the middle ear?
Ossicles: malleus, incus, and stapes or Ossicles: hammer, anvil, and stirrup
What disease is characterized by a sore ear with fluid drainage?
Otitis media
Which disease is characterized by a hardening of the bone(s) in the middle ear and it is inherited?
Otosclerosis
Phase designed to collaborate with the patient and family to identify desired outcomes and to prioritize identified problems
Outcomes identification/ Planning
What is the goal of moral reasoning in the post-conventional stage?
Own Ethical Principles: Life is better for all, Moral and Legal are not always the same
What measures the percentage of delivered oxygen?
Oxygen Analyzer
What are some examples that might affect these basic needs? a. Oxygen: b. Nutrition: c. Temperature:
Oxygen: Carbon monoxide, improper ventilation, pollutants Nutrition: Improper storage/refrigeration, inadequate cleaning of cooking surfaces, improper food preparation Temperature: Exposure to excessive heat or cold
Represents time taken for impulse to spread through the atria, AV node and bundle of His, bundle branches, and Purkinje fibers, to a point immediately before ventricular contraction
PR Interval
Identify the four pathological influences on mobility and an example of each one.
Pathological influences on mobility include: -postural abnormalities (torticollis, lordosis, kyphosis, scoliosis, congenital hip dysplasia, genu valgum, genu varum, clubfoot, footdrop, pigeon toes) -muscle abnormalities (muscular dystrophy) -damage and disorders of the CNS (trauma, stroke, meningitis, ALS, MS, Parkinson's, myasthenia gravis) -direct trauma to the MS system (fractures, osteoporosis, osteogenesis imperfecta).
The part of the ear that we see outside is called the... (both names)
Pinna and auricle
How should you help a person stand?
Place your toes against the person's toes and bend your knees so that they rest against or near the patient's knees.
11. Identify safety concerns in the home environment for the following age groups: a. Toddler: b. Older adult:
Safety concerns in the home environment include: a. Toddler: Access to poisons, such as cleaning supplies; electrical outlets; ability to exit the home; swim-ming pools; kitchen appliances; auto accidents; choking on small objects b. Older adult: Poor lighting, slippery floors and unsecured rugs, excessive water temperature, stairs
Collection of air in the pleural space
Pneumothorax
Your patient presents after a fall with dyspnea, left sided chest pain, diminished breath sounds. Untreated you may note JVD or tracheal deviation. Diagnosis and treatment?
Pneumothorax; O2, needle thoracostomy
Name one nursing intervention frequently used to promote oxygenation
Positioning and teaching breathing techhniques
13. Identify a goal/outcome for a patient with a nursing diagnosis of Disturbed Sensory Perception.
Possible goals/outcomes include: The patient will manage self-care, ambulate safely, verbalize feelings, remain oriented to surroundings, communicate/ interact with others, participate in planning care, identify community resources.
Identify a possible nursing diagnosis for a patient with anemia.
Possible nursing diagnoses for a patient with anemia include Alteration in activity level/ability and Fatigue
What are the three stages of Kohlberg's Moral Development?
Pre-Conventional, Conventional, Post-Conventional
Amount of blood in the ventricles at the end of diastole
Preload
With this disorder you would need bifocals.
Presbyopia
10. Prescriptive use or administration of more medication than indicated clinically is termed:
Prescription or use of more medications than indicated is called polypharmacy.
Name 4 ways to prevent pressure ulcers
Providing good skin care Encourage movement Observe for signs of skin breakdown Assist with regular toileting and perineal care Encourage good nutrition/fluid intake Reposition Wrinkle-free linens
With an immobilized child, the nurse's focus is on:
Providing the immobilized child with physical and psychosocial stimulation in order to keep pace with motor and intellectual development.
What monitors the oxygen saturation of blood?
Pulse oximetry
Which is the correct pathway of vision? (starting with an image/light enters the cornea...)
Pupil, lens, retina, rods and cones, optic nerve, and brain
What is a form of controlled ventilation in which the client consciously prolongs the expiration phase of breathing?
Pursed-lip breathing
Identify the meaning of the following for fire management: R: A: C: E: P: A: S: S:
R - Rescue and remove all patients in immediate danger A - Activate the alarm. Always do this before trying to extinguish even a minor fire. C - Confine a fire by closing doors and windows and turning off oxygen and electrical equipment. E - Extinguish a fire using an appropriate extinguisher. P - Pull the pin. Hold the extinguisher with the nozzle pointing away from you and release the locking mechanism. A - Aim low. Point the extinguisher at the base of the fire. S - Squeeze the lever slowly and evenly. S - Sweep the nozzle from side-to-side.
An episodic vasospastic disorder of small cutaneous arteries, most often involving the fingers and toes
Raynaud's phenomenon
Before having the patient sit what must you ask them to do?
