Hesi: Fondamentals

Medical diagnosis

is the identification of a disease condition Is identified by the primary health care provider based on the results of diagnostic tests

Paronychia

is the inflammation of the skin at the base of nail

Nurse administrator's function

is to prepare the budget, staffing, strategic planning of programs and services, employee evaluations, and employee development

Orem's theory

known as self-care deficit theory which focuses on the patient's self care needs self-care deficit theory focuses on the client's self-care needs.

Hyperpnea

labored, increased in depth, and increased in rate (>20) occurs normally during exercise

Nurse Practice Act

law established to regulate nursing practice Describe and define the legal boundaries of nursing practice within each state

preauricular

lymph node in front of ear

submental lymph nodes

midline, behind the tip of the mandible

The nurse assesses a client's nails and finds a slight convex curve at the angle from the skin to nail base of about 160 degrees. Which condition would the nurse suspect?

normal finding

Watson's theory

of transpersonal caring defines the outcome of nursing activity with regards to the humanistic aspects of life

Referred pain

pain that is felt in a location other than where the pain originates

The nurse's advocate role for a victim of intimate partner violence (IPV) would include which important component? Select all that apply. One, some, or all responses may be correct. planning for future safety Normalizing victimization Ordering tests for sexual diseases Validating the experiences Promoting access to community services Providing housing for the victim Administering medications for comfort Reporting findings to community health

planning for future safety Validating the experiences Promoting access to community services The nurse would include planning for future safety, validating the experiences, and promoting access to community services. Planning for the client's future safety needs, validating the client's experiences by letting the victim know that he or she is not alone, and promoting access to community services are all important roles of the nurse advocate. An advocate would not normalize the victimization by seeing the abuse as normal in the victim's relationship and failing to respond to the disclosure of the abuse. Ordering tests for sexually transmitted diseases is not within the scope of practice for a nurse. The advocate role would include information and resources for housing if needed, but not necessarily provide it. The administration of medications would not meet the criteria for advocacy, as it is a provider order that should be followed. Reporting findings to community health of some sexual diseases is mandatory, however this action does not promote patient advocacy. Clinical Judgment Skill(s):Take Actions

Nursing diagnosis

problems that require treatment by the nurse

Leininger's theory

provide care consistent with nursing's emerging science and knowledge with caring as central focus recognizes the importance of culture and its influence on everything that involves the client and the providers of nursing care is cultural diversity, with the goal of nursing care being to provide the client with culturally specific nursing care

Hyperventilation

rate and depth of respirations increase. Hypocarbia sometimes occurs

Hypoventilation

rate is abnormally low, and depth of ventilation is depressed. Hypercarbia can occur

Kussmaul's respiration

respirations are abnormally deep, regular, and increased in rate

Cheyene-Stokes respirations

respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation. Respiratory cycle begins with slow, shallow breaths that gradually increase to abnormal rate and depth. The pattern reverses, breathing slows and becomes shallow, concluding as apnea before respirations resumes

False imprisonment

restraining an individual or restricting an individual's freedom if the nurse uses restraints withour a legal warrant on a cliant, the nurse may be charged with false imprisonment

Intractable pain

severe pain that is extremely resistant to relief measures

Papule

small, solid skin elevation is palpable, circumscribed has a solid elevation and a size smaller than 1 cm

Roy's theory

the goal of nursing is to help a client adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness

Benner and Wrubel's theory

the model of primacy of caring is the base for development of this theory. this theory focuses on clients need for caring as a means of coping with stressors of illness

Advocacy

the nurse speaking in support of the best interest of a vulnerable client reflects which nursing duty. this means promoting what is best for the client. this is accomplished by ensuring that the client's needs are met and by protecting the client's rights.

Inference

the skill of inference is associated with noticing relationships in the findings.

clubbing of nails

there is a change in the angle between the nail and the nail base larger than 180 degrees.

Which information would the nurse provide to the client about the benefits of rehabilitation? Select all that apply. One, some, or all responses may be correct.

