Nursing 230 Final

Nursing Diagnosis List potential or actual nursing diagnosis related to a client in pain

-anxiety -fatigue -hopelessness -impaired physical mobility -imbalanced nutrition: less than -powerlessness -chronic low self-esteem -disturbed sleep pattern -impaired social interaction -spiritual distress

Explain the following mind-body interventions *Biofeedback*

Process providing a person with visual or auditory information about autonomic physiological functions of the body such as muscle tension, skin temperature, and brain wave activity through the use of instruments

Status epiepticus

Prolonged or repeated seizures

RIGHT SUPERVISION/EVALUATION

Provide appropriate monitoring, evaluation, intervention as needed, and feedback. NAP need to feel comfortable asking questions and seeking assistance.

Intervention: Teach children to swim at an early age but always provide supervision near water

Rationale: Learning to swim is a useful skill that can someday saves a child's life

Intervention: Encourage enrollment in driver education classes

Rationale: Many injuries in this age range are related to MVA's

Intervention: Teach children how to cross streets and walk in parking lots. Instruct them to never run out after a ball or toy

Rationale: Pedestrian accidents involving young children are common

Intervention: have infants sleep on their back or side

Rationale: Placing infants on their back lowers the risk of SIDS

Intervention: Teach children proper bicycle safety, including use of helmet and rules of the road

Rationale: Reduces injury from falling off a bike or being hit by a car

Intervention: Remove plastic bags from the home

Rationale: Removal reduces risk for suffocation from plastic bags.

Intervention: Infants should be immunized

Rationale: immunizations reduce the risk of SIDS by 50%

FRICTION

force that occurs in a direction to oppose movement the greater the surface area of the object that is moved, the greater the friction

critical thinking

form therapeutic relationships to gather relevant and comprehensive information about their patience, draw on theoretical knowledge about communication and integrate this knowledge with that previously learned through clinical experience Interpret messages to obtain new information, correct misinformation, promote patient understanding, assist with planning patient-centered care

Orem's theory

nurse cares for and helps patient attain total self care. (ex. nursing care is needed when the patient is unable to fulfill needs.)

TROCANTER ROLL

prevents external rotation of the hips when a patient is in a supine position.

coping realm

problem solving, use of resources, family life stressors and daily hassles, family coping strategies and effectiveness, past experiences with handling crises, family resistance resources.

content

product and information obtained from the system.

Watson's theory

promote health, restore health, and prevent illness (ex. involves the science of caring)

Therapeutic communication

promotes personal growth and attainment of patients' health-related goals

Gerotranscendence

proposes older adults experience shifts in perspective with age. The person moves from materialistic and national view of the world to a more cosmic and transcendent one, causing an increase in overall life satisfaction.

Nurses' responsibilities within the operating room focus on

protecting the patient from potential harm.

SKELETAL SYSTEM

provides attachements for muscles & ligaments provides leverage necessary for mobility

Preception of well being defines

quality of life

5 AREAS OF ASSESSMENT OF PATIENT MOBILITY

range of motion gait exercise activity tolerance body alignment

The nurse can help the older adult and family prepare for retirement by

discussing with them several key areas, including relations with spouse, children; meaningful activities and interests; building social networks; issues related to income; health promotion and maintenance; and long range planning including wills and advance directives

Music for Pain

diverts the person's attention away from the pain and creates a relaxation response

What are the physiological causes of delirium?

electrolyte imbalances cerebral anoxia hypoglycemia medication effects tumors subdural hematomas cerebrovascular infection infarction hemorrhage

PSYCHOSOCIAL EFFECTS

emotional & behavioral responses sensory alterations changes in coping

Seizure precautions

encompass all nursing interventions to protect the patient from traumatic injury, position for adequate ventilation and drainage of oral secretions, and provide privacy and support following the seizure

Gynomastia,

enlarged breasts less dense, and less nodular breast

What are the common causes of falls in older adults?

environmental hazards, gait disturbance, balance disorders, weakness, vertigo, polypharmacy, adverse reactions to medications or drug interactions, alcohol use, acute illness, cognitive impairment, postural hypotension and central nervous system disorders

the FICA assessment tool

evaluates spirituality and is closely correlated to quality of life. F- Faith or Belief I- Importance and Influence C- Community A- Address (interventions to address)

What classification does a ablative surgery fall under ? and what is the description of one

excision or removal of diseased part. Example ;Amputation,removal or appendix or organ

Interdisciplinary theory

explains a systematic view of phenomenon specific to the discipline of inquiry.

SBAR recommendation

explanation of what you require, how urgent, and when action needs to be taken make suggestion of what action is to be taken clarify what action you expect to be taken

initial inspection reveals

eye contact and facial expression are appropriate to the situation and universal aging changes such as facial wrinkles, gray hair,, loss of body mass in the extremities, and increase of body mass in the trunk

integrity realm

family values, family beliefs, family meaning, family rituals, family spirituality, family culture and practices

ACTIVITIES OF DAILY LIVING (ADLs)

feeding bathing ambulating turning/positioning grooming toileting oral care vital signs (on stable patient) measuring basic fluid intake/output

Cultural Pain

feelings a patient may have after a healthcare worker disregards the patients way of life

Eye contact

readiness to communicate via eye contact allows people to closely evaluate each other lack of eye contact may indicate: anxiety, defensiveness, discomfort, lack of confidence in communicating looking down shows authority, be aware of cultural differences in meaning of eye contact

NURSING INTERVENTIONS - CARDIOVASCULAR SYSTEM

reduce orthostatic hypotension reduce cardiac workload prevent thrombus formation use of SCDs and TED hose

RANGE OF MOTION (ROM) EXERCISES

reduce the risk of contractures

How does chronic respiratory disease (Emphysema ,bronchitis ,asthma increase risk in surgery ?

reduces patient means to make up (Compensate) for acid base alterations anesthetic agents reduce respiratory function increasing risk for sever hypoventilation

NERVOUS SYSTEM

regulates movement and posture

CONCEPTS OF PATIENT-CENTERED CARE

respect and dignity information sharing participation collaboration

when assertiveness doesn't work

restate your concerns in another way engage another health care worker (IE respiratory therapy) engage you supervisor engage another physician on the team

ACTIVITY TOLERANCE

type and amount of exercise or work that a person is able to perform without undue exertion or possible injury Assessment of activity tolerance is necessary when planning activity such as walking, ROM exercises, or ADLs. Activity tolerance assessment includes data from physiological, emotional, and developmental domains

What are the risks for ageism going unopposed?

undermining the self confidence of older adults, limit their access to care distort care givers understanding of the uniqueness of the older adult

URINARY ELIMINATION CHANGES

urinary stasis UTI renal calculi

Electronic Communication

use of technology to create ongoing relationships with patients and their health care team secure messaging patient portal

skillful nurse communication: personal questions

uses judgement about what to share, provides minimal information, deflects questions with gentle humor, refocus conversation back to patient

SBAR assessment

vital signs system by system concerns list if any VS are outside of parameters clinical impression severely of patient, additional concerns

Type of dependence: Pseudoaddiction

Client behaviors (drug seeking) that occur when pain is undertreated.

spots that appear as smooth, brown, irregularly shaped spots are and occur where

age spots or senile lentigo; hands and forearms

PRIORITY ASSESSMENT

airway breathing circulation

PATIENT IDENTIFICATION

always use at least TWO patient identifiers - full name - date of birth - SSN - medical record number - telephone number

Pain clinics

treat persons on an inpatient or outpatient basis; multidisciplinary approach to find the most effective pain-relief measures

POSITIONING TECHNIQUES

trocanter roll hand roll trapeze bar supported Fowler's supine prone side-lying Sim's

Exercise

physical activity

Family members are important in assisting patient with any

physical limitations and providing emotional support during postoperative recovery.

DEVELOPMENTAL CHANGES - ADULTS

physiological systems at risk potential job loss

UTI in an older patient may present with what symptoms

confusion, incontinence and elevation of body temperature (within normal limits) instead of fever, dysuria, frequency, or urgency

JOINTS

connections between bones classified according to its structure and degree of mobility CARTILAGINOUS FIBROUS SYNOVIAL

The term referring to the sender's attitude towards the self, the message, and the listener is

connotative meaning

BEFORE DELEGATING...

consider the person's education, training, and experience a person who is not trained or licensed to manage a nursing task should not perform the task

Posture

position of the body in relation to the surrounding space

Example of, Giving personal opinions

"if I were you, I'd put my mother in a nursing home"

Example of, Autonomic responses

"older adults are always confused"

creatinine normal range

0.5-1.5 mg/dL

Normal BUN levels (blood urea nitrogen)

10-20

The most frequently occurring health related conditions associated with the older patients are?

1. hypertension 2. arthritis 3. heart disease 4. cancer 5. diabetes 6. sinusitis

platelet count normal range

100,000 - 450,000

VITAL SIGNS - RESPIRATIONS

12-20 cycles per minute (cpm) unlabored

hemoglobin normal range

12.0-16.5

The nurse is caring for a patient with pneumonia who has severe malnutrition. The nurse recognizes that, because of the nutritional status, the patient is at risk for: (Select all that apply) 1. Heart disease 2. Sepsis 3. Pleural effusion 4. Cardiac arrythmias 5. Diarrhea

2,3,4

normal potassium levels

3.5-5.0

Patients choose to use unconventional therapy because: 1.) They are willing to pay more to feel better 2.) They are dissatisfied with conventional medicine. 3.) They want religious approval for the remedies they use. 4.) It is now widely accepted by the FDA

2.) They are dissatisfied with conventional medicine.

Pacing

thinking before speaking and developing an awareness of the rhythm of your speech. speak slowly and enunciate clearly bad: talking loudly, using awkward pauses, speaking slowly deliberately

Isometric Contractions

tightening or tensing muscles without moving body parts e.g. contraction of gluteal muscles

Small, round, red or brown cherry angiomas occur on

trunk

RBC normal range

4.0-5.5

Receiver

A person that decodes the message

Key principle of providing age appropriate nursing care

timely detection of these cardinal signs of illness so early treatment can begin

Biculturalism

AKA multiculturalism occurs when an individual identifies equally with two or more cultures.

Activities of Daily Living (ADLs)

Activities usually performed in the course of a normal day in the patient's life such as eating, dressing, bathing, brushing teeth, or grooming.

activity theories

considers the continuation of activities performed during middle age as necessary for successful aging

Older adults often complain about what GI disorder.

constipation

Which areas should the nurse assess to determine the effects of external variables on a patient's illness? (Select all that apply.) a. Patient's perception of the illness b. Patient's coping skills c. Socioeconomic status d. Cultural background e. Social support

ANS: C, D, E

Sharing empathy

Ability to understand and accepts another person's reality.

Accepting and respecting the client's right to decide, even if the nurse believes the decision to be wrong.