Reach for the chair behind them.
What is an age related change that can affect respiratory function in older adults?
Reduced gas exchange and efficiency in ventilation, increased use of accessory muscles, increased mouth breathing, increased snoring
Calcium stones in the kidney
Renal calculi
A nurse is monitoring the ECG of a patient admitted with ACS. Which ECG characteristic would be most suggestive of myocardial ischemia
Sinus rhythm with a depressed ST segment
Where does a CNA stand when transferring a patient with a walker?
Slightly behind them on their weak side
Decrease impulse conduction in the atria, ventricles, and His-Purkinje system
Sodium Channel Blocker
21. Behaviors that are specific for an adult with a visual impairment include (select all that apply): a. Poor coordination b. Rocking c. Squinting d. No reaction to being touched e. Accidental falls f. Increase in appetite
Specific adult behaviors include: a. Poor coordination c. Squinting e. Accidental falls
Specific range of motion exercises to prevent thrombophlebitis include:
Specific exercises to prevent thrombus formation include: -ankle pumps -foot circles -knee flexion -hip rotation
Decongestants
Stimulates adrenergic receptors on blood vessels, promotes vasoconstriction, reduces nasal congestion
Pseudoephedrine (sudafed)
Stimulates adrenergic receptors on blood vessels, promotes vasoconstriction, reduces nasal congestion
The recommended treatment for an initial VTE in an otherwise healthy person with no significant co-morbidities would include
Subcutaneous low-molecular-weight heparin as an outpatient
The nurse documents the patient is experiencing nausea-- that is this type of data
Subjective
Which of the following are appropriate interventions for patient suctioning? Select all that apply. a. Performing pharyngeal suctioning before tracheal suctioning b. Avoiding routine use of normal saline instillations when suctioning c. Applying suction for 30 seconds at a time d. Suctioning during the insertion and removal of the tube e. Allowing 1-2 minutes between suction passes f. Providing regular suctioning every 1-2 hours around the clock
The appropriate interventions for suctioning are: b and e. b. Avoiding routine use of normal saline instillations when suctioning e. Allowing 1-2 minutes between suction passes
Which type of asepsis is used for tracheal suctioning?
Surgical asepsis or sterile technique is used to suction the trachea.
Tracheostomy
Surgically created stoma in the anterior portion of the trachea
What is the term for harmful agents a mother can put in her body?
Teratogens
What resources/agencies are available for patient safety standards?
The Joint Commission (TJC), Quality and Safety Education for Nursing (QSEN), Centers for Medicare and Medicaid Services (CMS), Occupational Safety and Health Administration (OSHA), the Institute for Healthcare Improvement (IHI), the Agency for Healthcare Research and Quality (AHRQ), and the U.S. Department of Veterans Affairs (VA)
The framework for the organization of individualized nursing care
The Nursing Process
What personal protective equipment (PPE) is used when preparing to suction a patient?
The PPE for suctioning includes: -Gloves: Clean gloves for oropharyngeal suctioning. Two sterile gloves or one sterile and one clean glove for tracheal suctioning. -Mask, goggles, or face shield; isolation gown if indicated.
The nurse may only carry out interventions as governed by
The State's Nurse Practice Act
16. What are the characteristics of the adolescent age group? Select all that apply. a. Preference for same sex peers b. Completion of language development c. Search for personal identify d. Following the rules of new authority figures e. Adoption of the parents' moral standards f. Development of secondary sex characteristics
The accurate statements for an older adult are: b, c, and f. b. Completion of language development c. Search for personal identify f. Development of secondary sex characteristics
19. Indicate which of the following are true for older adult individuals. Select all that apply. a. Cognitive impairment is always expected. b. Strong visual memory is retained. c. Delirium is potentially reversible. d. Depression is becoming more common in this population. e. Short-term memory is unaffected. f. Sense of touch remains strong.
The accurate statements for an older adult are: b, c, d, and f. b. Strong visual memory is retained. c. Delirium is potentially reversible. d. Depression is becoming more common in this population. f. Sense of touch remains strong.
15. Which of the following are appropriate in promoting sensory stimulation in the home environment? Select all that apply. a. Reducing glare by using sheer curtains on windows b. Using pale colors on surfaces c. Serving bland foods with similar textures d. Using a pocket magnifier e. Introducing fragrant flowers f. Playing recorded music with high-frequency sound
The appropriate actions for promotion of sensory stimulation in the home are: a. Reducing glare by using sheer curtains on windows d. Using a pocket magnifier e. Introducing fragrant flowers
Which of the following herbs or spices are contraindicated for patients with high blood pressure or asthma? Select all that apply. a. Pepper b. Ginseng c. Paprika d. Ma huang e. Garlic capsules
The contraindicated herbs or spices are: b, d, and e b. Ginseng d. Ma huang e. Garlic capsules
The leading cause of death in the toddler and preschool age groups is:
The leading cause of death in the toddler and preschool age group is accidents.