"Specialized rehabilitation services help clients and caregivers to adjust to lifestyle changes." "Rehabilitation helps prevent complications associated with illness or injury at the initial stages." "Cliants who recieve rehabilitation attain their fullest physcial, mental, social, vocational, and economic potential." "These services enable the client to function with the limitations of their illness." Specialized rehabilitation services, such as cardiovascular, neurological, musculoskeletal, pulmonary, and mental health rehabilitation programs, enable clients and their caregivers to adjust to lifestyle changes. At the initial stages, rehabilitation aims to prevent complications associated with the illness or injury. Rehabilitation enables clients to reach their highest physical, mental, social, vocational, and economic potential possible. Rehabilitation services assist the client to function within the limitations of their illness. Insurance may limit coverage for certain types of rehabilitation, either fully, partially, or not covering the service at all. Drug rehabilitation is only one type of rehabilitation program. Clients may require rehabilitation after a physical or mental illness, injury, or chemical addiction. When the client's condition stabilizes, rehabilitation helps maximize his or her functioning and level of independence. Rehabilitation often takes place in the community setting at conveniently located facilities for the client and is not limited to specialty hospitals. Clinical Judgment Skill(s):Analyze Cues

Sustained pattern of fever

A constant body temperature continuously above 100.4 with little fluctuation

Libel

A written defamation of a person's character, reputation, business, or property rights. is the written defamation of character

Borborygmi

Are rumbling or gurgling noises made by the movement of fluid and gas in the intestines

Mastoid lymph nodes

Behind ears; drains scalp

remittent pattern of fever

Fever spikes and falls without a return to normal temperature levels

Henderson's Theory

Help patient perform 14 basic needs through physiological, psychological, sociocultural, spiritual, and developmental domains focuses on assisting the individual in the performance of activities that he or she can perform unaided that will

Nystagmus

Involuntary rapid eye movements involuntary oscillation of the eyes and usually occurs after an eye injurt

Parenteral vitamins are prescribed for the client with Crohn's disease. The client asks why the vitamins have to be given intravenously (IV) rather than by mouth. Which rationales will the nurse provide? Select the 4 findings that offer the correct rationale. They provide more rapid action results They decrease COlon irritability Oral vitamins are less effective Intestinal absorption may be inadequate Allergic responses are less likely to occur It doesn't rely on liver absorption

It doesn't rely on liver absorption It doesn't rely on liver absorption Oral vitamins are less effective They provide more rapid action results Absorption through the gastrointestinal (GI) tract is impaired, and parenteral administration goes directly into the intravascular compartment resulting in more rapid results. Oral vitamins are less effective in general because of the reliance on proper absorption and processing. Because the mucosa of the intestinal tract is damaged, its ability to absorb vitamins taken orally is greatly impaired. When vitamins are given parenterally, they bypass the entire GI system, including the liver. IV vitamins do not decrease colonic irritability associated with Crohn disease. The route of administration does not affect allergic response. Clinical Judgment Skill(s):Analyze Cues

Somatic pain

Pain that originates from skeletal muscles, ligaments, or joints.

Relapsing pattern of fever

Periods of fever interspersed with acceptable temperature values. Febrile episodes and periods of normothermia may last longer than 24hrs. periods of febrile episodes coupled with periods of acceptable temperature values

A client is diagnosed with hyperthyroidism and is treated with I-131. Before discharge the nurse teaches the client to observe for signs and symptoms of therapy-induced hypothyroidism. Which clinical manifestation would be included in the teaching? Select all that apply. One, some, or all responses may be correct. Fatigue Dry Skin Insomnia Intolerance to heat Progressive weight gain Constipation Hot flashes Shaking hands