Advocacy

theory

contains a set of concepts, definitions, and assumptions or propositions that explain a phenomenon.

arterial blood gas

Analysis is an effective method of evaluating acid-base balance and oxygenation

Explain the following manipulative and body-based methods *Acupressure*

Applying digital pressure in a specified way on designated points on the body to relieve pain, produce analgesia, or to regulate a body function

Circulating Nurse

Assistant to the scrub nurse and surgeon whose role is to provide necessary supplies; dispose of soiled instruments and supplies; and keep an accurate count of instruments, needles, and sponges used.

A patient learns that a normal adult heartbeat is 60 to 100 beats/min after a teaching session with a nurse. In which domain did learning take place? a.Kinesthetic b.Cognitive c.Affective d.Psychomotor

B

Avoidance of harm or hurt

Nonmaleficence

You have been given the following postoperative patients to care for on your shift. Based on the information provided, which patient should you see first?

B. A 57-year-old following hip replacement 6 hours earlier who is receiving intravenous patient-controlled analgesia (PCA) with a history of OSA. The pulse oximeter has been alarming and reading 85% The patient with OSA has a risk of airway obstruction, which takes immediate precedence. She is symptomatic of oxygen desaturation.

The philosophy sometimes called the ethics of care suggests that ethical dilemmas can best be solved by attention to which of the following? A. Patients B. Relationships C. Ethical principles D. Code of ethics for nurses

B. Relationships

Taking positive actions to help others

Beneficence

HCO3

Bicarbonate 23 to 30 mEq/L

A patient has been taught how to change a colostomy bag but is having trouble measuring and manipulating the equipment and has many questions. What is the nurse's next action? a.Refer to a mental health specialist. b.Refer to a wound care specialist. c.Refer to an ostomy specialist. d.Refer to a dietitian.

C

PRONE POSITION

lying face down/chest down head is often turned to the side (no pillow)

The point of the ethical principal to "do no harm" is an agreement to reassure the public that in all ways the health care team not only works to heal patients but agree to do this in the least painful and harmful way possible. Which principle describes this agreement? A. Beneficence B. Accountability C. Nonmaleficence D. Respect for autonomy

C. Nonmaleficence

Interventions unlikely to produce benefit for the patient

Care at the end of life

Sharing humor

Coping strategy to adjust to stress.

A nurse argues that we need to reform our health care system because we have a large number of people who are uninsured and end up need expensive emergent care when low-cost measures could have prevented their illnesses. What ethical framework is she using to make this case? A. Deontology B. Ethics of care C. Feminist ethics D. Utilitarianism

D. Utilitarianism

Nursing process: Assessment Identify the ABCDE clinical approach to pain assessment and management D

D: Deliver interventions in a timely, logical, and coordinated fashion.

A nurse is teaching about the goals of Healthy People 2020. Which information should the nurse include in the teaching session?

Eliminate health disparities in America

Active transport

Energy requiring movement of electrolytes or other substances across cell membranes against a concentration gradient. Required energy usually in the form of ATP.

First assessment after anesthesia is to?

Establish a patent airway

Primary Appraisal

Evaluation an event for it's personal meaning.

Focuses on the inequality between people

Feminist Ethics

What are the risks and benefits to individuals and to society of learning about the presence of a disease that has not yet caused symptoms, or for which a cure is not yet available?

Genetic Screening

RIGHT DIRECTION/COMMUNICATION

Give a clear, concise description of a task, including its objective, limits, and expectations. Communication needs to be ongoing between the RN and NAP during a shift of care.

Pollutant

Harmful chemical or waste material discharged into the water, soil, or air.

Sharing observations

Helps the patient communicate without the need of extensive questioning

KYPHOSIS

Increased convexity in curvature of thoracic spine

Allogeneic transfusion

Infusion of a donors blood into a patient.

KNOCK-KNEE (GENU VALGUM)

Legs curved inward so knees come together as person walks

Cultural care accomodations/negotiation

Leininger defines a nursing decision and action mode that assists the patient to adapt or negotiate with others for a beneficial or satisfying health outcome

Explain the following manipulative and body-based methods *Chiropractic medicine*

Manipulating the spinal column; includes physiotherapy and diet therapy

Explain the following movement therapies *Pilates*

Method of body movement used to strengthen, lengthen, and improve the voluntary control of muscles and muscle groups, especially those used for posture and core strengthening; awareness of breathing and precise movements are integral components

Anion

Negatively charged ions. Major ones are chloride, bicarbonate, and phosphate.

Central to discussions about end-of-life care, cancer therapy, physician-assisted suicide, and DNR

Quality of Life

R.A.C.E.

R = rescue client A = activate fire alarm C = confinement of fire closing doors and windows E = extinquish the fire

Clarity and brevity

Simple, brief and fast. Elderly: fewer words=less confusion repeat important parts

Most abundant cation in the extracellular fluid

Sodium

What classification does a diagnostic surgery fall under ? and what is the description of one

Surgical exploration that allows health care provider to confirm diagnosis . Purpose

Venipuncture

Technique for assessing oven by the puncture through the skin using a sharp rigid stylet.

Which statement about nonverbal communication is correct

The nurse's verbal messages should be reinforced by nonverbal cues.

Coping

The persons effort to manage psychological stress. A persons age and culture have a huge impact on this.

maslows levels

The third level contains love and belonging needs, including family and friends. The first level includes physiological needs. The second level includes safety and security needs. The fourth level encompasses esteem and self-esteem needs. The fifth and final level is the need for self-actualization.

Explain the following mind-body interventions *Psychotherapy*

Treatment of emotional and mental disorders by psychological techniques

Fluid

Water that contains disowned or suspended substances such as glucose, mineral salts, and protiens.

NURSING INTERVENTIONS - PSYCHOSOCIAL SYSTEM

anticipate change in patient status provide routine/informal socialization stimuli to maintain patient's orientation

family structure

based on organization. relationships are numerous and complex.

Entropy

lack of order

buddhist four noble truths

1. life is suffering 2. suffering is caused by clinging 3. suffering can be eliminated by eliminating clinging 4. to eliminate clinging and suffering, one follows an eightfold path (i.e., right understanding, intention, speech, action, livelihood, effort, mindfulness, and concentration).

Average loss of fluid through feces

100 - 200 milliliters of fluid

serum sodium normal range

135-145 mEq/L

A patient with type 1 diabetes mellitus had normal blood glucose levels before going to the gym. While performing strenuous exercise at the gym, the patient suddenly collapsed. What is the most probable reason for this? 1 Low blood pressure 2 Low blood sugar 3 Vasovagal syncope 4 High blood sugar

2 Exercise tends to decrease sugar levels and the patient is most likely to have low blood sugar or hypoglycemia. A patient with type 1 diabetes mellitus should perform low- to moderate-intensity exercises and carry a hard candy or sugar packets. The patient should also be informed to wear an alert bracelet. According to the scenario, the patient does not present with blood pressure-related problems, thus it is highly unlikely for hypotension or vasovagal syncope to be present in this patient. Hyperglycemia or high blood sugar would not cause a sudden collapse.

What type of diet does the nurse provide a patient who has decreased cardiac output related to a decrease in myocardial contractility? Select all that apply. 1 Low-protein diet 2 Low-sodium diet 3 High-fat diet 4 Low-calorie diet 5 High-protein diet

2, 4, 5 During heart failure exercise intolerance, cardiac output decreases due to decreased cardiac contractility. Therefore, this patient should be provided with a low-sodium, low-calorie, and high-protein diet. Reduced sodium intake would prevent fluid retention in the body and thus decrease the workload on the heart. A low-calorie diet is very important in preventing atherosclerosis, which would further impair cardiac function. A high-protein diet should be advised, because protein in the diet helps to repair the body. A low-protein and high-fat diet is not desirable for the patient.

How does the nurse move his or her own body while transferring a patient to a bed? 1 The nurse relaxes the abdominal muscles. 2 The nurse twists the back and the pelvis slightly. 3 The nurse keeps the feet wide apart and bends at the knees. 4 The nurse avoids asking the patient to help as much as possible.

3 The nurse keeps the feet wide apart and bends at knees to get a broader base of support, which increases stability and maintains a center of gravity. The nurse should tighten, not relax, the abdominal muscles to reduce the risk of injury to the lumbar vertebrae and muscle groups. The nurse avoids twisting and keeps the back, neck, pelvis, and feet aligned to decrease the risk of injury. The nurse encourages the patient to help as much as possible to promote patient independence and strength while minimizing the nurse's workload.

serum potassium normal range

3.5-5.0 mEq/L

MCHC % normal range

31-37

WBC normal range

4.5-10.0

pH

7.35-7.45

glucose normal range

70-110mg/dL

Nursing process: Assessment Identify the ABCDE clinical approach to pain assessment and management A

A: Ask about pain regularly. Assess pain systematically.

2. The nurse is caring for an ambulatory surgery patient. To be discharged home, what criteria must the patient meet? (Select all that apply.) a. Able to drink fluids b. Able to eat crackers c. Manageable pain d. Able to void e. Dry and intact dressing f. Able to dress self

ANS: A, C, D, E To be discharged home, patients need to meet certain criteria. These criteria include meeting phase 1 criteria of activity, circulation, respiration, consciousness, and O2 saturation, as well as phase 2 criteria of dressing dry and intact, manageable pain, ambulation, able to drink fluids, and voiding. Eating and the ability to dress self are not included in these criteria.

The ChooseMyPlate program includes guidelines for a. Children younger than 2 years. b. Balancing calories. c. Increasing portion size. d. Decreasing water consumption.

ANS: B The ChooseMyPlate program includes guidelines for balancing calories; decreasing portion size; increasing healthy foods; increasing water consumption; and decreasing fats, sodium, and sugars. These guidelines have been put forth for Americans over the age of 2 years.

In providing diabetic teaching for a patient with type 1 diabetes mellitus, the nurse instructs the patient that a. Insulin is the only consideration that must be taken into account. b. Saturated fat should be limited to less than 7% of total calories. c. Cholesterol intake should be greater than 200 mg/day. d. Nonnutritive sweeteners can be used without restriction.

ANS: B The diabetic patient should limit saturated fat to less than 7% of total calories and cholesterol intake to less than 200 mg/day. Type 1 diabetes requires both insulin and dietary restrictions for optimal control. Nonnutritive sweeteners can be eaten as long as the recommended daily intake levels are followed.

The patient has just been started on an enteral feeding and has developed diarrhea after being on the feeding for 2 hours. The most likely cause of the diarrhea would be a. Clostridium difficile. b. Antibiotic therapy. c. Formula intolerance. d. Bacterial contamination.

ANS: C Hyperosmolar formulas can cause diarrhea. If that is the case, the solution is to lower the rate, dilute the formula, or change to an isotonic formula. Antibiotics destroy normal intestinal flora and disturb the internal ecology, allowing for Clostridium difficile toxin buildup. However, this takes time, and no indication suggests that this patient was on antibiotics. Proximity to the start of the enteral feedings is more suspicious. Bacterial contamination of the feeding usually occurs when feedings are left hanging for longer than 8 hours.

