NCLEX EAQ

False high blood pressure reading

-arm is unsupported -repeated assessments -deflating cuff too slow

5. Maintenance stage (behavioral change stages)

-begins six months after change has started -continues indefinitely

SATO2 need to knows:

-carbon monoxide artificially elevates the oxygen sat -nail polish interfere with the ability of the oximeter -IV dyes will artificially lower the oxygen sat -Skin pigmentation will overestimate the saturation

2. Contemplation stage (behavioral change stages)

-client begins to consider a change within the next six months as he or she develops more belief in the value of change

3. Preparation (behavioral change stages)

-client believes that advantages outweigh disadvantages of behavior change -client needs assistance planning for a change in the next month

1. Precontemplation stage (behavioral change stages)

-client may be defensive when confronted with information about the behavior -client does not intend to make any changes within the next six months

AGING ADULT

-decreased vasomotor response -diminished elasticity of blood vessels therefore do not respond quickly to changes from horizontal to vertical ---> orthostatic hypotension; Changing positions slowly allows the body to adjust, which prevents dizziness and loss of balance. -Usual fluid intake patterns can be maintained. Furosemide should be taken with meals to prevent gastric irritation. It is best to take it in the morning rather than at night so that sleep is not interrupted with the need to void. There is no link between furosemide and skin breakdown.

Hypertension symptoms

-headache and shortness of breath

4. Action (behavioral change stages)

-last up to six months -client actively engaged in strategies to change behavior while the nurse identifies barriers to change

Respite care

-offered at home, in day care settings, or in a health care institution that provides overnight care. -medicare does not cover respite care service and medicaid has strict requirements and eligibility. -Provide short-term relief or "time off" for people providing home care to an ill, disabled, or frail older adult.

Tertiary prevention

-preventing further disability or reduced functioning in the clients -achieving as high a level of functioning as possible -prevent complications and deteriorations in order to minimize the effects of long-term disease or disability -applied when client has a defect or disability that is permanent and irreversible -rehabilitative care instead of diagnosis and treatment

False low blood pressure reading

-stethoscope too firmly against antecubital fossa

Stages of experiencing a change in body image

1. initial reaction - shock 2. withdrawal phase - refuse to discuss the subject 3. acknowledgment phase - begin to acknowledge the condition and move through grieving 4. acceptance phase 5. rehabilitation phase

Assessment of pain

1. location 2. client's experience of pain and rate pain 0-10 3. precipitating factors 4. inspect area of tenderness

6-year-old blood pressure normal

105/65 mmHg

12-year-old blood pressure normal

110/65 mmHg

14-17 year old normal blood pressure

119/75 mmHg

resp rate

12-20

infant heart rate

120-160

According to Erikson's theory, at which age would a child develop self-control and independence?

18 months to 3 years old According to Erikson's theory, between the ages of 18 months and 3 years, a child develops self-control and independence. At the age of 3 to 6 years old, a child is highly imaginative. At the age of 6 to 12 years old, a child is engaged in tasks and activities. Between the ages of 12 and 19 years of age, a child can differentiate between identity and role confusion.

Body Temp Range and what temperature would client be shivering uncontrollably and experiencing memory loss, depression, and poor judgement?

36-38 is normal range below 35 client will exhibit those symptoms below 30 client will demonstrate lack of response to stimuli, slow respiration, and slow pulse *31-33 moderate hypothermia

Normal temp in Celsius

37 (98)

Adult heart rate

60-100

normal pulse

60-100

Adolescent heart rate

60-90

School-age child heart rate

75-100

Preschooler heart rate

80-110

Toddler heart rate

90-140

normal oxygen saturation

95-100%

1-year-old blood pressure normal

95/65 mmHg

A client who is suspected of having tetanus asks a nurse about immunizations against tetanus. Before responding, what should the nurse consider about the benefits of tetanus antitoxin?

A passive immunity is produced.

Myopia (nearsightedness)

A refractive error in which the eyeball is too long in relation to its focusing power; thus the point of focus for rays of light from distant objects is in front of the retina.

Hyperthyroidism; eye symptoms

Bulging eyes

Circulatory insufficiency.

Chronically recurring ulcers in the lower legs or the feet accompanied by an absence of leg hair growth are serious signs

Sustained pattern

Constant body temperature continuously about 38 with little fluctuation

Kussmaul respirations

Deep, rapid breathing; usually the result of an accumulation of certain acids when insulin is not available in the body.