Progressive weight gain Constipation Fatigue Dry Skin Fatigue is caused by a decreased metabolic rate associated with hypothyroidism. Dry skin most likely is caused by decreased glandular function associated with hypothyroidism. Progressive weight gain is associated with hypothyroidism in response to a decrease in the metabolic rate because of insufficient thyroid hormone. As gastrointestinal processes slow due to decreased metabolism, the client becomes prone to constipation. Insomnia is associated with hyperthyroidism, not hypothyroidism, in response to an increase in the metabolic rate because of excessive thyroid hormone. Intolerance to heat is associated with hyperthyroidism, not hypothyroidism, in response to an increase in the metabolic rate because of excessive thyroid hormone. Hyperthyroidism is also associated with common signs and symptoms, such as hot flashes and shaking hands. Clinical Judgment Skill(s):Take Actions

Highlight relevant findings

Relevant findings include middle school has been directly hit by the tornado, desk leg impaled through her left calf, compound fracture to the right leg, and 12-year-old female with left sprained ankle who can walk. The nurse needs a preliminary understanding of the ages and types of victims who will need treatment; knowing the middle school has been directly hit is relevant. The type of injury (desk leg impaled through left calf, compound fracture, and sprained ankle but can walk) is relevant information on how to triage and care for victims. The findings that are irrelevant include large Midwest city, five people have already been declared dead, female school secretary, and male janitor. It does not matter what type of city has been affected when caring for the victims. In a disaster, the nurse cares for the living, not the dead; thus, how many people have died is irrelevant at this time. The occupation (school secretary and janitor) has no bearing on how to treat disaster victims. Clinical Judgment Skill(s):Recognize Cues

Which information would the nurse provide to a client diagnosed with chlamydia and prescribed doxycycline? Select all that apply. One, some, or all responses may be correct. Report worsening symptoms Refrain from sexual relations Use barrier protection devices Contact provider for continued infection Contact partners to be tested Take the entire course of antibiotics Wear protective clothing clothing when outside

Report worsening symptoms Refrain from sexual relations Take medications on an empty stomach Use barrier protection devices Contact provider for continued infection Contact partners to be tested Take the entire course of antibiotics Wear protective clothing clothing when outside The nurse would instruct clients taking doxycycline for a sexually transmitted infection (STI) to report worsening symptoms to the health care provider as it could indicate antibiotic resistance. Clients would also be instructed to refrain from sexual relations while the infection is being treated. If they do choose to have sexual relations, they would be instructed on the importance of using barrier protection. The client should report continued infection to provider immediately because of the potential for superinfection. The nurse would also instruct clients to contact their sexual partners and inform them of the need to be tested and treated for the STI. Clients should take the entire prescribed course of antibiotics to prevent recurrence of the infection. Photosensitivity may occur; therefore, the client should avoid direct sunlight and wear protective clothing when outside. The client can take doxycycline with or without food but may take it with food or milk if gastrointestinal upset occurs. Clinical Judgment Skill(s):Take Actions

explaination

Requires knowledge and experience for choosing strategies for care for clients.

Select the 4 actions that the LPN expects the RN to carry out.

The 4 actions the nurse would implement include: assign the nurse from the neurological floor to the 42-year-old female school secretary; help discharge afebrile, stable, ambulatory ED clients; collaborate with the medical command physician; and reassess tagged victims from the middle school. The nurse would assign the neurological nurse to care for the 42-year-old female school secretary because a lump on the forehead indicates a head injury. Afebrile (no fever), stable, ambulatory ED clients are discharged to allow room for the disaster victims. The ED nurse collaborates with the medical command physician to organize and coordinate safe care of the victims. The nurse reassesses victims from the middle school because victim status may have changed during transit. The nurse would not assign the nurse from the intensive care unit to the 14-year-old male, would not deactivate the emergency response plan after the last disaster victim is cared for, and would not allow physical therapy to care for the 35-year-old female teacher. The 14-year-old male with several abrasions and contusions is a green-tagged victim; the intensive care nurse would be assigned to other higher-priority cases. The hospital incident commander, not the ED nurse, deactivates the emergency response plan when the last major casualties have been treated and/or no other victims are expected to arrive. Even though physical therapists care for musculoskeletal injuries (35-year-old female teacher with a desk leg impaled through her left calf), this is unsafe delegation; this is not within their scope of practice. Clinical Judgment Skill(s):Take Actions

Collaborative problems

The nurse assesses the client to gather information for reaching diagnostic conclusions. And are identified by the nurse during this process. If the client's health problem requires treatment by other disciplines, such as medical or physical therapy, the client has a collaborative problem

Choose the most likely options for the information missing from the statement by selecting from the lists of options provided.