6. The nurse is caring for a patient in the postanesthesia care unit who has undergone a left total knee arthroplasty. The anesthesia provider has indicated that the patient received a left femoral peripheral nerve block. Which assessment would be an expected finding for a patient with this type of regional block? a. Decreased pulse at the left posterior tibia b. Left toes cool to touch and slightly cyanotic c. Sensation decreased in the left leg d. Patient report of pain in the left foot

ANS: C Induction of regional anesthesia results in loss of sensation in an area of the body. The peripheral nerve block influences the portion of sensory pathways that are anesthetized in the targeted area of the body. Decreased pulse, toes cool to touch, and cyanosis are indications of decreased blood flow and are not expected findings. Reports of pain the in the left foot may indicate that the block is not working or is subsiding and is not an expected finding in the immediate postoperative period.

21. The nurse is making a preoperative education appointment with a patient. The patient asks if he should bring family with him to the appointment. What is the best response by the nurse? a. "There is no need for an additional person at the appointment." b. "Your family can come and wait with you in the waiting room." c. "We recommend including family in this appoint to ease everyone's anxiety." d. "It is required that you have a family member at this appointment."

ANS: C It is ideal to attempt perioperative education before admission, during the hospital stay, and after discharge. Including family members in perioperative education is advisable. Often a family member is a coach for postoperative exercises when the patient returns from surgery. If anxious relatives do not understand routine postoperative events, it is likely that their anxiety will heighten the patient's fears and concerns. Perioperative preparation of family members before surgery helps to minimize anxiety and misunderstanding. An additional person is needed at the appointment if at all possible, and he or she needs to be involved in the process, not just waiting in the waiting room; however, it is certainly not a requirement for actually completing the surgery that someone comes to this appointment.

During the evaluation stage of the critical thinking model applied to a patient coping with stress, the nurse will a. Select nursing interventions to promote the patient's adaptation to stress. b. Establish short- and long-term goals with the patient experiencing stress. c. Identify stress management interventions for achieving expected outcomes. d. Reassess patient's stress-related symptoms and compare with expected outcomes.

ANS: D During the evaluation stage, the nurse compares current stress-related symptoms against established measurable outcomes to evaluate the effectiveness of the intervention. Selecting appropriate interventions and establishing goals are part of the planning process.

An adult who was in a motor vehicle accident is brought into the emergency department by paramedics, who report the following in-transit vital signs: Oral temperature: 99.0° F Pulse: 102 beats per minute Respiratory rate: 26 breaths per minute Blood pressure: 140/106 The nurse can identify that which hormones are the likely causes of the abnormal vital signs? a. ADH and ACTH b. ACTH and epinephrine c. ADH and norepinephrine d. Epinephrine and norepinephrine

ANS: D Epinephrine and norepinephrine are catecholamine hormones secreted by the adrenal medulla that rapidly elevate heart rate and blood pressure. ACTH originates from the anterior pituitary gland and stimulates cortisol release; ADH originates from the posterior pituitary and increases renal reabsorption of water. ACTH, cortisol, and ADH do not increase heart rate

Hypernatremia

Abnormally high sodium concentration in ECV caused by loss of relatively more water than salt or gain of relatively more salt than water. (water deficit)

Visceral pain

Arises from visceral organs, such as the gastrointestinal tract and pancreas.

A nurse is determining if teaching is effective. Which finding best indicates learning has occurred? a.A nurse presents information about diabetes. b.A patient demonstrates how to inject insulin. c.A family member listens to a lecture on diabetes. d.A primary care provider hands a diabetes pamphlet to the patient.

B

A nurse is planning a teaching session about healthy nutrition with a group of children who are in first grade. The nurse determines that after the teaching session the children will be able to name three examples of foods that are fruits. This is an example of: A. A teaching plan. B. A learning objective. C. Reinforcement of content. D. Enhancing the children's self-efficacy.

B

A child's immunization may cause discomfort during administration, but the benefits of protection from disease, both for the individual and society, outweigh the temporary discomforts. Which principle is involved in this situation? A. Fidelity B. Beneficence C. Nonmaleficence D. Respect for autonomy

B. Beneficence

Nursing process: Assessment Identify the ABCDE clinical approach to pain assessment and management B

B: Believe the client and family in their report of pain and what relieves it.

Explain the following biofield energy therapies *Magnet therapy*

Bioelectromagnetic therapy; devices applied to the body surface, producing a measurable magnetic field; used primarily to alleviate pain associated with musculoskeletal injuries or disorders

Colloid

Blood product

A patient newly diagnosed with cervical cancer is going home. The patient is avoiding discussion of her illness and postoperative orders. What is the nurse's best plan in teaching this patient? A. Teach the patient's spouse B. Focus on knowledge the patient will need in a few weeks C. Provide only the information that the patient needs to go home D. Convince the patient that learning about her health is necessary

C

A patient with heart failure is learning to reduce salt in the diet. When will be the best time for the nurse to address this topic? a.At bedtime, while the patient is relaxed b.At bath time, when the nurse is cleaning the patient c.At lunchtime, while the nurse is preparing the food tray d.At medication time, when the nurse is administering patient medication

C

Which assessment finding will cause the nurse to begin teaching a patient because the patient is ready to learn? a.A patient has the ability to grasp and apply the elastic bandage. b.A patient has sufficient upper body strength to move from a bed to a wheelchair. c.A patient with a below-the-knee amputation is motivated about how to walk with assistive devices. d.A patient has normal eyesight to identify the markings on a syringe and coordination to handle a syringe.

C

Which statement made by an adult patient demonstrates understanding of healthy nutrition teaching? A. I need to stop eating red meat. B. I will increase the servings of fruit juice to four a day. C. I will make sure that I eat a balanced diet and exercise regularly. D. I will not eat so many dark green vegetables and eat more yellow vegetables.

C

a patient is admitted to the hospital with severe dyspnea and wheezing. arterial blood gas levels on admission are pH 7.26; PaCO2, 55 mm Hg; PaO2, 68 mm Hg; and HCO3, 24. The nurse interprets these laboratory values to indicate A. metabolic acidosis B. metabolic alkalosis C. respiratory acidosis D. respiratory alkalosis

C

an older adult patient is receiving intravenous 0.9% NaCl. a nurse detects new onset of crackles in the lung bases. what is the priority action? A. notify a health care provider B. record in medical record C. decrease the iv flow rate D. discontinue the iv site

C

Which of the following statements by the nurse would be most helpful when a nurse is assisting clients in clarifying their values? A. "That was not a good decision. Why did you think it would work?" B. "The most important thing is to follow the plan of care. Did you follow all of your doctor's orders?" C. "Some people might have made a different decision. What led you to make your decision?" D. "If you had asked me, I would have given you my opinion about what to do. Now how do you feel about your choice?"

C. "Some people might have made a different decision. What led you to make your decision?"

The patient's son requested to view the documentation in his mother's medical record. What is the nurse's best response to this request? A. "I'll be happy to get that for you." B. "You will have to talk to the physician about that." C. "You will need your mother's permission." D. "You are not allowed to see it."

C. "You will need your mother's permission."

The ANA code of nursing ethics articulates that the nurse "promotes, advocates for, and strives to protect the health, safety, and rights of the patient." This includes the protection of patient privacy. On the basis of this principal, if you participate in a public online social network such as Facebook, could you post images of a patient's x-ray film if you deleted all patient identifiers? A. Yes because patient privacy would not be violated as long as the patient identifiers were removed B. Yes because respect for autonomy implies that you have the autonomy to decide what constitutes privacy C. No because, even though patient identifiers are removed, someone could identify the patient based on other comments that you make online about his or her condition and your place of work D. No because the principal of justice requires you to allocate resources fairly

C. No because, even though patient identifiers are removed, someone could identify the patient based on other comments that you make online about his or her condition and your place of work

Neurological and surgery

Changes in function reduce the ability to respond to warning signs of complications and may lead to confusion after anesthesia

Renal system and surgery

Changes in structure and function increase the possibility of shock with blood loss, limit the ability to metabolize drugs/toxic substances, increase the frequency of urination and the amount of residual urine, and reduce the sensation of the need to void

Cardiovascular disease and surgery

Changes in structure and function reduce cardiac reserve and predispose the patient to postoperative hemorrhage, increased blood pressure, and clot formation

A nurse is following the goals of Healthy People 2020 to provide care. Which action should the nurse take?

Create social and physical environments that promote good health

A nurse is teaching a group of healthy adults about the benefits of flu immunizations. Which type of patient education is the nurse providing? a.Health analogies b.Restoration of health c.Coping with impaired functions d.Promotion of health and illness prevention

D

The patient for whom you are caring needs a liver transplant to survive. This patient has been out of work for several months and doesn't have health insurance or enough cash. What principles would be a priority in a discussion about ethics? A. Accountability because you as the nurse are accountable for the well-being of this patient B. Respect for autonomy because this patient's autonomy will be violated if he does not receive the liver transplant C. Ethics of care because the caring thing that a nurse could provide this patient is resources for a liver transplant D. Justice because the first and greatest question in this situation is how to determine the just distribution of resources

D. Justice because the first and greatest question in this situation is how to determine the just distribution of resources

LORDOSIS

Exaggeration of anterior convex curve of lumbar spine

place the following steps for discontinuing an IV access in the correct order: A. preform hand hygiene and apply gloves B. explain procedure to the patient C. remove IV site dressing and tape D. use two identifiers to ensure correct patient E. stop the infusion and clamp the tubing F. carefully check the health care providers order G. clean the site, withdraw the catheter and apply pressure

F, D, B, A, E, C, G

Agreement to keep promises

Fidelity

Maslow's Hierarchy

Fifth Level-need for self-actualization, the state of fully achieving potential.

Maslow's Hierarchy

First Level-physiological needs like air, water, and food

Interstitial fluid

Fluid between the cells and outside of the blood vessels.

Confrontation

Helping the patient to become aware of inconsistencies in his or her feelings, attitudes, beliefs, and behaviors.

The nurse is working in a drug rehabilitation clinic and is in the process of admitting a patient for "detox." What should the nurse do next?

Identify the patient's stage of change

FOOTDROP

Inability to dorsiflex and invert foot because of peroneal nerve damage permanent fixation of the foot in plantar flexion

Identify the limitations of acupuncture.

Inadequately sterilized needles can cause infections. Other limitations are broken nails, puncture of internal organ, bleeding, fainting, seizures, and post-treatment drowsiness.

Family as system

Includes both relational and transactional concepts. ??

What is meditation?

It is any activity that limits stimulus input by directing attention to a single unchanging or repetitive stimulus

Crystalloids

Iv fluid and electrolyte therapy

Infiltration

Iv fluids leak into the subcutaneous tissue around the venipuncture site because the catheter tip no longer is in the vein. Swelling, coolness, paleness.

Medulla Oblongata

Located in the lower portion of the brainstem, controls heart rate, blood pressure, and respirations.

Osmolality

Measure of the number of particles per kilogram of water reported in a milliosmoles per kilogram.