Which of the following are lifestyle factors that contribute to poor cardiopulmonary status? Select all that apply. a. Having a diet low in protein b. Participating in a daily exercise regimen c. Drinking significant amounts of alcohol d. Being a construction worker e. Having a high stress job
The lifestyle factors that contribute to poor cardiopulmonary outcomes are: a, c, d, and e. a. Having a diet low in protein c. Drinking significant amounts of alcohol d. Being a construction worker e. Having a high stress job
Place the following steps for in-line suctioning in the correct sequence. The nurse has already positioned the patient and performed hand hygiene. a. Reassess pulmonary status b. Insert the catheter until resistance is felt c. Hyperoxygenate the patient d. Withdraw the catheter, applying suction e. Repeat the procedure, if indicated f. Pick up the catheter enclosed in the plastic sheath
The sequence for in-line suctioning is: c, f, b, d, a, e c. Hyperoxygenate the patient f. Pick up the catheter enclosed in the plastic sheath b. Insert the catheter until resistance is felt d. Withdraw the catheter, applying suction a. Reassess pulmonary status e. Repeat the procedure, if indicated
Identify the signs/symptoms of dyspnea. Select all that apply. a. Labored breathing b. Nasal flaring c. Chest pain d. Increased respiratory rate e. Coughing
The signs/symptoms of dyspnea are: a, b, and d. a. Labored breathing b. Nasal flaring d. Increased respiratory rate
The interventions in CPR are: C - A - B - The rate of chest compressions for an adult is __________ /minute.
The steps of CPR: C: Circulation A: Airway B: Breathing The rate of chest compressions is 100-120/minute for adults.
This refers to the ability humans have to recognize and attribute mental states not only in themselves but in other people, and to understand that feelings and beliefs we have may be different than others.
Theory of Mind
A patient awakens in a panic and feels as though she is suffocating. This is noted by the nurse as:
This condition is noted by the nurse as paroxysmal nocturnal dyspnea (PND).
A nonatherosclerotic, segmental, recurrent inflammatory disorder of the small and medium arteries and veins of the upper and lower extremities
Thromboangitis obliterans (Buerger's disease)
Accumulation of platelets, fibrin, clotting factors, and cellular elements attached to the interior wall of an artery or vein
Thrombus
You can get this when you take antibiotics; it is white raised patches on the tongue.
Thrush
This is not a disease but only a side effect and it is characterized by a ringing in the ears.
Tinnitis
An important concept when working with patients who are immobilized is to maintain the patient's autonomy. The nurse can accomplish this by:
To maintain the patient's autonomy, the nurse encourages the patient to do as much as possible, demonstrate activities, and participate in goal setting and decision making.
In order to reduce the incidence of ventilator associated pneumonia (VAP), the nurse will implement:
To prevent the incidence of VAP, the nurse should: -Maintain head of the bed elevation between 30 and 45 degrees to reduce aspiration of oropharyngeal and/or gastric fluids, unless contraindicated. Be cognizant of the increased risk of development of decubitus ulcers when patients are placed greater than 30 degrees. -Suction frequently to remove oropharyngeal secretions to reduce the risk of early-onset VAP. -Monitor ETT cuff pressure frequently to ensure that there is an adequate seal to prevent aspiration of secretions. -Provide daily oral care with chlorhexidine. -Consult with health care providers to ensure that medications for DVT and peptic ulcer disease prophylaxis are ordered -Collaborate with other members of the healthcare team to ensure early mobilization of the patient. -Always drain ventilator circuit condensation away from patient and into the appropriate receptacle.
9. To promote awareness of time, place, and person in an extended care environment, a nurse implements:
To promote awareness of time, place, and person, the nurse should implement reality orientation.
Name 2 causes of airway obstruction.
Tongue, foreign body, laryngeal spasm, allergic reaction, swelling from trauma, inhaled burns
The nurse anticipates that treatment for hyperventilation will include:
Treatment for hyperventilation involves treating the underlying cause, improving tissue oxygenation, restoring ventilation, reducing respiratory rate, and achieving acid-base balance.
Name 3 signs of respiratory distress that you may detect during your assessment.
Tripod position, flaring nostrils, pursed lips, accessory muscles, adventitious breath sounds, cyanosis
A nurse anticipates that a patient on prolonged bed rest will have an increased heart rate. True or False
True
Among adults 65 years and older, falls in the home are the leading cause of unintentional death. True or False.