The nurse expects the 27-year-old female teacher to be black-tagged because of impending death. A victim with extensive head trauma and unresponsive indicates impending death. During a disaster, unfortunately, victims who are severely/critically injured who might have received treatment in other circumstances are allowed to die if imminent death is expected; these types of victims are black-tagged. This allows resources to be used on victims who have a chance of survival/recovery, following a form of triage/care that facilitates the greatest good for the greatest number of victims. The 27-year-old female teacher would not be red-, green-, or yellowed-tagged. Red-tagged victims are treated first because of immediate threat to life. Green-tagged victims are the "walking wounded" or who have nonurgent/minor injuries. Yellow-tagged indicates the victim has urgent injuries who can wait a short time before care is received (major injuries requiring treatment). Clinical Judgment Skill(s):Analyze Cues

Victims include: 10-year-old boy with closed fracture of left arm 35-year-old female teacher with a desk leg impaled through her left calf 37-year-old male teacher with a compound fracture to the right leg 42-year-old female school secretary with a 1-inch (2.5-cm) lump on left forehead 14-year-old male with several abrasions and contusions 27-year-old female teacher with extensive head trauma and unresponsive 65-year-old male janitor who developed an obstructed airway 12-year-old female with left sprained ankle who can walk The nurse first assesses who?

The nurse first assesses the 65-year-old janitor. The janitor has an obstructed airway, which is an immediate threat to life with a high chance of survival; this type of victim is red-tagged. Using the ABCs (airway, breathing, circulation), the 35-year old female teacher with a desk leg impaled through her left calf needs treatment; however, she is not as high a priority as the obstructed airway. While the 42-year-old female school secretary with a 1-inch (2.5-cm) lump on left forehead also needs further assessment, she is not as high a priority as the obstructed airway. The 27-year-old female teacher with extensive head trauma and unresponsive is allowed to die and would not be assessed first. The 10-year-old boy with closed fracture of left arm, 14-year-old male with several abrasions and contusions, and 12-year-old female with left sprained ankle who can walk are examples of the "walking wounded" (green-tagged) and would not be assessed first. The 37-year-old male teacher with the compound fracture to the right leg is a yellow-tagged victim and can wait 30 minutes or more for treatment and would not be assessed first. Clinical Judgment Skill(s):Prioritize Hypotheses

The nurse is caring for a client who is terminally ill with cancer. The health care team meets and agrees to provide the client with information to help the client make decisions regarding treatment. Which ethical principle is applied in this situation? Select all that apply. One, some, or all responses may be correct.

The nurse follows the principle of veracity by telling the truth to the client regarding their health status. Telling the truth helps the client in decision-making, which is in accordance with the principle of autonomy or self-determination and self-management. Justice is an ethical principle that involves treating a client fairly without discrimination. Fidelity involves being loyal to the client. Nonmaleficence is the obligation to do no harm, this principle does not apply because the team is not providing any care or making any health care decisions at this point. Paternalism references a decision that is made by the healthcare provider when they think they know what is best for the client, this is in contradiction to the principle of autonomy and should not be used in this scenario. Beneficence involves acting in a way that causes the least harm to the client, like maleficence this principle does not apply since the team is not providing care at this point. Futility involves decisions regarding treatments that the healthcare provider believes will not provide a benefit to the client, it also does not apply since no treatments are being provided.

For each delegation task, click to specify if it is Appropriate (indicated or necessary) or Inappropriate (could be harmful, not indicated, or unnecessary). Each row must have only one response option selected.