Using touch

Most potent for communication

Type of dependence: Pseudotolerance

Need to increase opioid dose for reasons other than opioid tolerance: progression of disease, onset of new disorder, increased physical activity, lack of adherence, change in opioid formulation, drug-drug interaction, drug-food interaction.

Filtration

Net effect of several forces that tend to move fluid across a membrane. Fluid moves into an out of capillaries.

Systems theory

Neuman's system theory defines a total person model of wholism and an open-systems approach,

A nurse is using Maslow's hierarchy to prioritize care for an anxious patient that is not eating and will not see family members. Which area should the nurse address first?

Not eating

Family as client

Nursing approach that takes into consideration the effect of one interventions on all members of a family.

Reducing pain perception

One simple way to promote comfort is by removing or preventing painful stimuli; also distraction, prayer, relaxation, guided imagery, music, and biofeedback

Incident pain

Pain that is predictable and elicited by specific behaviors such as physical therapy or wound-dressing changes

Is S3 an age related change to cardiovascular or a pathology change.

Pathology change. When assessing an older adults heart sound always consider the s3 abnormal. low pitched heart sounds heard best with the bell of the stethoscope over the apex of the heart.

Identify the limitations of herbal therapy.

Problems with herbal therapies include contamination with other chemicals or herbs, toxic agents, a variety of standards used from one company to another

Intervention: Encourage mentoring relationships between adults and adolescents

Rationale: Adolescents are in need of role models after whom they can pattern their behavior

Intervention: teach them safe use of the internet

Rationale: Avoids overuse and possible exposure to inappropriate websites.

Intervention: Install key less locks on doors above a child's reach, even when they are standing on a chair

Rationale: Deadbolts prevent a toddler from leaving the house and wandering off. Key less locks allow for rapid exit in case of Fire.

Intervention: Place window Guard on windows.

Rationale: Guards prevent children from falling out of windows.

Intervention: Teach children the safe use of equipment for play and at work

Rationale: Helps child avoid injury

Interventions: Do not attach pacifiers to string or ribbon and place around a child's neck,

Rationale: cause risk for choking

Maslow's Hierarchy

Second Level-safety and security needs

Progressive relaxation training helps to:

To teach the individual how to effectively rest and reduce tension in the body

Explain the following manipulative and body-based methods *Simple touch*

Touching the patient in appropriate and gentle ways to make connection, display acceptance and give appreciation

Explain the following mind-body interventions *Acupuncture*

Traditional Chinese method of producing analgesia or altering the function of a body system by inserting thin needles along a series of lines or channels, called meridians; direct needle manipulation of energetic meridians influences deeper internal organs by redirecting qi

Personal beliefs about the worth of a given idea, attitude, custom, or object that set standards that influence behavior.

Values

Rites of passage

Van Gennep originated the concept as significant social markers of changes in a person life.

The patient had a colostomy placed 1 week ago. When approached by the nurse, the patient and spouse refuse to talk about it and refuse to be taught about how to care for it. How will the nurse evaluate this couple's stage of adjustment?

Withdrawal

nursing theory

a conceptualization of some aspect of nursing that describes, explains, predicts or prescribes nursing care.

What is the nurses position in relation to the adult children and aging parents?

a counselors to both the parents and the children

Cognitive function deterioration leads to

a decline in the ability to perform basic ADL's and IADL.

ORTHOSTATIC HYPOTENSION

a drop of blood pressure greater than 20 mmHg in systolic pressure or 10 mmHg in diastolic pressure symptoms include: - dizziness - light-headedness - nausea - tachycardia - pallor - fainting (syncope) occurs when patient changes from the supine to standing position

A routine preoperative safety checklist is

a guide for final preparation of the patient before surgery.

What are the baby boomers?

a large group of adults born between 1946 and 1964

MOBILITY

a person's ABILITY to move about freely

For a nurse to able to relate to others, he or she must have the ability to:

a) Take the initiative in establishing and maintaining communication. b) Be authentic (one's self) c) Respond appropriately to the other person. d) Have a sense of mutuality. e) Believe that the nurse-patient relationship is a partnership with equal participants.

Implementation 35. The agency for healthcare research and quality (AHRQ) guidelines for acute pain management cite non pharmacological interventions appropriate for clients who meet certain criteria. List those criteria.

a. find such interventions appealing b. express anxiety or fear c. will possibly benefit from avoiding or reducing drug therapy d. are likely to experience and need to cope with a prolonged interval of postoperative pain e. have incomplete pain relief after use of pharmacological interventions

Identify the physiological factors that influences pain

a. age b. fatigue c. genes d. neurological function

Identify the cultural factors that can influence pain

a. meaning of the pain b. ethnicity

Three types of analgesics used for pain relief

a. nonopioids b. opioids c. adjuvants/coanalgesics

Identify the common characteristics of pain that the nurse would assess.

a. onset and duration b. location c. intensity d. quality e. pain pattern f. relief measures g. contributing symptoms h. effects of pain on the client i. behavioral effects j. influence on activities of daily living

JOINT CONTRACTURE

abnormal and possibly permanent fixation of a joint caused by disuse, atrophy, and shortening of muscle fibers

Micturation (urination)

act of releasing urine

faith

allows people to have firm beliefs despite lack of physical evidence.

Why does nursing care of older adults pose special challenges?

because of the great varation in their physiological, cognitive, and psychosocial health

A common early circulatory problem is ?

bleeding and hemorrhage

Footboards

boards placed on the end of beds; patients push against them to move up in bed; helps prevent drop foot

RENAL CALCULI

calcium stones that lodge in the renal pelvis or pass through the ureters immobilized patients are at risk for calculi because they frequently have hypercalcemia.

hazards of immobility

cluster of symptoms, such as the effects (often apparent in a matter of days) of muscular deconditioning associated with lack of physical activity.

ATELECTASIS

collapse of alveoli

Somatic

comes from bone, joint, muscle, skin, or connective tissue. It is usually aching or throbbing in quality and is well-localized.

sounds

communicate feelings or thoughts

Transcultural Nursing

comparative study of cultures to understand similarities (culture universal) and differences (culture-specific) across human groups.

Peplau's theory

develop interaction between nurse and patient. (ex. nurse facilitates interpersonal relationships)

Culture-bound syndrome

illnesses that are specific to one culture

RESPIRATORY CHANGES

increased risk for pulmonary/respiratory complications including: - atelectasis - hypostatic pneumonia

family function

involves the processes used by the family to achieve goals. processes include goal setting, conflict resolution, caregiving, nurturing, and use of resources

If the bun level is low what could happen

liver disease/fluid overload

Center of Gravity

midpoint or center of the weight of a body or object

Accurate pain assessment and intervention are

necessary for healing.

Extended family

nuclear family relatives (aunts,uncles,grandparents and cousins)

what patients are more at risk for developing postoperative hypothermia

older adults and pediatric patients

Gerontology

study of all aspects of the aging process and its consequenses

IMMOBILITY

the INABILITY to move about freely

agnostic

they believe that there is no known ultimate reality

Intonation

tone of voice wrong tone can send unintended messages

SYNOVIAL JOINTS

true joints, hinge type at the elbow are freely movable and the most mobile, numerous, and anatomically complex body joints

Sharing hope

"Sense of possibility"

Example of, Asking for explanations

"why are you so anxious?"

Evaluation identify some principles to evaluate related to pain management.

-evaluate the client for the effectiveness of the pain management after an appropriate period of time -entertain new approaches if no relief -evaluate the client's perception of pain

Which activities does the nurse delegate to nursing assistive personnel with regard to crutch walking? Select all that apply. 1 Notifying the nurse if the patient reports pain before, during, or after exercise 2 Notifying nurse of patient complaints of increased fatigue, dizziness, and/or light-headedness when obtaining and vital signs before and after exercise 3 Notifying the nurse of vital sign values 4 Evaluating the patient's ability to use crutches properly 5 Preparing the patient for exercise by assisting in dressing and putting on shoes

1, 2, 3, 5

The nurse is teaching a group of menopausal women about osteoporosis. What are some causes of osteoporosis? Select all that apply. 1 Lack of exercise 2 Brittle bones 3 Decreased estrogen levels 4 Increase in bone mass 5 Increased resorption of bone tissue

1, 3, 5 Lack of exercise causes demineralization of bones leading to osteoporosis. Decreased estrogen levels and increased resorption also cause bone to become porous. Brittle bones are a manifestation of osteoporosis, not a cause. Bone mass and bone density decrease in osteoporosis.

VITAL SIGNS - BLOOD PRESSURE

120/80 mmHg or less systolic < 120 mmHg diastolic < 80 mmHg pulse pressure: 30 - 50 mmHg

Which of the following steps should nurses take to be better informed about alternative therapies? 1.) Review herb manufacturers' literature on specific herbs 2.) Read current books and magazines on alternative therapies 3.) Familiarize themselves with general principles of phototherapy 4.) Familiarize themselves with recent case studies on alternative therapies

2.) Read current books and magazines on alternative therapies

PaCO2

35-45 mmHg Partial pressure of carbon dioxide

hematocrit normal range

36-50

The nurse evaluates which laboratory values to assess a patient's potential for wound healing? 1. Fluid status 2. Potassium 3. Lipids 4. Nitrogen balance

4

The nurse is assessing joint movements in a patient. What happens during the process of flexion at the elbow joint? 1 Triceps brachii acts as an antagonistic muscle and contracts. 2 Biceps brachii acts as a synergistic muscle and relaxes. 3 Triceps brachii acts as a synergistic muscle and contracts. 4 Biceps brachii acts as a synergistic muscle and contracts.

4 During flexion of the elbow joint, the biceps brachii acts as a synergistic muscle and contracts. Contraction of the biceps brings the arm and forearm closer to each other and causes flexion. At the same time, the triceps brachii acts as an antagonistic muscle and relaxes. The biceps brachii relaxes and the triceps brachii contracts during extension of the joint.

A patient with a body mass index (BMI) of 36 has a sedentary job. She has been advised to reduce her weight through exercise. To begin an exercise program, she needs to go through five steps. Arrange the steps in the appropriate order. 1. Assemble equipment. 2. Get started. 3. Design the fitness program. 4. Monitor progress. 5. Assess fitness level.

5, 3, 1, 2, 4 A health care provider assesses the patient's fitness level, which is used as a basis for the fitness program; then the fitness program needs to be designed. The exercise equipment should be assembled accordingly. Next, the patient should begin the program. Progress is monitored regularly to determine the effect of the exercise. Fitness is assessed at 6 weeks and then every 3 to 6 months.

What age is considered the lower boundary for old age?

65

What is creative visualization?

A form of self-directed imagery that is based on the principle of mind-body connectivity

The primary reason that family members should be included when the nurse teaches the patient preoperative exercises is so they can:

A. Coach and encourage the patient after surgery. Patients may need support from family to be motivated to return to their previous state of health. The family may also have better retention of preoperative teaching and will be with the patient and able to help them in their recovery.