True
The application of physical restraints may be delegated to nursing assistive personnel. True or False.
True
There is a greater risk for poisoning as a result of finding multiple medications in the home of an older adult. True or False.
True
True or False, As we age our gag reflex diminshes
True
True or False: Oxygen cannot be administered without a prescription
True
An infant cries uncontrollably because they fear their caretaker will not return. Erikson says this infant has failed to achieve a sense of _____.
Trust
Pulmonary edema
Upon inspection you find tachypnea, labored respirations, cyanosis, blood-tinged sputum, fine or course crackles
What are the bumps of the surface of the tongue called?
papillae
Two major complications that may result from acute pericarditis
pericardial effusion and cardiac tamponade
What is the movement of air in and out of the lungs?
Ventilation
Name 3 abnormal lung sounds and what they may represent.
Wheezes: asthma Diminished: pneumothorax, effusion Rales/crackles: pneumonia, pulmonary edema Ronchi: mucus accumulation Stridor: upper airway obstruction, anaphylaxis
A musical, high-pitched lung sound that may be heard on inspiration or expiration is:
Wheezing is a high-pitched, musical lung sound that is heard on inspiration and/or expiration
A critical thinker will always seek to know
Why/More
Using the algorithm for patient transfers, the appropriate intervention for a patient who is cooperative, has upper body strength, but cannot bear full weight should be:
With the algorithm, a transfer aid should be selected for use or the assistance of another person.
State the 3 stages of prenatal development.
Zygote, Embryo, Fetus
Bone mineral density
a diagnostic test used to determine the core mineral content and the density of bone. This test is used for the diagnosis of osteoporosis and osteopenia
Arthroscopy
a procedure that allows direct visualization of the interior of a joint through an endoscope. This procedure is most commonly performed on the knee, but it can be done on other joints as well
Myelogram
a radiographic study of the spinal cord and nerve root using a contrast dye. This is particularly useful in the evaluation of individuals with back pain
What are the 4 main types of growth and development that occur?
physical, mental (cognitive), emotional, social
5. Identify how the following factors may influence sensory function: a. Age: older adulthood b. Medications c. Smoking d. Environment
a. Age, older adulthood: • Decreased hearing acuity, speech intelligibility, and pitch discrimination • Increased dryness of cerumen, with obstruction of the auditory canal • Reduced visual fields; increased glare sensitiv-ity; impaired night vision; reduced accommoda-tion, depth perception, and color discrimination • Reduced sensitivity to odors and diminished taste discrimination • Difficulty with balance, spatial orientation, and coordination • Diminished sensitivity to pain, pressure, and temperature b. Medications: May cause ototoxicity or optic nerve irritation (chloramphenicol) or may reduce sensory perception (analgesics, sedatives, antidepressants) c. Smoking: May cause atrophy of taste buds and in-terference with olfactory function d. Environment: Excessive stimuli (e.g., noise), fre-quent activities, noise, TV, bright lights, pain, confinement
20. a. The single best predictor of adult hypertension is: b. The risk of hypertension is increased if the child is:
a. Blood pressure elevation in childhood is the single best predictor of adult hypertension. b. The risk of hypertension is increased if the child is overweight or obese.
Identify at least one major change that may occur in each of the following body systems as a result of immobility and a nursing intervention to prevent or treat the change. a. Cardiovascular b. Respiratory c. Integumentary d. Gastrointestinal e. Urinary f. Musculoskeletal
a. Cardiovascular: -Orthostatic hypotension: Move the patient slowly from one position to another. -Increased cardiac workload: Place the patientin an upright position (if possible), provide regular exercise and adequate fluid intake. -Thrombus formation: Provide regular exercise, adequate fluid intake, and antiembolic stockings. b. Respiratory: -Hypostatic pneumonia and atelectasis. Encourage coughing and deep breathing, adequate fluid intake, and exercise; turning; upright positioning; chest physiotherapy c. Integumentary: -Pressure ulcers: Assess the skin, use supportive devices, provide adequate nutrition and hydration, change position every 1-2 hours, and perform meticulous skin care. d. Gastrointestinal: -Reduced appetite, inadequate/imbalanced nutri- tion, decreased peristalsis: Provide adequate nu- trition (fruits, vegetables, fiber) and hydration, measure I&O, administer prescribed cathartics, promote activity or movement, and institute a bowel program. e. Urinary: -Urinary stasis resulting in greater risk for infection and calculi: Provide adequate hydration and promote activity and movement. f. Musculoskeletal: -Loss of strength and endurance, reduced muscle mass, decreased stability and balance, with possible contractures and disuse osteoporosis: Provide or encourage range-of-joint-motion exercises, turn every 1-2 hours, change position, and refer to physical therapy.