The nurse would assign the following tasks: take vital signs on the 37-year-old male teacher, gather blankets for victims, and obtain clean supplies for the nurse. Vital signs and obtaining items for victims and clean supplies are within the responsibilities of unlicensed assistive personnel (UAP). The UAP can obtain vital signs from yellow-tagged victims (37-year-old male teacher with a compound fracture to the right leg). Obtaining blankets and clean supplies for the nurse are responsibilities the UAP can legally and ethically offer at this time. The nurse would not assign the following tasks: sit with the black-tagged victims to provide emotional support, provide general information about the disaster to the local newspaper, assist the 12-year-old female with crutches, and send to the DMAT. Black-tagged victims (dying or dead) are made comfortable; however, extensive care is not a priority at this time—highest chance for survival is the priority. The community relations or public information officer (not the UAP) is the person to provide general information about the disaster to the local newspaper and other media. The 12-year-old female with a sprained ankle who can walk is a green-tagged victim (walking wounded) and is not treated at this time; care can wait. Unlicensed assistive personnel are not qualified members of DMAT; adequate and advanced training is needed before working as a member of the DMAT. DMATs provide relief services for the community affected by disasters; some examples of team members include registered nurses, physicians, advanced clinicians, and paramedics. Clinical Judgment Skill(s):Generate Solutions

After the disaster is resolved, the nurse and health care team evaluate overall management of the disaster. Which statements indicate successful handling of the tornado disaster by the hospital? Select all that apply.

The statements that indicate successful handling of the tornado disaster by the hospital include "Testing our emergency plan twice last year helped in this situation," "The hospital incident commander had a global view of the entire system to determine resources," "The administrative debriefing allowed for workers to give their opinion both verbally and in writing," and "Attending the small-group debriefing sessions with the crisis support team was helpful in coping after the disaster." Hospitals are mandated by regulatory agencies to have emergency preparedness plans that are tested twice a year with drills or actual participation in a real event. A physician or administrator who assumes overall (global view) leadership for carrying out the institutional emergency plan and activating resources is called the hospital incident commander. An administrative debriefing allows participants to express positive and negative reviews first verbally and then days later, with a written review. Critical incident stress debriefing allows small-group debriefing sessions with the crisis support team to promote effective coping strategies after the disaster. The statements that do not indicate successful handling of the tornado disaster include: "In summary, the hospital responded appropriately to this natural, internal disaster," "Tagging the 'walking wounded' with yellow tags was appropriate procedure," "Employees who score above 33 on the Impact of Event Scale-Revised (IES-R) should just be debriefed," "The medical command physician did an excellent job at triaging the disaster victims," "Since we handled all the victims at our hospital, we experienced a mass casualty event," and "Most of the disaster workers are continuing to work 16 hours even after the disaster." While a tornado is a n

For each action, click to indicate whether the specified action is generally associated with assessment, analysis, planning, implementation, and/or evaluation. Each row must have at least one, but may have more than one, response option selected.

Use of accessory muscles present and obtained health history from mother are assessments (gathering data/cues about the client from various sources). Client demonstrated correctly how to use inhaler is evaluation (determining if goals/outcomes were achieved and if teaching was effective). Developed outcome for adequate gas exchange is planning (development of goals, outcomes, and appropriate interventions). Vital signs at 1315 are implementation, assessment, and evaluation. Obtaining vital signs are actions the nurse takes (implementation) and these vital signs reflect whether treatment was effective, making this set of vital signs assessment and evaluation. Notified ED physician of acute asthma attack is analysis and implementation. The nurse analyzed data/cues from 1300 to determine the client is having an acute asthma attack (wheezes, difficulty breathing, low oxygen saturation, has asthma), which is analysis, and the nurse notified the physician, which is performing actions (implementation). Administering albuterol is a dependent nursing action (requires a physician's order), making it implementation. Clinical Judgment Skill(s):Take Actions, Recognize Cues, Analyze Cues, Prioritize Hypotheses, Generate Solutions, Evaluate Outcomes