Which philosophy of health care ethics would be particularly useful when making ethical decisions about vulnerable populations? A. Feminist ethics B. Deontology C. Bioethics D. Utilitarianism

A. Feminist ethics

When a nurse assesses a patient for pain and offers a plan to manage the pain, which principal is used to encourage the nurse to monitor the patient's response to the pain? A. Fidelity B. Beneficence C. Nonmaleficence D. Respect for autonomy

A. Fidelity

Four patients in labor all request epidural analgesia to manage their pain at the same time. Which ethical principal is compromised when only one nurse anesthetist is on call? A. Justice B. Nonmaleficence C. Beneficence D. Fidelity

A. Justice

After a surgical patient has been given preoperative sedatives, which safety precaution should a nurse take?

A. Reinforce to the patient to remain in bed or on the stretcher It is important for patient safety in patients who have been given sedatives to inform them of the importance of remaining in bed after preoperative sedatives are administered. It is inappropriate to have a bed or stretcher in the high position because of the increased fall risk and potential for injury. Informed consent should be obtained and allergy assessment done before sedative administration.

Following a motor vehicle crash, the parents refuse to permit withdrawal of life support from the child with no apparent brain function. Although the nurse believes the child should be allowed to die and organ donation considered, the nurse supports their decision. Which moral principle provides the best basis for the nurse's actions? A. Respect for autonomy B. Nonmaleficence C. Beneficence D. Justice

A. Respect for autonomy

The nurse is concerned about pulmonary aspiration when providing her patient with tube feedings. The nurse should a. Verify tube placement before feeding. b. Lower the head of the bed to a supine po-sition. c. Add blue food coloring to the enteral formula. d. Run the formula over 12 hours to decrease volume.

ANS: A A major cause of pulmonary aspiration is regurgitation of formula. The nurse needs to verify tube placement and elevate the head of the bed 30 to 45 degrees during feedings and for 2 hours afterward. The addition of blue food coloring to enteral formula to assist with detection of aspi-rate is no longer used. Do not hang formula longer than 4 to 8 hours. Formula becomes a medium for bacterial growth after that length of time.

29. The nurse is caring for a patient in the operating suite. Which of the following outcomes would be most appropriate for this patient? a. At the end of the intraoperative phase, the patient will be free of burns at the grounding pad. b. At the end of the intraoperative phase, the patient will be free of infection. c. At the end of the intraoperative phase, the patient will be free of nausea and vomiting. d. At the end of the intraoperative phase, the patient will be free of pain.

ANS: A A primary focus of intraoperative care is to prevent injury and complications related to anesthesia, surgery, positioning, and equipment use, including use of the electrical cautery grounding pad for prevention of burns. The perioperative nurse is an advocate for the patient during surgery and protects the patient's dignity and rights at all times. Evaluation of many goals and outcomes does not occur until after surgery. Signs and symptoms of infection do not have the time to present during the intraoperative phase. During the intraoperative phase, the patient is anesthetized and unconscious and typically has an endotracheal tube that prevents conversation and complaints. These complaints typically begin in the postoperative phase of the experience.

8. The nurse is completing a medication history for the surgical patient in preadmission testing. Which of the following medications should the nurse instruct the patient to hold in preparation for surgery? a. Ibuprofen b. Acetaminophen c. Vitamin C d. Miconazole

ANS: A Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen inhibit platelet aggregation and prolong bleeding time, increasing susceptibility to postoperative bleeding. Acetaminophen is a pain reliever that has no special implications for surgery. Vitamin C actually assists in wound healing and has no special implications for surgery. Miconazole is an antifungal and has no special implications for surgery.

A structural curvature of the spine associated with vertebral rotation is known as a. Scoliosis. b. Osteogenesis. c. Osteomalacia. d. Arthritis

ANS: A Scoliosis is a structural curvature of the spine associated with vertebral rotation. Osteogenesis imperfecta is an inherited disorder that makes bones porous, short, bowed, and deformed. Osteomalacia is an uncommon metabolic disease characterized by inadequate and delayed mineralization, resulting in compact and spongy bone. Arthritis is an inflammatory joint disease characterized by inflammation or destruction of the synovial membrane and articular cartilage, and by systemic signs of inflammation

The nurse is providing home care for a patient diagnosed with AIDS. In preparing meals for this patient, the nurse should a. Provide small, frequent nutrient-dense meals. b. Encourage intake of fatty foods to in-crease caloric intake. c. Prepare hot meals because they are more easily tolerated. d. Avoid salty foods and limit liquids to preserve electrolytes.

ANS: A Small, frequent, nutrient-dense meals that limit fatty foods and overly sweet foods are easier to tolerate. Patients benefit from eating cold foods and drier or saltier foods with fluid in between.

27. The nurse is caring for a patient intraoperatively. Primary roles of the circulating nurse include a. Establishing and implementing the plan of care. b. Maintaining a sterile field. c. Assisting with applying sterile drapes. d. Handing sterile instruments and supplies to the surgeon.

ANS: A The circulating nurse must be a registered nurse and has the responsibilities of preoperative assessment, establishing and implementing the plan of care, evaluating the care provided, and ensuring continuity of care postoperatively. The scrub nurse, who can be a registered nurse, a licensed practical nurse, or a surgical technologist, maintains the sterile field, assists with applying the sterile drapes, and hands sterile instruments and supplies to the surgeon.

Fats are composed of triglycerides and fatty acids. Triglycerides a. Are made up of three fatty acids. b. Can be saturated. c. Can be monounsaturated. d. Can be polyunsaturated.

ANS: A Triglycerides circulate in the blood and are made up of three fatty acids attached to a glycerol. Fatty acids (not triglycerides) can be saturated or unsaturated (monounsaturated or polyunsatu-rated).

A trauma survivor is requesting sleep medication because of "bad dreams." Concerned about posttraumatic stress disorder, the nurse asks a. "Are you reliving your trauma?" b. "Are you having chest pain?" c. "Can you describe your phobias?" d. "Can you tell me when you wake up?"

ANS: A People who have PTSD often have flashbacks, reexperiencing the trauma. The other answers involve assessment of problems not specific to PTSD.

6. The nurse is using a preoperative checklist to assist in preparing a patient on the day of surgery. What will the checklist include? (Select all that apply.) a. Vital signs b. Laboratory data c. Living will d. NPO e. Identification (ID) band on f. Family location

ANS: A, B, D, E Vital signs are included in the checklist as a baseline for intraoperative vital signs. Laboratory work is included to assist health care providers in attaining an accurate picture of the patient's health status. NPO, or nothing by mouth, is important, to decrease risks of vomiting and aspiration during the procedure. An ID band is important for identifying the patient, especially when anesthetized and unable to speak. A living will, although important for the patient's stay at a facility, is not on the preoperative checklist. Family location, although important for communication, is not part of the list of items that need to be completed for the patient before going to surgery.

The patient is asking the nurse about the best way to stay healthy. The nurse explains to the patient that from a nutritional point of view, the patient should (Select all that apply.) a. Maintain body weight in a healthy range. b. Increase physical activity. c. Increase intake of meat and other high-protein foods. d. Keep total fat intake to 10% or less. e. Choose and prepare foods with little salt.

ANS: A, B, E According to the 2005 Dietary Guidelines for Americans, key recommendations include main-taining body weight in a healthy range; increasing physical activity and decreasing sedentary ac-tivities; increasing intake of fruits, vegetables, whole grain products, and fat-free or low-fat milk with less red meat; keeping fat intake between 30% and 35% of total calories, with most fats coming from polyunsaturated or monounsaturated fatty acids (most meats contain saturated fatty acids); and choosing prepared foods with little salt while at the same time eating potassium-rich foods.

37. The nurse is caring for a patient who will undergo a coronary artery bypass graft procedure. What level of care will the patient require immediately post procedure? a. Acute care—medical-surgical unit b. Acute care—intensive care unit c. Ambulatory surgery d. Ambulatory surgery—extended stay

ANS: B Patients undergoing extensive surgery and requiring anesthesia of longer duration recover more slowly. If a patient is undergoing major surgery such as a procedure on the heart, a stay in the hospital and specifically in the intensive care unit is required to monitor for potential risks to well-being. This patient would require more care than can be provided on a medical-surgical unit. It is not appropriate for this type of patient to go home after the procedure or to stay in an extended stay area of an ambulatory surgery area because of the complexity and associated risks.

An assessment finding example for caregiver strain would be which of the following? a. Caregiver routinely creates a weekly menu plan. b. Caregiver has not received medical care when ill. c. Caregiver can identify respite care provider. d. Caregiver attends religious service.

ANS: B A nurse will identify a caregiver's lack of self-care as a potential example of caregiver role strain. Sacrificing their own health to care for the identified patient places caregivers at risk for becoming ill themselves. If caregivers jeopardize their own health, they may not be able to care for the actual patient. In all of the other options, the caregiver is handling caregiver stress appropriately.

In providing prenatal care to a patient, the nurse teaches the expectant mother that a. Protein intake needs to decrease to pre-serve kidney function. b. Calcium intake is especially important in the first trimester. c. Folic acid is needed to help prevent birth defects and anemia. d. The mother should take in as many extra vitamins and minerals as possible.

ANS: C Folic acid intake is particularly important for DNA synthesis and growth of red blood cells. In-adequate intake may lead to fetal neural tube defects, anencephaly, or maternal megaloblastic anemia. Protein intake throughout pregnancy needs to increase to 60 g daily. Calcium intake is especially critical in the third trimester, when fetal bones are mineralized. Prenatal care usually includes vitamin and mineral supplementation to ensure daily intakes; however, pregnant women should not take additional supplements beyond prescribed amounts.

38. The ambulatory surgical nurse calls to check on the patient at home the morning after surgery. The patient is reporting continued nausea and vomiting. Which of the following discharge education points should be reviewed with the patient? a. Instruct the patient to take deep breaths. b. Instruct the patient to drink ginger ale and eat crackers. c. Instruct and attempt to connect the patient with the physician. d. Instruct the patient to go to the emergency department.

ANS: C Postoperative nausea and vomiting sometimes occur once the patient is at home even if symptoms were not present in the surgery center. Options for therapy include medications. Instructing the patient to call the physician and connecting the patient with the physician can help the patient to obtain relief. Taking deep breaths, drinking ginger ale, and eating crackers are interventions that may be helpful, but this patient needs additional help. Instructing the patient to go to the emergency department is an option with continued nausea and vomiting

A person states that he was not shoplifting from the store despite very clear evidence on the store surveillance tape. This person is demonstrating which ego defense mechanism? a. Dissociation b. Conversion c. Denial d. Compensation

ANS: C Denial consists of avoiding emotional conflicts by refusing to consciously acknowledge anything that causes intolerable emotional pain. Dissociation involves creating subjective numbness and less awareness of surroundings. Conversion involves repressing anxiety and manifesting it into a physiological problem. Compensation occurs when an individual makes up for a deficit by strongly emphasizing another feature.

In determining kcal expenditure, the nurse knows that carbohydrates and proteins provide 4 kcal of energy per gram ingested. The nurse also knows that fats provide _____ kcal per gram. a. 3 b. 4 c. 6 d. 9

ANS: D Fats (lipids) are the most calorie-dense nutrient, providing 9 kcal per gram.