4. Provide the correct term for each of the following: a. A buildup of ear wax in the external auditory canal b. Hearing loss associated with aging c. Opacity of the lens resulting in blurred vision d. Decreased salivary production or dry mouth
a. Cerumen accumulation b. Presbycusis c. Cataract d. Xerostomia
a. Identify at least four signs or symptoms of hypoventilation. b. How is hypoventilation treated?
a. Clinical signs and symptoms of hypoventilation include dizziness, occipital headache on awakening, lethargy, disorientation, decreased ability to follow instructions, cardiac dysrhythmias, hypertension, seizures, and possible coma or cardiac arrest. b. Treatment for hypoventilation involves treating the underlying cause, improving tissue oxygenation, restoring ventilation, and achieving acid-base balance.
11. For a patient with cataracts, the nurse anticipates which of the following signs and symptoms? Select all that apply. a. Cloudy vision b. Eye pain c. Glare d. Burning sensation e. Poor night vision f. Double vision
a. Cloudy vision c. Glare e. Poor night vision f. Double vision
For a patient who will have antiembolic stockings: a. The contraindications for their use are: b. How often are they are removed? c. A nurse makes sure that the stockings are NOT: d. Application of the stockings may be delegated to an unlicensed nursing assistant. True or False
a. Contraindications for use include: -dermatitis -open skin lesions -new skin grafts -decreased circulation b. The stockings are removed every 8 hours or per agency policy. c. The stockings should not be: -partially rolled down or wrinkled -the toes should not be uncovered d. True
Provide an example of a physiological alteration or problem that may cause each of the following: a. Decreased oxygen carrying capacity b. Decreased inspired oxygen concentration c. Hypovolemia d. Increased metabolic rate
a. Decreased oxygen carrying capacity: Anemia, inhalation of toxic substances (carbon monoxide) b. Decreased inspired oxygen concentration: Airway obstruction, higher altitudes c. Hypovolemia: Fluid loss, dehydration, shock d. Increased metabolic rate: Fever, pregnancy, hyperthyroidism
For older adults: a. Identify at least three physiological changes that increase the risk of accidents for older adults: b. Indicate at least two areas that should be included in teaching the older adult about: (1) Driving safety (2) Home environment safety
a. Diminished vision, hearing, mobility, reflexes, and circulation are some of the reasons that older adults are predisposed to accidents. b. (1) Driving safety: Advise older adults to drive only short distances and in the daylight; avoid driving in inclement weather; use side and rear view mirrors carefully; look behind them toward their blind spot before changing lanes; and keep a window rolled down in order to hear sirens and horns. (2) Home environment safety: -Because of visual impairments in older adults, teach patients to keep living areas well lighted and free of clutter and to keep eyeglasses in good condition. -Older adults have musculoskeletal changes that make movement difficult and increase the risk for falling. Teach patients to keep assistive devices in proper working order (canes, hand rails in tub and bathroom, and elevated seats) and to use nonskid strips in bathtubs. -Advise older adults to avoid smoking in bed, to lower thermostats on water heaters, to avoid overloading electrical outlets, and to install and maintain smoke and carbon monoxide detectors in the house.
Briefly define the following abnormal chest wall movements: a. Retraction b. Paradoxical breathing
a. Retraction is the visible sinking in of the soft tissues of the chest between and around firmer tissue and ribs, often seen in the intercostal spaces. b. Paradoxical breathing is asymmetrical or asynchronous breathing where the chest contracts during inspiration and expands during expiration.
The primary goal when using restraints (safety reminder devices) is to:
prevent falls and other injuries
Diuretics
reduces edema, pulmonary venous pressure and preload
For each of the following, identify a nursing intervention that may be implemented to prevent injury and promote patient safety. a. Falls: b. Patient-inherent accidents: c. Procedure-related risks: d. Equipment-related risks:
a. Falls: Complete a risk assessment, provide supervision, place the patient close to the nurses' station, orient the patient to the surroundings, use gait belts and other assistive devices for transfers and walking, include a low bed and bed/chair alarm, remove clutter, maintain proper lighting, have the patient use non-skid shoes, identify the patient's risk (colored name band), use physical restraints if absolutely necessary. b. Patient-inherent accidents: Institute seizure precautions, remove foreign substances or hazardous items (sharps), provide supervision of the patient's activities. c. Procedure-related risks: Follow policies and procedures carefully, use appropriate technique and body mechanics for performing procedures. d. Equipment-related risks: Learn how to operate the equipment, have it checked regularly for proper functioning.