Vesicle

a circumscribed elevation of the skin filled with serous fluid and a lesion size of less than 1 cm

Concepts

a mental grouping of similar objects, events, ideas, or people

Visceral pain

a poorly localized, dull, or diffuse pain that arises from the abdominal organs, or viscera

Tort

a wrongful act or an infringement of a right (other than under contract) leading to civil legal liability. an illegality committed by one person against the property or person of another

Biot's respirations

are abnormally shallow for two to three breaths, followed by irregular period of apnea

Subacute care

is not a part of continuing care, restorative care, or secondary acute care health care services

Occipital lymph nodes

base of skull

Neuman's systems model

based on the individuals relationship to stress, the reaction to it, and reconstitution factors that are dynamic in nature. Reconstitution is the state of adaptation stressors. -the client is an open system consisting of basic structure or central core of energy resources. -lines of resistance represent internal factors that help the client defend against a stressor. Categories of stressors: -Intrapersonal occur within the individual -Interpersonal occur between individuals -Extrapersonal occur outside the person (finances) is a grand theory

Bruit

blowing sound created by blood turbulence when passing through narrowed arteries

Tachypnea

breathing is regular but abnormally rapid (>20(

Bradypnea

breathing is regular but abnormally slow (<12)

APnea

cease for several seconds. Persistent cessation results in respiratory arrest

Peplau's Theory

develop interaction between nurse and patient. (ex. nurse facilitates interpersonal relationships) Focuses on interpersonal relationships between the nurse, the client, and the client's self-care needs

Descriptive theories

do not direct specific nursing activites. Instead they help explain client assessments. They are first level of theory develoment. they explain, relate, and in some situations predict nursing phenomena. They describe phenomena, speculate on why they occur, and describe their consequences

Ptosis

drooping of the eyelids over pupil

Grand theories of nursing

ex Neuman's systems model is a grand theory Grand theories require further specification through research Grand theories are systematic and broad in scope and complexity. Grand theories do not provide guidance for specific nursing interventions; instead they provide the structural framework for broad and abstract ideas about nursing

intermittent pattern of fever

fever spikes are interspersed with normal temperature levels

Veracity

filled with truth and accuracy relates to the habitual observance of truth, fact, and accuracy

Middle-Range Theories of Nursing

focus on answering a specific practice problem Middle-range theories provide a basis to help nurses understand how clients cope with uncertainty and the illness response. Include Mishel's theory of uncertainty in illness, which focuses on a Client's experiences with cancer while living with continual uncertainty These theories tend to focus on a specific field of nursing (such as uncertainty, incontinence, social support, quality of life, and caring) rather than reflect on a wide variety of nursing care situations

Mishel's theory of uncertainty in illness

focusses on patients experiences with cancer while living continual uncertainty. The theory provides a basis to help nurses understand how patients cope with uncertainty and the illness response is not an example of a grand theory; it is a middle-range theory.

Tertiary care

highly complex care and therapy services from practitioners in a hospital or overnight facility The nursing student would include subacute care under tertiary

Caring

is a behavioral characteristic of the nurse. Veracity relates to the habitual observance of truth, fact, and accuracy

Ectropion

is a condition in which the eyelid is turned outward away from the eyeball

Analysis

is a critical thinking skill that requires open-mindedness while looking at the client's information.

Entropion

is a malposition resulting in an inversion of the eyelid margin

Malpractice

is a type of negligence that is regarded as professional negligence

Nodule

is an elevated solid mass, deeper and firmer than a papule and 1 to 2 cm in diameter

Confidentiality

is an ethical principle and legal right that the nurse will hold secret all information relating to the client unless the client gives consent to permit disclosure

Negligence

is any conduct that falls below the standard of care

Interpretation

is associated with ordered data collection

Pustule

is circumscribed elevation of the skin similar to a vesicle but filled with pus and varies in size

Koilonychia

is the concave curves in the nails