Sedative hypnotic physical findings of the skin (including alcohol)

Diaphoresis

GESELL'S THEORY

Growth in humans is both cephalocaudal and proximodistal. The cephalocaudal pattern describes the sequence in which growth is fastest at the top (from the head and then down). The proximodistal growth starts at the center of the body and moves toward the extremities. Poor nutrition or chronic disease often affect growth rate and result in smaller stature despite of the genetic blueprint. According to Gesell's theory of development, each child's pattern of growth is unique, and this pattern is directed by gene activity. According to Gesell's theory, genes direct the sequence of development, but environmental factors also influence development and result in developmental changes.

The student nurse prepares a concept map while caring for a client recovering from surgery. What is the first step that the student nurse should take when preparing the concept map?

Identify patterns reflecting the client's problem

Hypokalemia is associate with what clinical finding?

Muscle weakness

Opioids physical findings of the skin

Needle marks

Vesicular breath sounds

Normal breath sounds -quiet, soft, and inspiration sounds that are short and almost silent on expiration -heard over lung periphery

three-part nursing diagnostic label

P - problem E - etiology S - symptoms NANDA-1 label, related factor, and defining characteristics

HYPERTENSION

PRE: 120/80 - 139/89 BP mainly influenced by heart rate and cardiac output -when cardiac output and hematocrit are increased so does BP -increased cardiac output and increased hematocrit is at higher risk for stage 1 hypertension HEMATOCRIT LEVELS: men 45-52% women: 37-48% decreased cardiac output risk for hypotension

Relapsing pattern

Periods of febrile episodes coupled with periods of acceptable temperature values

Splinter hemorrhages

Red or brown linear streaks in the nail bed caused by minor trauma to nails, subacute endocarditis, or trichinosis

PCP - Phencyclidine physical findings of the skin

Red, dry skin

Normal BP

Systolic <120 Diastolic <80

According to Avedis Donabedian, which is the most important validator of quality and effectiveness of health care in a hospital?

The client outcomes achieved by the care provided

phlebitis signs

The symptoms of phlebitis include localized redness, tenderness, and swelling over the vein sites of the calves.

The nurse should flush the IV line with normal saline to maintain patency. The nurse should stop the insertion procedure when there is a break in technique.

This intervention helps prevent catheter-related bloodstream infections and provides high-quality care to the client. Nurse should change the IV line every 72-96 hours to prevent the risk of infection. The nurse should avoid inserting the catheter in the client's femur because it increases the risk of bloodborne infections. 18 gauge is not an appropriate size and increases the risk of phlebitis

Beau lines

Transverse depressions in nails indicating a temporary disturbance of nail growth

Input comonent

When the nurse assessing a client's medical records before surgery finds that the client is allergic to latex, this discovery is an example of the input component. When the nurse checks the medical records of the client for blood transfusion reaction before administering a blood transfusion, this action is an example of the input component.

A client with osteoporosis is encouraged to drink milk. The client refuses the milk, explaining that it causes gas and bloating. Which food should the nurse suggest that is rich in calcium and digested easily by clients who do not tolerate milk?

Yogurt

4+ pulse

a bounding pulse

Clubbing of nails

a change of the angle between the mail and nail base -softening of the nail bed and enlarged finger tips with flattened nails are signs of clubbing nails -seen in conditions of oxygen deficiency, such as heart or pulmonary diseases

Vesicle

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

Koilonychia

a malformation of the nails in which the outer surface is concave or scooped out like the bowl of a spoon (concavely curved) -iron deficiency anemia and syphilis

2+ pulse

a normal and expected pulse

Crackles

abnormal breath sounds -soft, crackling, bubbling sounds produced by air moving across fluid in the alveoli

Rhonchi

abnormal breath sounds heard over the large airways of the lungs -consist of a low pitch and are caused by the movement of secretions in the larger airways; usually clear with coughing

Tumors; eye symptoms

abnormal eye protrusions

Maturity

accepting multiple solutions to a problem

Occupational health services

aim to increase worker productivity, decrease absenteeism, and reduce the use of costly medical care; include a complete program designed for health promotion and accident or illness prevention in the workplace

Hypocalcemia

allows sodium to move freely into cells because typically calcium ions block the movement of sodium; this increases excitability of the nervous system; initially symptoms are paresthesias, this can lead to tetany if untreated

True Fever

alteration in the hypothalamic set point; pyrogens act as antigens that trigger the immune system response; hypothalamus reacts by raising the set point; pyrogens are removed; heat loss responses

Postconventional reasoning level

and individual begins thinking about what an ideal society would be like;individual finds a balance between basic human rights and obligations and societal rules and regulation; an individual moves away from moral decisions based on authority or conformity to groups to define their own moral values and principles

Self-regulation

applicable when the nurse when the nurse identifies was to improve his or her own performance

During general anesthesia the lungs

are not fully inflated during surgery and the cough reflex is suppressed, so mucus collects within airway passages.