14. In relation to screening for sensory deficits: a. Provide an example of a general screening that is conducted to determine visual and/or auditory deficits. b. The recommendation of frequency for hearing screenings is:
a. General screenings include examinations for congenital blindness and visual impairment in infants and young children and routine vision and hearing tests of school-age and adolescent children. In the absence of symptoms or risk factors for disease, the Academy recommends a baseline eye examination at 40 years of age. Follow-up examination interviews are based on risk factors for disease and the results of the initial screening. Adults 65 years of age and older need examinations every 1-2 years. b. The specific recommendation for hearing screenings is for at least once every decade through age 50, and then once every three years.
12. Indicate how a nurse may assist patients with the fol-lowing deficits to adapt their home environments for safety: a. Hearing deficit b. Diminished sense of smell c. Diminished sense of touch
a. Hearing deficit: Amplify low-pitch sounds, use lamps with sound activation, use assistive devices for telephones, and obtain closed captioning for the television. b. Diminished sense of smell: Use smoke and carbon monoxide detectors, take special care with dis-posal of matches and cigarettes, and check the expiration dates on foods. c. Diminished sense of touch: Lower the tempera-ture of the water heater (no higher than 120° F) and use caution when checking the bath or shower water. Shoes should be worn at all times to protect the feet from injury.
Identify at least one Patient Safety Goal identified by The Joint Commission for the following: a. Hospitals b. Home care
a. Hospitals -Use at least two patient identifiers. -Eliminate transfusion errors related to patient misidentification. -Report critical results on a timely basis. -Label all medications and containers on and off the sterile field. -Reduce patient harm associated with anticoagulant therapy. -Maintain and communicate accurate patient medication information. -Clinical alarm safety. -Use evidence-based practices to prevent health care associated infections. -Use evidence-based practices to prevent central line associated bloodstream infections. -Use evidence-based practices to prevent surgical site infections. -Use evidence-based practices to prevent catheter associated urinary tract infections. -Identify patients at risk for suicide. -Conduct a preprocedure verification process. b. Home care -Identify patients correctly -Use medicines safely -Prevent infection -Prevent patients from falling -Identify patient safety risks (i.e., patients on oxygen and risk of fire).
For home oxygen therapy: a. It is indicated when the patient has a SaO2 value of: b. What safety measures should be implemented when oxygen is used in the home?
a. Indications for home oxygen therapy include stable disease in patients with PaO2 of 55 mm Hg or less or an arterial oxygen saturation (SaO2) of 88%. Others who qualify for long-term home oxygen therapy include those with a PaO2 of 55-59 mm Hg and exhibit signs of hypoxia. b. Safety measures for home oxygen use include: -Place "No smoking" signs on the patient's room door and over the bed. Inform the patient, visitors, roommates, and all personnel that smoking is not permitted in areas where oxygen is in use. -Determine that all electrical equipment in the room is functioning correctly and is properly grounded. -Know the fire procedures and the location of the closest fire extinguisher. -Check the oxygen level of portable tanks before transporting to ensure there is enough oxygen in the tank. -Have an alternative source of oxygen in case of a power failure
For each of the following age groups, identify an example of a potential safety hazard and instruction that can be provided. a. Infant, toddler, preschooler: b. School age child: c. Adolescent: d. Adult: e. Older adult:
a. Infant, toddler, preschool: Injuries- falls, ingestion (poison, foreign bodies, medications), and burns. -Instruction on preventing access to poisonous substances; creating a safe sleeping environment; using car seats correctly; using safe, age-appropriate toys; and teaching young children safety rules, immunizations b. School-age child: Sports, after-school activities, bicycle accidents, school bus injuries. -Instruction on the importance of children wearing seat belts whenever riding in a car; wearing helmets when riding a bicycle, skateboard, or scooter; and keeping adults informed of where the child is. -Educate how to cross a street safely and to refrain from talking to or accepting rides or gifts from strangers. Teach children what to do if a stranger approaches and how to get help, as well as how to avoid unsafe and isolated areas. c. Adolescent: Smoking, substance abuse, motor vehicle accidents, drowning, sexual activity. -Provide accurate instructions about abstinence and safe sexual practices. -Educate them and their families about signs of school violence, including bullying, fighting, weapon use, gang violence, and electronic aggression -Education about complying with rules and regulations regarding safe driving and the use of a car. d. Adult: Alcohol/substance abuse, motor vehicle accidents, stress-related activities. -Help adults understand their safety risks and guide them in making lifestyle modifications by referring them to resources such as classes to help quit smoking and for stress management, or employee assistance programs. -Encourage them to exercise regularly, maintain a healthy diet, practice relaxation techniques, and get adequate sleep. e. Older adult: Falls, medication misuse. -Providing information about neighborhood resources, such as modes of transportation, church schedules, and food resources, daily "hello" programs, emergency services, and elder-abuse hot lines is also helpful. -Instruct about accident prevention and safe medication use.