Is Arcus senilis an age related change to vision or pathology changes?

Age related change-grey or white arc or circle is visible around the outer part of the cornea.

The nurse teaches a patient who has had surgery to increase which nutrient to help with tissue repair? A. Fat B. Protein C. Vitamin D. Carbohydrate

B

When a nurse is teaching a patient about how to administer an epinephrine injection in case of a severe allergic reaction, the nurse tells the patient to hold the injection like a dart. Which of the following instructional methods did the nurse use? A. Telling B. Analogy C. Demonstration D. Simulation

B

which patient does a nurse plan to teach regarding water restriction? A. a 23 year old with extracellular fluid volume (ECV) deficit B. a 34 year old with hyponatremia C. a 47 year old with hypercalcemia D. a 69 year old with metabolic acidosis

B

The nurse is planning to teach a patient about the importance of exercise. When is the best time for teaching to occur? Select all that apply. A. When there are visitors in the room B. When the patient states that he or she is pain free C. Just before lunch, when the patient is most awake and alert D. When the patient is talking about current stressors in his or her life E. When the patient is being transported for a procedure

B, C

If a nurse decides to withhold a medication because it might further lower the patient's blood pressure, the nurse will be practicing the principle of? A. Responsibility B. Accountability C. Competency D. Moral Behavior

B. Accountability

The patient tells the nurse that she is afraid to speak up regarding her desire to end care for fear of upsetting her husband and children. Which principle in the nursing code of ethics ensures that the nurse will promote the patient's cause? A. Responsibility B. Advocacy C. Confidentiality D. Accountability

B. Advocacy

You are caring for a 65-year-old patient 2 days after surgery and helping him walk down the hallway. The surgeon has ordered exercise as tolerated. Your assessment indicates that the patient's heart rate at baseline is 88. After walking approximately 30 yards down the hallway, the heart rate is 110. What should be your next action?

B. Ask him how he feels; determine if there is any discomfort or shortness of breath; and, if not, continue exercise. The patient's maximum heart rate with exercise should be 220-65 = 155. He is still in a safe range. An assessment of how the patient feels is good practice. The patient can safely continue to walk.

A precise definition for the word quality is difficult to articulate when it comes to quality of life. Why? (Select all that apply.) A. Quality of life is measured by potential income, and average income varies in different regions of the country. B. Community values are subject to change, and communities influence definitions of "quality." C. Individual experiences influence perceptions of quality in potentially different ways, making consensus difficult. D. Placing measurable value on elusive elements such as cognitive skills, ability to perform meaningful work, and relationship to family is challenging.

B. Community values are subject to change, and communities influence definitions of "quality." C. Individual experiences influence perceptions of quality in potentially different ways, making consensus difficult. D. Placing measurable value on elusive elements such as cognitive skills, ability to perform meaningful work, and relationship to family is challenging.

Ethical dilemmas often arise over a conflict of opinion. What is the critical first step in negotiating the difference of opinion? A. Consult a professional ethicist to ensure that the steps of the process occur in full. B. Gather all relevant information regarding the clinical, social, and spiritual aspects of the dilemma. C. Ensure that the attending physician or health care provider has written an order for an ethics consultation to support the ethics process. D. List the ethical principles that inform the dilemma so negotiations agree on the language of the discussion.

B. Gather all relevant information regarding the clinical, social, and spiritual aspects of the dilemma.

A nurse is teaching a culturally diverse patient with a learning disability about nutritional needs. What must the nurse do first before starting the teaching session? a.Obtain pictures of food. b.Get an interpreter. c.Establish a rapport. d.Refer to a dietitian.

C

Which is the best method of negotiating or processing difficult ethical situations? A. Ethical issues arise between dissenting providers and can be best resolved by deference to an independent arbitrator such a chaplain. B. Since ethical issues usually affect policy and procedure, a legal expert is the best consultant to help resolve disputes. C. Institutional ethics committees help to ensure that all participants involved in the ethical dilemma get a fair hearing and an opportunity to express values, feelings, and opinions as a way to find consensus. D. Medical experts are best able to resolve conflicts about outcome predictions.

C. Institutional ethics committees help to ensure that all participants involved in the ethical dilemma get a fair hearing and an opportunity to express values, feelings, and opinions as a way to find consensus.

In most ethical dilemmas in health care, the solution to the dilemma requires negotiation among members of the health care team. Why is the nurse's point of view valuable? A. Nurses understand the principle of autonomy to guide respect for patient's self-worth. B. Nurses have a scope of practice that encourages their presence during ethical discussions. C. Nurses develop a relationship to the patient that is unique among all professional health care providers. D. The nurse's code of ethics recommends that a nurse be present at any ethical discussion about patient care.

C. Nurses develop a relationship to the patient that is unique among all professional health care providers.

Nursing process: Assessment Identify the ABCDE clinical approach to pain assessment and management C

C: Choose pain-control options appropriate for the client, family, and setting.

A client that is unresponsive

Call the patient by name, verbally and by touch, speak to patient as though the patient can hear; explain all procedures; provide orientation.

Vascular access devices

Catheters or infusion ports design for repeated access to the vascular system

Antagonistic muscles

Cause movement at the joint

Pulmonary system and surgery

Changes in structure and function reduce vital capacity, increase the volume of residual air left in the lungs, and reduce blood oxygenation

Ions

Charged particles

NEGATIVE NITROGEN BALANCE

Condition occurring when the body excretes more nitrogen than it takes in.

Based on knowledge of peptic ulcer disease (PUD), the nurse anticipates the presence of which bacteria when reviewing the laboratory data for a patient suspected of having PUD? A. Micrococcus B. Staphylococcus C. Corynebacterium D. Helicobacter pylori

D

The nurse is assessing a patient receiving enteral feedings via a small-bore nasogastric tube. Which assessment findings need further intervention? A. Gastric pH of 4.0 during placement check B. Weight gain of 1 pound over the course of a week C. Active bowel sounds in the four abdominal quadrants D. Gastric residual aspirate of 350 mL for the second consecutive time

D

Which learning objective/outcome has the highest priority for a patient with life-threatening, severe food allergies that require an EpiPen (epinephrine)? a.The patient will identify the main ingredients in several foods. b.The patient will list the side effects of epinephrine. c.The patient will learn about food labels. d.The patient will administer epinephrine.

D

Which statement made by a patient of a 2-month-old infant requires further education? A. I'll continue to use formula for the baby until he is a least a year old. B. I'll make sure that I purchase iron-fortified formula. C. I'll start feeding the baby cereal at 4 months. D. I'm going to alternate formula with whole milk starting next month.

D

What is the best example of the nurse practicing patient advocacy? A. Seek out the nursing supervisor in conflicting procedural situations B. Document all clinical changes in the medical record in a timely manner C. Work to understand the law as it applies to an error in following standards of care D. Assess the patient's point of view and prepare to articulate it

D. Assess the patient's point of view and prepare to articulate it

When people work together to solve ethical dilemmas, individuals must examine their own values. This step is crucial to ensure that? A. The group identifies the once correct solution. B. Fact is separated from opinion. C. Judgement attitudes are not provoked. D. Different perspectives are respected

D. Different perspectives are respected

After recovering from her hip replacement, an elderly client wants to go home, The family wants the client to go to a nursing home. If the nurse is acting as a client advocate, the nurse would perform which of the following actions? A. Informs the family that the client has a right to decide on her own. B. Ask the primary care provider to discharge the client to home. C. Suggest the client hire a lawyer to protect her rights. D. Help the client and family communicate their views to each other.

D. Help the client and family communicate their views to each other.

Your patient is about to undergo a controversial orthopedic procedure. The procedure may cause periods of pain. Although nurses agree to do no harm, this procedure may be the patient's only treatment choice. This example describes the ethical principal of? A. Autonomy B. Fidelity C. Justice D. Nonmaleficence

D. Nonmaleficence

In the postanesthesia care unit (PACU) the nurse notes that the patient is having difficulty breathing and suspects an upper airway obstruction. The nurse would first:

D. Position the patient on one side with the face down and the neck slightly extended so the tongue falls forward. Weak pharyngeal/laryngeal muscle tone from anesthetics can occur. Positional change helps to move the tongue forward to open the airway. The immediate intervention should be to open the airway. Suctioning the bronchial tree or providing oxygen does not alleviate an upper airway obstruction.

Defines actions as right or wrong

Deontology

UAP - TASKS ALLOWED WITH ADDITIONAL TRAINING

EKG blood glucose testing

Maslow's Hierarchy

Fourth Level-encompasses esteem and self-esteem needs

Appraisal

How people interpret the impact of the stressor on themselves or on what is happening and what they are able to do about it.

Clinical dehydration

Hypernatremia and extracellular volume deficit

Transpersonal

Interaction that occurs within a person's spiritual domain

Communication

Is a lifelong learning process that is as essential part of patient-centered nursing care. Make meaningful relationships where you collect relevant assessment data, provide education, and interact during nursing interventions

What is the relaxation response?

It is the state of generalized decreased cognitive, physiological, or behavioral arousal

A nurse is using the World Health Organization definition of health to provide care. Which area will the nurse focus on while providing care?

Making sure to involve the whole person

Hypotonic solution

More dilute than normal blood such as 3% sodium chloride, post fluid from cells by osmosis causing them to shrink.

Crisis

Occurs when stress overwhelms existing coping mechanisms, patients lose emotional balance. This is can be a live changing experience.

Providing information

Patients have the right to know about their health status and what is happening in their environment.

Sender:

Person who encodes and delivers the message Senders message acts as a referent for receiver

Cations

Positively charged ions. Some major ones are sodium, potassium, calcium, and magnesium.

Intervention: Caregivers need to learn CPR and the Heimlich maneuver

Rationale: Caregivers need to be prepared to intervene in acute emergencies such as choking

Flashbacks

Recurrent and intrusive recollections of an event. Associated with PTSD.

Alarm Reaction

Rising hormone levels result in increased blood volume, blood glucose levels, epinephrine and norepinephrine amounts, heart rate, blood flow to muscles, oxygen intake, and mental alertness.

Isotonic

Same as osmolality of normal blood solutions such as 0.9% sodium chloride. Expand the extracellular fluid volume of the body without causing water to shift in or out of the cells.

Transcellular fluid

Secreted by epithelial cells and includes cerebrospinal, GI, peritoneal, and synovial fluids.

Pituitary Gland

Small gland that is located immediately below the hypothalamus. It produces hormones (TSH, HGH, FSH) necessary for adaptation to stress.

self-disclosure

Subjectively true, personal experiences about self that are intentionally revealed to another.

Hydrostatic pressure

The force of a fluid pressing outward against the walls of its container-helps move fluid from capillaries into the interstitial area.

What is the most important concept of Traditional Chinese medicine?