Lithotomy poistion

assess and examine female genitalia

Prone position

assess the musculoskeletal system

Nursing care for a client in skeletal traction

assessing pin sites every shift and as needed needed weight for a client is prescribed by the physician, not as desired nurse should ensure that the knots are not tied to the pulley and move freely. The performance of range of motion is indicated for all joints except the ones proximal and distal to the fracture because the area is immobilized by the skeletal traction to promote healing and prevent further injury and pain

The NIC (nursing interventions classifications)

assigns codes for entering various interventions followed by nurse to reduce client's illness

Systematicity

being organized and focused

Infiltration of IV site

blanched skin, edema of 15.2 cm, cool temperature, and pain at the site

somatic pain

bone, joint, muscle, skin, or connective tissue and is usually aching or throbbing in quality and well localized

Circulatory overload

can occur if IV solutions are infused too rapidly or in great amounts

Pustule

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

Acceptance Stage

client frequently detaches from the environment and may become indifferent to family members; the family may take longer to accept the inevitable death than does the client

Hypothyroidism; hair symptoms

coarseness of the hair of the eyebrows and the failure of the eyebrows to extend beyond the temporal canthus

NANDA

codes for nursing diagnoses

Related factor

condition or etiology that gives a context for defining characteristics

Cold causes the blood vessels to

constrict, which reduces the leakage of fluid into the tissues and prevents swelling and therefore muscle spasms. promotes analgesia but not circulation may numb nerves but does not dilate blood vessels

Gamma globulin

contains most of the antibodies circulating in the blood. When injected into an individual it prevents a specific antigen from entering a host cell. It does not stimulate antibody production and does not affect antigen-antibody function.

Alcohol, other sedative hypnotics, IV opiods physical findings of the skin

contusion, abrasion, cuts, scars

Presbyopia

decreased accommodative ability of the lens that occurs with aging

hypoventilation

decreased rate and depth of air movement into the lungs

Contact dermatitis

delayed immune response that occurs 12-48 hours after exposure

1+ pulse

diminished or barely palpable pulse

injury to cranial nerve III

drooping of the eyelids

Bilateral jugular venous pressures higher than 2.5 cm are considered

elevated and are a sign of right-sided heart failure One sided pressure elevation is caused by obstruction

Nodule

elevated solid mass, deeper and firmer than a papule and of 1-2 cm in diameter

Conventional Reasoning level

emphasis is given on social rules and community-centered approach

School health services

emphasize program management, interdisciplinary collaboration, and community health principles

health promotion

encourages the client to maintain the present levels of health; good nutrition and regular exercise are examples

Deontology

examines a situation for the presence of essential right or wrong; actions can be decided as right or wrong based on their "right-making characteristics"

Referred pain

experienced in clients with tumors, felt in another part of the body

Remittent pattern

fever spikes and falls without returning to normal temperature levels.

intermittent pattern

fever spikes are interspersed with normal temp values

Client admitted to the mental health unit involuntarily, the nurse should

file with the court within 96 hours of the initial detention

Macule

flat, nonpalpable change in skin color, which is smaller than 1 cm

Performance improvement

focuses on evaluating current performance in order to initiate a qualitative change. A team designing a strategy for improving the performance of nurses when administering injections would be a performance improvement also a team implementing a new system to improve the performance of nurses to prevent infections during wound debridement is another example. Also evaluating the effectiveness of a weekly professional training programs is also performance improvement.

Quality Improvement

focuses on studying and improving the processes of providing healthcare services to clients. An example of this improvement is a team of nurses trying to determine the cause for delays of client admission into special units.

Clients with organ failure

follow the long-term limitations with intermittent serious episodes trajectory

Clients with cancer

follow the short period of evident decline disease trajectory

3+ pulse

full, strong pulse

Tropia (eye turn)

generally occurs at birth

Heat Stroke

giddiness, excessive thirst, nausea, and increased heart rate

Nursing theory

helps to identify the focus, means, and goals of practice. Theories give a perspective for assessing clients' situations and organizing data and methods for analyzing and interpreting information

client is admitted to hospice

if death is expected within 6 months

Hypersensitivity

immediate allergic reaction that occurs due to chemicals that are used to make gloves

Anaphylactic shock

immediate allergic reaction that occurs due to natural rubber latex

Application of nursing theory

in practice depends on the knowledge of nursing and other theoretical models, how they relate to one another, and their use in designing nursing interventions

Later recumbent position

indicated in clients to assess the heart

Lawrence Kohlberg's Theory of Moral Development - Social Contract Orientation stage

individual follows societal law, but also recognizes the possibility of changing the law to improve society

Lawrence Kohlberg's Theory of Moral Development - Instrumental Relativist Orientation stage

individual identifies that there is more than one right view. The views of a person can be different from others.