Identify whether the following signs and symptoms are associated with left ventricular or right ventricular heart failure: a. Dyspnea b. Distended neck veins c. Ankle edema d. Pulmonary congestion
a. Left ventricular heart failure b. Right ventricular heart failure c. Right ventricular heart failure d. Left ventricular heart failure
For an immobilized patient, identify the usual frequency of assessment for the following: a. Respiratory status: b. Anorexia: c. Urinary elimination: d. Total intake and output:
a. Respiratory status: Every 2 hours b. Anorexia: At meals c. Urinary elimination: At the beginning or end of every shift d. Total intake and output: Every 24 hours for daily measurement
Plays an important role in the rate of impulse formation, speed of conduction, and strength of cardiac contraction
autonomic nervous system
3. Identify at least one factor that can lead to each of the following Disturbed Sensory Perception diagnoses, and indicate possible patient responses, signs, and symptoms: a. Sensory deprivation b. Sensory overload
a. Sensory deprivation is an inadequate quantity or quality of stimulation that impairs perception (e.g., prolonged bed rest or hearing loss). Individuals can demonstrate cognitive changes such as the inability to solve problems, poor task performance, and dis-orientation. It can also cause affective changes (e.g., boredom, restlessness, increased anxiety, emotional lability) and/or perceptual changes (e.g., reduced attention span, disorganized visual and motor coor-dination, confusion of sleeping and waking states). b. Sensory overload occurs when the individual re-ceives multiple stimuli and the brain has difficulty distinguishing the stimuli (e.g., health care units and activities). The patient may demonstrate panic, confusion, and aggressiveness. Sleep loss is com-mon. Sensory overload causes a state similar to sensory deprivation.
For a patient with hypoxia: a. What are the signs and symptoms? b. What treatment is anticipated?
a. Signs and symptoms of hypoxia include, but are not limited to, tachycardia, tachypnea and dyspnea, peripheral vasoconstriction, dizziness, and mental confusion. b. Anticipated treatment includes oxygen therapy, maintenance of a patent airway with suctioning, breathing exercises, chest physiotherapy, pharmacotherapy (cardiac and respiratory stimulant drugs).
Carbon monoxide poisoning can occur in the home. a. Identify the signs and symptoms associated with low concentrations. b. What safety measure is necessary to prevent exposure?
a. Signs and symptoms of low concentration carbon monoxide poisoning are nausea, dizziness, headache, and fatigue. Higher concentrations are often fatal. b. It is important that there are carbon monoxide detectors in the home.
For the following areas, identify a specific environmental adjustment that should be made to promote safety. a. Tactile deficit: b. Visual deficit:
a. Tactile deficit: Check/adjust the water heater temperature, clearly label the settings on the stove/oven, obtain easy-open medication containers. b. Visual deficit: Maintain adequate lighting, use stair treads and handrails, decrease clutter, use distinct colors, have large print on labels.
a. An example of a teratogen is: b. Why are teratogens able to have an impact upon fetal development?
a. Teratogens include communicable diseases, alcohol and drugs, smoking, and pollutants. b. Because the placenta is extremely porous, teratogens pass easily from mother to fetus. Some examples of teratogens are viruses, drugs (prescribed, over-the-counter, and street drugs), alcohol, and environmental pollutants, such as lead.
a. You know that a piece of equipment in the acute care agency is safe to use when: b. Health care providers are exposed to possible poisons in the acute care environment by:
a. The equipment is safe to use when you see a safety inspection sticker with an expiration date. b. Health care providers may be exposed to chemicals such as chemotherapy drugs and toxic cleaning agents.
7. For visual and hearing impairments in children: a. A common cause of blindness is: b. What information should be included when teach-ing parents about eyesight safety? c. Common causes of hearing impairment in children:
a. Trauma is the leading cause of blindness in children, usually as the result of flying objects or penetrating wounds. b. Child eyesight safety includes avoiding toys with long, pointed handles or sharp edges; keeping the child from running with a pointed object; and keeping pointed objects and tools out of reach. c. Chronic middle ear infections and exposure to loud noise contribute to hearing loss in children.