The most important concept is yin and yang, which represents the opposing yet complementary phenomena that exist in a state of dynamic equilibrium

Activity tolerance

The type or exercise or work that a person is able to perform w/o undue exertion or possible injury

Alternative therapies

Therapies that include the same interventions as complementary but frequently become the primary treatment that replaces allopathic medical care

Define placebo

a medication or procedure that produces positive or negative effects in clients that are not related to the placebo's specific physical or chemical properties

List the goals and outcomes for the patient with the above diagnosis

a) Patient initiates conversation about diagnosis b) Patient is able to attend appropriate stimuli c) Patient conveys clear and understandable messages with team. d) Patient with express increased satisfaction with the process

List the contextual factors that influence communication:

a) Physical and emotional fears b) Developmental factors c) Sociocultural factors d) Gender

List the goals for the care of a client with epidural infusions. Describe one action for each goal.

a. Prevent catheter displacement: Secure catheter (if not connected to implanted reservoir) carefully to outside skin. b. Maintain catheter function: Check external dressing around catheter site for dampness or discharge. (Leak of cerebrospinal fluid may develop.) c. Prevent infection: Use strict aseptic technique when caring for catheter (see Chapter 33). d. Monitor for respiratory depression: Monitor vital signs, especially respirations, per policy. e. Prevent undesirable complications: Assess for pruritus (itching) and nausea and vomiting. f. Maintain urinary and bowel function: Monitor intake and output.

Identify the psychological factors that can influence pain

a. anxiety b. coping styles

type of feedback depends on:

background, experiences, attitudes, cultural beliefs, self-esteem

Acute listening

being attentive to what the patient is saying both verbally and non-verbally.

What is not a normal sign of aging?

confusion is not a normal sign of aging

ageism

discrimination against people because of increasing age.

descriptive theories

first level of theory development, explain patient assessments.

PATHOLOGICAL ABNORMALITIES AFFECT MOBILITY IN THE FOLLOWING WAYS:

impaired body alignment, balance, and mobility weakness muscle atrophy increased disability

Using Neuman's theory

in practice nurses focus their care on the systems response to stressors.

prostaglandins

increases sensitivity to pain

Local anesthesia

local infiltration of an anesthetic medication to induce loss of sensation to a body part

HAND ROLL

maintain the thumb in slight adduction and in opposition to the fingers maintains a functional position.

RANGE OF MOTION

maximum amount of movement available at a joint in one of the three planes of the body: sagittal, transverse, or frontal

mormonism dietary regulations

members abstain from alcohol and caffeine.

King's theory

nurse uses communication to help patient adapt (ex. adapt to environment)

HEMIPARESIS

one-sided weakness

dementia

onset: insidious/slow and often unrecognized course: long, no diurnal effects; symptoms progressive yet relatively stable over time; some deficits with increased stress duration:months to years progression slow but uneven consciousness is clear alertness generally normal attention is generally normal orientation generally normal to person but not to place or time memory is recent and remote impaired; thinking difficulty with abstraction; thoughts diminished; judgment impaired;words difficult to find perception is misperceptions usually absent psychomotor behavior is normal, some have apraxia sleep/wake cycle is fragmented associated features: affect tends to be superficial, inappropriate, and changing, attempts to hid deficits in intellect; personality changes, aphasia, agnosia sometimes present; lacks insight assessment: failings highlighted by family, frequent near miss answers, struggles with test, great effort to find an appropriate reply, frequent requests for feedback on performance

Hemiplegia

paralysis of one side of the body

paradigm

pattern of thought, used to describe the domain of a discipline. The elements of the NURSING PARADIGM direct the activity of the nursing profession.

POSTURE

position of the body in relation to the surrounding space

ACCOUNTABILITY

refers to individuals being answerable for their actions

nociceptor

sensory peripheral pain nerve fiber

DEVELOPMENTAL CHANGES - ADOLESCENTS

social isolation

Maceration

softening through liquid; overhydration

Pain threshold

the point at which a person feels pain

Tendons

white, glistening, fibrous bands of tissue that connect muscle to bone

Complications of opioid analgesia are:

• nausea and vomiting • urinary retention • Constipation • respiratory depression • pruritus

Example of, False reassurance

"Don't worry; everything will be alright."

Example of, Arguing

"How can you say that you didn't sleep a wink?" you were snoring all night long.

Example of, Sympathy

"I am sorry for your mastectomy; it must be terrible to lose a breast."

Example of, Changing the subject

"Let's not talk about your problems with the insurance company. It's time for your walk"

Example of, Defensive responses:

"No one here would intentionally hit to you."

Example of, Passive responses

"Things are bad, and there is nothing I can do about it."

PRECENTRAL GYRUS

"motor strip" the major voluntary motor area located in the cerebral cortex majority of motor fibers descend from the motor strip and cross at the level of the medulla.

assumptions

"taken for granted" statements that explain the nature of the concepts, definitions, purpose, relationships, and structure of a theory.

Florence Nightingale

"the nature of nursing as a profession that requires knowledge distinct from medical knowledge"

Synovial Joints

"true joints," freely movable and the most mobile, numerous, and anatomically complex; examples of synovial joints include: elbow joint, hip joint, etc.

Example of, Asking personal questions

"why don't you and John get married?"

Example of, Approval or disapproval

"you shouldn't even think about assisted suicide; it's not right."

Intimate zone

(0-18 inches)(great sensitivity needed) holding a crying infant performing physical assessment bathing, grooming, dressing, feeding, toileting patient changing surgical dressing

Public zone

(12 feet and greater) Speaking at a community forum Testifying at a legislative hearing Lecturing to a class of students

Personal zone

(18 inches to 4 feet) Sitting at a patient's bedside Taking the patient's nursing history Teaching an individual patient

Social zone

(9-12 feet) (permission not needed) giving directions to visitors in hallway asking if family needs assistance from patient doorway giving verbal report to group of nurses

Impaired verbal communication

(state in which the individuals experiences are decreased, delayed, or absent or the person has an inability to receive, process, transmit, and use symbols).

Interventions for school aged children

* Teach children the safe use of equipment for play and at work * Teach children proper bicycle safety, including use of helmet and rules of the road * Teach children proper techniques for specific sports and the need to wear proper safety gear * Teach children not to operate electrical equipment while unsupervised * Do not allow children access to firearms or other weapons. Keep all firearms in a locked cabinet

Interventions for preschoolers

* Teach children to swim at an early age but always provide supervision near water * Teach children how to cross streets and walk in parking lots. Instruct them to never run out after a ball or toy * Teach children not to talk to, go with, or accept any items from a stranger * Teach children basic physical safety measures; proper use and safety with scissors, never running with an object in their mouth or hand, an never attempting to use the stove or oven unassisted * Teach children not to eat items found in the street or grass * Remove doors from unused refrigerator and freezers. Instruct children not to play or hide in a car trunk or unused appliance

Interventions for adolescents

*Encourage enrollment in driver education classes * Provide information about the effects of using alcohol and drugs * Refer adolescents to community and school sponsored activities * Encourage mentoring relationships between adults and adolescents * teach them safe use of the internet

Interventions infants and toddlers

*Have infant sleep on their back or side, teach parents the Mnemonic " back to sleep", * Infants should be immunized, * Do not fill cribs with pillows, bumper pads, large stuffed toys, comforters. Use snug fitting sheets * Do not attach pacifiers to string or ribbon and place around a child's neck, * Follow all instructions for preparing and storing formula * Use large, soft toys without small parts such as buttons, * Do not leave the mesh side of playpens lowered, spaces between crib slates need to be less than 2 and 3/8 inches apart * Never leave crib sides down or babies unattended on changing tables or in infant seats, swings, strollers, or high chairs. * Discontinue using accessories such as infant seats and swings when the child becomes too active or physically too big and/or according manufacturers directions * Never leave child alone in the bathroom, tub or near any water source * Baby proof home; remove small or sharp objects and toxic or poisonous substances, including plants, install safety locks on floor level cabinets * Remove plastic bags from the home * Cover electrical outlets * Place window Guard on windows. * Install key less locks on doors above a child's reach, even when they are standing on a chair * Place children in the appropriate car and booster seats based on age and weight * Caregivers need to learn CPR and the Heimlich maneuver

TEEAMS APPROACH

*T* = time *E* = empowerment *E* = enthusiasm *A* = appreciation *M* = management *S* = support

Techniques for lateral violence

- address when it occurs calmly - describe how behavior effects functioning - ask for abuse to stop - notify manager for full support - make an action plan - document incidences in detail

expertise in communication express care by:

- becoming sensitive to self and others - promoting and accepting the expression of positive and negative feelings - developing caring relationships - instilling faith and hope - promoting interpersonal teaching and learning - providing a supportive environment - assisting with gratification of human needs - allowing for spiritual expression

substance P

- cause vasodilation and edema - Found in pain neurons of dorsal horn -Needed to transmit pain impulses from periphery to higher brain centers

Meaningful interpersonal communication results in:

- exchange of ideas - problem solving - expression of feelings - decision making - goal accomplishment - team building - personal growth

Planning List the client outcomes appropriate for the client experiencing pain.

-Reports that pain is a 3 or less on a scale of 0-10, does not interfere with ADLs, or personal pain intensity goal attained -Identifies factors that intensify pain and modifies behavior accordingly -Uses pain-relief measures safely

Transduction

-the energy of thermal, chemical, or mechanical stimuli is converted to electrical energy. -is the activation of pain receptor. -it begins in the periphery when a pain-producing stimulus (ex: exposure to hot surface) sends an impulse across a sensory peripheral pain nerve fiber (nociceptor), initiating an action potential.

How to pick a nursing home or nursing center.

. A nursing home should meet certain criteria: does not feel like a hospital. This is their home 1. is medicare and medicaid certified 2. has adequate, qualified staff members who have passed criminal background checks 3.Provides quality of care, in addition to assistance with basic activities of daily living 4.staff should assist residents with social and recreational activities 5.offers quality food and meal times choices 6. families should be welcome when they visit the facility 7. Is clean-no odors 8. provides active communication from staff to patient and family members of the nursing home staff are attentive to resident 9. requests and actively involved with assisting the residents. Focus on the person not the task.

How are the double adjustable-crutch and the axillary crutch similar? 1 Both have handgrips. 2 Both have metal bands. 3 Both are equally common in use. 4 Both have a curved surface at the top.

1 Both the double-adjustable crutch and the axillary crutch have a handgrip to support the body. A double-adjustable crutch, or forearm crutch, has a metal band that fits around the patient's forearm. An axillary crutch is more commonly used than a double-adjustable crutch. An axillary crutch has a padded curved surface at

1 Fibrous joints 2 Synovial joints 3 Ligaments 4 Cartilaginous joints

1 Fibrous joints are joints that fit closely together and are fixed, permitting little or no movement. Synovial joints, or true joints, are freely movable and the most mobile, numerous, and anatomically complex body joints. Ligaments are white, shiny, flexible bands of fibrous tissue that bind joints and connect bones and cartilage. Cartilaginous joints have little movement but are elastic and use cartilage to unite separate bony surfaces.