Lawrence Kohlberg's Theory of Moral Development - Punishment and Obedience Orientation stage

individual notices that punishment is a proof of being wrong; this perception changes when the individual steps into instrumental relativist orientation stage

Lawrence Kohlberg's Theory of Moral Development - Good Boy-Nice Girl Orientation stage

individual wants to win consent and maintain the expectations of one's immediate group

Paronychia

inflammation of skin at base of nail

Phlebitis

inflammation of the inner layer of a vein Findings: redness, tenderness, pain, and warmth along the course of the vein starting at the access point

Blood and blood products for transfusion should be

infused/diluted only with 0.9% normal saline solution, solutions other than normal saline are incompatible and may cause RBC destruction by hemolysis

Interpretation

involved in the orderly collection of data

Interpretation

involves clarifying any data about which the nurse is uncertain

Content components

involves information about the nursing interventions for clients with specific heath care problems. ex. nurse in charge asks the nurse to check the IV tubing for air bubbles to prevent air emboli; When the nurse understands that many clients practice polypharmacy by purchasing prescribed medications from multiple stores, this understanding is an example of the content component. When the nurse knows that clients with airborne diseases should be placed in an airborne infection isolation room (AIIR) to prevent spread of pathogens, this knowledge is an example of the content component.

Evaluation

involves reflecting on the nurse's own behavior

Explanation

involves supporting findings and conclusions

Explanation

involves using knowledge and experience to choose strategies to use to care for clients

Cheyne-Stokes

irregular respiratory rate and depth characterized by alternating periods of apnea and hyperventilation

Occlusion

is characterized by pain, pallor, pulselessness, paresthesias, and paralysis.

Calcium

is important for blood coagulation. When tissue damage occurs, serum calcium is necessary to promote coagulation by activating certain clotting factors. Calcium acts as a catalyst in the clotting process in both the extrinsic and intrinsic pathways. Responsible for a number of body functions, such as bone health, blood clotting, and muscle contraction, and nerve impulses. Not directly relation to bile and blood production or digestion of fats

Wheel

localized edema, usually caused by a mosquito bite. irregular in shape and have elevated surface

Infants of age 10-12 months

may be able to hold a pencil and may be able to place objects into a container

Infants of age 6-8 months

may be able to transfer objects from hand to hand

After surgery patients lungs

may have reduced volume and may require greater effort to cough and deep breathe; inadequate lung expansion can lead to atelectasis and pneumonia. Purposely utilizing diaphragmatic breathing can decrease this risk.

Sentinel event

may result in death of the client and are cause by a severe variation in the standard of care. These events are analyzed using the root cause analysis tool

Infants of age 8-10 months

may show hand preference

Adverse hospital event

medical error that may result in causing harm to the client, however the harm is not too severe or life-threatening to the client. Adverse events are caused by human errors made by health care professionals or error in the hospital system. These events are analyzed using the failure mode effective analysis tool

Intractable pain

neuropathic pain; severe, constant, and is not curable

Bronchial breath sounds

normal and consist of a full inspiration and expiratory phase with the expiratory phase being louder -heard over the trachea and large bronchi of the lungs

To comply with patient centered care

nurse should understand that the client is the source of control when providing healthcare. ex. asking patient if prefers artificial limbs or crutches

To improve quality of care

nurse uses data from previous cases to improve the quality of care provided to the client. This nursing action adheres to the QSEN competency called quality improvement.

To comply with teamwork and collaboration

nurse works with a physical therapist to enhance the remaining limb function of the client ex.

Nurse-managed clinics

nursing services with a focus on health promotion and education as well as on chronic disease.

Primary care

nutrition counseling to the the client qualifies as primary care

Dehydration in older adults

older adults are sensitive to changes in fluid and electrolyte levels; sodium, potassium, and chloride. Will manifest in mental status and confusion. It is difficult to assess for dehydration in older adults based on sunken eyes, dry skin, and decreased bowel sounds because these can be prominent as general normal findings in the elderly client

Analyticity

one of the concepts of a critical thinker and involves the use of EB knowledge for clinical decision-making. This skill may also help in anticipating possible results or consequences of a procedure or given situation.