a. The prevalence of atrial fibrillation increases with age. True or False b. Care of chest tubes can be delegated to a nursing assistant. True or False
a. True b. False
Match the type of fire extinguisher with the form of fire. Type A, Type B, Type C a. Grease fire b. Electrical fire c. Paper fire
a. Type B b. Type C c. Type A -type A: for paper and rubbish -type B: for grease and anesthetic gas -type C: for electrical
Indicate safety measures for the following: a. Use of home oxygen b. Food preparation
a. Use of home oxygen -Post "No Smoking" and "Oxygen in Use" signs -Do not use oxygen around electrical equipment or flammable products. -Store oxygen tanks upright in carts or stands to prevent tipping or falling over. -Make sure that there is a sufficient supply on hand of oxygen and spare tubing. b. Food preparation: -Proper refrigeration, storage, and preparation of food decrease risk of food-borne illnesses. -Store perishable foods in refrigerators to maintain freshness. -Refrigerate foods at 40° F within 2 hours of cooking. Label leftovers with a date. -Thaw frozen foods in the refrigerator -Wash hands for at least 15 seconds before preparing food. -Rinse fruits and vegetables thoroughly. -Avoid cross-contamination of one food with another during preparation, especially with poultry. -Use a separate cutting board for vegetables, meat, and poultry. -Cook foods adequately to kill any residual organisms. -Refrigerate leftovers promptly and label the date when leftovers are saved.
Identify the following positions for patients: A. Lay flat on back B. Lay on stomach C. Lay on side with knee up
a. supine (lay flat on back) b. prone (lay on stomach) c. lateral (lay on side with knee up)
25. In assisting the visually impaired patient to ambulate, the nurse should (select all that apply): a. warn the patient when approaching doorways. b. stand on the nondominant/injured side c. position the patient so that they are directly behind you. d. walk one-half step ahead and slightly to the side. e. have the patient grasp your waist. f. walk at a comfortable pace. g. use a gait belt for unstable patients.
a. warn the patient when approaching doorways. d. walk one-half step ahead and slightly to the side. f. walk at a comfortable pace. g. use a gait belt for unstable patients.
Electromyography
an evaluation of electrical activity generated within the muscle. This is used to determine the quality of neuromuscular innervation
systematic gathering of information about a patient
assessment
If the patient has been laying down for a long time, you should allow her to sit at the edge of the bed for a minimum of?
at least 2 minutes
12. What are the expected physical assessment findings for a middle-aged adult? Select all that apply. a. Abnormal visual fields and ocular movements b. Palpable lateral thyroid nodes c. Pulse rate of 60 to 100 beats per minute d. Decreased strength of abdominal muscles e. Responsive sensory system f. Diminished motor responses
c. Pulse rate of 60 to 100 beats per minute d. Decreased strength of abdominal muscles e. Responsive sensory system
Place the steps for the Timed Get Up and Go Test in order: a. Stand still momentarily b. Sit down c. Walk 10 feet (3 meters) (in a line) d. Turn around e. Stand up from the arm chair f. Walk back to chair g. Turn around What is an abnormal result for the test?
e, a, c, g, f, d, and b. e. Stand up from the arm chair a. Stand still momentarily c. Walk 10 feet (3 meters) (in a line) g. Turn around f. Walk back to chair d. Turn around b. Sit down An abnormal result is when a person takes more than 20 seconds to complete the test.
At what stage should a persons vocabulary advance to 1,500-2,500 words?
early childhood
During what stage do you expand from self-centered to sociable?
early childhood
During which life stage do people tend to throw temper tantrums?
early childhood
Bone scan
evaluates the bone uptake of a radionuclide material; the uptake is related to the metabolism of the bone. The primary indication of this test is to detect metastatic cancer in the bone, but it is also used to evaluate avascular necrosis or unexplained bone pain
X-ray
evaluates the integrity of bones and joints and is the most common radiographic test used to diagnose fractures
What disease is characterized by an inflammation of the auditory canal?
external otitis
Computed tomography (CT) scan
identifies soft tissue and bony abnormalities and evaluates musculoskeletal trauma
Torticollis
inclining of head to affected side, in which sternocleidomastoid muscle is contracted
During which stage are love and security essential for mental growth?
infancy
During which stage do life events have a strong influence on an individuals emotional behavior in life?
infancy
During which stage do people mimic and imitate gestures, facial expressions, and vocal sounds?
infancy
What are the seven main life stages?
infancy, early childhood, late childhood, adolescence, early adulthood, middle adulthood, late adulthood
Identify an example of a medication safety strategy that is used in a health care agency.
medication safety is promoted by using the "six rights" for administration and the triple check for accuracy (when obtaining, preparing, and giving medications), ensuring proper labeling and storage, and including the patient and family in the plan of care.
During what stage do work relationships begin to replace family?
middle adulthood
During which life stage do health care providers encourage you to develop a healthy lifestyle?
middle adulthood
A compensatory mechanism involved in HF that leads to inappropriate fluid retention and additional workload of the heart
neurohormonal response
a full diagnostic statement describing client health status which contains the problem, etiology and assessment findings
nursing diagnosis
The eyes are protected by what four structures?
orbital socket, eyebrows, eyelashes, eyelids
Evaluation determines the ________ of the nursing plan of care
outcome
Dehydration __________ lack of fluid intake
related to