Visceral pain

organ pain

Feedback component

outcome that is reflected by the client's responses to nursing interventions. This component also includes responses from family members and consultation from other health care professionals.

Community Health centers

outpatient clinics that provide primary care to a specific population such as clients with young children or clients with diabetes

Diaphragmatic breathing does not influence

pain, healing time, or thrombus formation

Papule

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

Stages of Health Behavior Change

precontemplation (not intending to make a change), contemplation (considering a change), preparation (making small change), action (actively engaged in change), maintenance (sustained change)

Community health centers

primary care to specific client population living in a specific community

The AMIA (American Medical Informatics Association)

professional organization that is developing nursing informatics competencies - does not provide codes for entering client's data in the EHR

Clients with disabling stroke, alzheimer disease, and frailty disease

prolonged dwindling disease trajectory

Turning the client to the side (postoperative client)

promotes drainage of secretions and prevents aspiration, especially when the gag reflex is not intact. This position also bring the tongue forward, preventing it from occluding the airway when it is in the relaxed state. Risk for aspiration is increased when the supine position is assumed by a semi-alert client. High fowlers position may cause the neck to flex in a client who is not alert, interfering with respirations. Trendelenburg position is not used for a postoperative client because it interferes with breathing

illness prevention

protects people from actual or potential threats to health ex. immunization

When ascultating blood pressure

readings between the arms can vary as much as 10 mm Hg and are often higher in the right arm. Readings that differ by 15 mm Hg or more suggest atherosclerosis or disease of the aorta.

Knee-chest position and sims position

rectal examinations

Infection of IV site

redness, heat, swelling at entry point and possible purulent drainage

Self-regulation

reflecting on the nurse's experience

Quality and Safety Education for Nurses (QSEN) quality improvement

requires nurses to integrate the best current evidence with clinical expertise and client's needs and preferences. The nurse complies with this competency by reading medical textbooks to understand the implications of the client's condition on psychological health.

Three important attributes of health care quality

safety (good clinical decisions), effectiveness (curative and preventive interventions) , and efficient care (cost-effective interventions, reducing duration of hospital stay)

Assisted living

services like laundry, assistance with meals and personal care, 24-hour oversight, and housekeeping. -group of residents live together, but each resident has his or her own room and shares dining and social activity areas

Occupational health services

services that aim to increase worker productivity, decrease absenteeism, and reduce the use of expensive medical care

Block and parish nursing

services to older clines who are unable to leave their homes

Biot's respirations

shallow breaths interrupted (2-3 breaths) then followed by irregular periods of apnea

Symptoms of ascites

shiny and taut appearance of the abdominal skin

Eczema

skin condition that can be worsened with excessive drying

Assessing skin turgor in aging adult

skin over the sternum should be used instead of skin on the arm for checking turgor.

Alcohol, stimulants physical findings of the skin

spider angiomas

Omaha System

standardized technology to support nurse practices. It includes codes for entering the data obtained from a problem rating scale in the EHR use omaha system to enter the client's score

The WHO defines health as a

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

Resolution of an ethical dilemma

step 1: is this an ethical dilemma? step 2: gather information related to case step 3: clarify values; distinguish facts step 4: verbalize problem step 5: identify possible course of action step 6: Negotiate a plan step 7: evaluate the plan over time

Cross eyes is a result of

strabismus, neuromuscular injury or congenital anomaly

lymphedema

swelling in one or more extremities that is the result of impaired flow of the lymphatic system

wellness education

teaches people how to care for themselves

Progressive atrophy of the convolutions of the brain with a decrease in its blood supply, during the aging process produces

tendency to become more forgetful, a reduction in short-term memory, and susceptibility to personality changes

The American Nurses Association recognizes

the International Classification of Nursing Practice (ICNP) as standardized terminology for nursing. It provides vocabulary to include nursing data in computerized information systems, such as the EHR. ICNP is not a drug guide, so it does not provide information about medications and their side effects; it does not give information on cultural practices and beliefs; unlike public health informatics ICNP does not help develop new tools and methodologies for conducting biosurveillance

Self-confidence

trusting one's own reasoning process

Education

using criteria to determine results of nursing actions

Utilitarianism

value of something is decided by its usefulness; also called consequentialism since the primary emphasis is on the outcome of consequence of the action. The right action is based on the greatest good for the greatest number of people

Cocaine skin findings physical findings of the skin

vasculitis

Thirst reflex diminishes

with age; leads to a decline in fluid intake

Women at most risk for breast cancer

women over 40 years of age, family history, late-age menopause (after 50), who have not had children or who conceived after the age of 30 years, women with excessive oral contraceptives, and early-start menarche