The nurse is caring for a pregnant patient. The nurse understands that the body posture and alignment in a pregnant patient may change. Where does the center of gravity of a pregnant woman shift? 1 To the anterior 2 To the posterior 3 To the left lateral side 4 To the right lateral side

1 In pregnant women, changes in body posture and alignment occur due to weight gain and the growing fetus. The center of gravity of the body shifts to the anterior. Therefore, a pregnant woman leans backward and may report back pain. The center of gravity does not shift to the posterior or to any lateral sides; this might cause abnormal curvature of the spine.

Exercise lowers blood glucose levels. For how long does the effect of exercise last on blood glucose levels? 1 For at least 24 hours 2 For at least 36 hours 3 For at least 48 hours 4 For at least 72 hour

1 It is important for the nurse to know the effects of exercise on glucose levels. Exercise lowers blood glucose levels and the effects of exercise on blood glucose levels often last for at least 24 hours. The lowered blood glucose levels do not last as long as 36, 48, or 72 hours. Therefore, the patient with high blood glucose should exercise on a daily basis.

Which of the nursing assistant's statements about orthostatic hypotension indicates a need for further learning? 1 "Younger patients are prone to orthostatic hypotension." 2 "Diabetic patients are prone to orthostatic hypotension." 3 "Immobilized patients are prone to orthostatic hypotension." 4 "Patients on prolonged bed rest are prone to orthostatic hypotension."

1 Older, not younger, patients are prone to orthostatic hypotension. The other statements indicate understanding. Patients with chronic illnesses such as diabetes mellitus are prone to orthostatic hypotension. Patients who are immobilized or who are on prolonged bed rest are also prone to orthostatic hypotension.

A patient is discharged after an exacerbation of chronic obstructive pulmonary disease (COPD). She states, "I'm afraid to go to pulmonary rehabilitation." What is your best response? 1 Pulmonary rehabilitation provides a safe environment for monitoring your progress. 2 You have to participate or you will be back in the hospital. 3 Why are you concerned about pulmonary rehabilitation? 4 The staff at our pulmonary rehabilitation facility are professionals and will not cause you any harm.

1 Pulmonary rehabilitation is beneficial in helping patients reach an optimal level of functioning. Some patients are fearful of participating in exercise because of the potential for worsening dyspnea (difficulty breathing). Pulmonary rehabilitation provides a safe environment for monitoring the progress of patients.

What should the nurse teach a diabetic patient about exercise? 1 "Exercise leads to improved glucose control." 2 "You can perform medium- to high-intensity exercise." 3 "The effect of exercise on blood glucose levels often lasts for 10 hours." 4 "You can start an exercise routine on your own without any physical examination."

1 The nurse should teach a diabetic patient that exercise leads to improved glucose control. Diabetic patients should perform low- to-medium intensity exercise. The effect of exercise on blood glucose lasts for 24 hours, not 10 hours. The nurse should instruct the patient to undergo a complete physical examination before starting any physical exercise routine.

The nurse is asked to assist an elderly patient with ambulation at 5:00 PM. At 5:00 PM, the nurse finds that the patient is distressed and is not oriented to time, place, or self. What is the most appropriate step that should be taken by the nurse? 1 Postpone the ambulation to another time. 2 Assist the patient in walking as scheduled. 3 Ask for help from another colleague to ambulate the patient. 4 Remove any obstacles on the floor before the ambulation.

1 The patient is disoriented and may be at risk of falling if ambulated. Therefore, the nurse should postpone the patient's ambulation to another time when the patient is oriented and stable. This ensures the patient's safety. Assisting the disoriented patient as per the schedule may increase the risk of falling, even if help is received from a colleague and obstacles are removed from the floor.

The nurse works at an occupational therapy clinic. A patient with type 1 diabetes mellitus has recovered from a fractured tibia and is advised to use a cane for walking. When teaching the patient about the use of canes, which information should the nurse include? Select all that apply. 1 Canes are lightweight, easily movable devices made of wood or metal. 2 Canes should be kept on the stronger side of the body. 3 Canes should be of a length equal to the distance between the greater trochanter and the floor. 4 Canes have a metal band and handgrip that are adjusted to fit the patient's height. 5 Canes have a padded, curved surface at the top, which fits under the axilla.

1, 2, 3 A cane is an assistive device for walking. It is lightweight and easily movable. Most canes are made of wood or metal. To provide good support, the length of the cane should be equal to the distance between the greater trochanter of the hip and the floor and the cane should be kept on the stronger side of the body. The metal band and handgrips are components of crutches. Canes do not have a padded, curved surface at the top. It is a component of an axillary crutch.

What are the possible effects of exercise in a healthy individual? Select all that apply. 1 Reduced bone loss 2 Decreased work of breathing 3 Decreased resting heart rate 4 Increased blood pressure 5 Decreased gastric motility

1, 2, 3 Exercise affects various body systems in a healthy individual. Some of the effects include reduced bone loss due to mineralization, decreased work of breathing due to better lung expansion, and decreased resting heart rate due to improved cardiac output. Blood pressure usually decreases due to relaxation of the vessel wall, and gastric motility increases, which helps to prevent constipation.

Which actions are appropriate for the nurse to implement when a patient experiences orthostatic hypotension? Select all that apply. 1 Call for assistance. 2 Allow patient to sit down. 3 Take patient's blood pressure and pulse. 4 Continue to ambulate patient to build endurance. 5 If patient begins to faint, allow him or her to slide against the nurse's leg to the floor.

1, 2, 3, 5 If the patient complains of dizziness and/or lightheadedness upon standing, call for assistance and allow the patient to sit back down. If the patient has a fainting episode (syncope), assume a wide base of support with one foot in front of the other, thus supporting the patient's body weight. Extend one leg and let the patient slide against it; gently lower the patient to the floor, protecting his or her head. Take the patient's blood pressure and pulse as soon as possible after the incident. Continuing to ambulate the patient in this condition is unsafe and can result in a fall or other injury; it will not help improve the patient's endurance.

The nurse is attending to an older adult patient. The nurse understands that the patient is at risk of osteoarthritis due to advanced age. What questions should the nurse ask the patient to assess the osteoarthritis? Select all that apply. 1 "Do you feel pain in the legs when climbing stairs?" 2 "Do you have pain in your knee or back when you walk?" 3 "Do you consume fruits daily? If yes, which fruits?" 4 "Are you able to go for morning walks even with the pain and discomfort?" 5 "Do you void regularly? Is there any difficulty in defecation?

1, 2, 4 Assessment questions for osteoarthritis include asking about mobility, endurance, and pain. Bowel and bladder elimination is not directly related to osteoarthritis. Eating fruit in the diet is not directly related to osteoarthritis.

The nurse is attending to an older adult patient who has sustained a fall and has broken a femur. The nurse explains to the patient that as the body ages, the bones become weak due to osteoporosis and become more prone to fracture. Which statements are true about osteoporosis? Select all that apply. 1 The cause may be hormonal imbalances or insufficient intake of nutrients. 2 There is a structural curvature of the spine associated with vertebral rotation. 3 Osteoporosis is a disorder of aging and results in the reduction of bone density or mass. 4 There is inadequate and delayed mineralization, resulting in compact and spongy bone. 5 The bone remains biochemically normal but has difficulty maintaining integrity and support.

1, 2, 5 In osteoporosis, the bones remain biochemically normal but have a reduction in density or mass. The cause of osteoporosis is uncertain, and theories vary from hormonal imbalances to insufficient intake of nutrients. Osteoporosis is common in aging adults. Osteomalacia, not osteoporosis, is an uncommon metabolic disease characterized by inadequate and delayed mineralization, resulting in compact and spongy bones. Scoliosis is a structural curvature of the spine associated with vertebral rotation.

A patient wants to know how exercise affects the body. What effects/changes does the nurse list? Select all that apply. 1 Increased joint mobility 2 Increased cardiac output 3 Increased resting heart rate 4 Increased respiratory rate followed by a slower return to resting state 5 Increased basal metabolic rate

1, 2, 5 The nurse explains that exercise increases joint mobility, cardiac output, and basal metabolic rate. Exercise decreases the resting heart rate, and while it does increase the respiratory rate, the return to resting state becomes quicker.

Which actions should the nurse perform during the assessment phase when caring for a patient diagnosed with impaired physical mobility? Select all that apply. 1 Inspect the patient's body alignment, posture, and mobility 2 Reassess the patient for signs of improved activity and exercise tolerance 3 Observe the response of the patient's body systems to activity and exercise 4 Consult and collaborate with members of the health care team to increase activity 5 Ask for the patient's perception of activity and exercise status after interventions

1, 3 Inspecting the patient's body alignment, posture, and mobility and observing how the patient's body systems respond to activity and exercise are parts of the assessment phase of a patient diagnosed with impaired physical mobility. Reassessing the patient for signs of improved activity and exercise tolerance is part of the evaluation phase. Consulting and collaborating with members of the health care team to increase activity form a part of the planning phase. Asking for the patient's perception of activity and exercise status after the intervention forms a part of the evaluation phase

Which statements apply to the proper use of a cane as an assistive device? Select all that apply. 1 For maximum support when walking, the patient places the cane forward 15 to 25 cm (6 to 10 inches), keeping body weight on both legs. The weaker leg is moved forward to the cane so body weight is divided between the cane and the stronger leg. 2 A person's cane length is equal to the distance between the elbow and the floor. 3 Canes provide less support than a walker and are less stable. 4 The patient needs to learn that two points of support such as both feet or one foot and the cane need to be present at all times. 5 The straight-legged cane is the most common and provides the most support.

1, 3, 4 A person's cane length is equal to the distance between the greater trochanter and the floor, not the elbow and the floor. For maximum support when walking, the patient places the cane forward 15 to 25 cm (6 to 10 inches), keeping body weight on both legs. Canes provide less support than a walker and are not as stable. The patient needs to learn that two points of support (i.e., both feet or one foot and the cane) are present at all times. The straight-legged cane is the most common, but the quad cane provides the most support and is used when there is partial or complete leg paralysis or some hemiplegia.

The nurse is assessing the body alignment and posture of a patient. Which are the indicators of an optimal standing posture? Select all that apply. 1 The knees are in a straight line between the hips and ankles. 2 The head is flexed anteriorly and in midline. 3 The feet are flat on the floor and slightly apart. 4 The spine is straight with normal curvatures. 5 The abdominal muscles are relaxed.

1, 3, 4 When assessing a patient's standing posture, the nurse must ensure that the knees are in a straight line between the hips and ankles and slightly flexed. This position of the knees is required so that the weight-bearing forces are evenly distributed on the surfaces of the joints. The feet should be flat on the floor, pointed directly forward, and slightly apart to maintain a wide base of support. This is required to maintain balance of the body over the limbs. The spine must be straight with normal curvatures. Abnormalities in spinal curvature could cause the weight-bearing forces to damage the vertebrae. The head should be erect in both standing and sitting positions. The abdominal muscles must not be relaxed but should be well tucked. The abdominals form an important part of the core muscles that support the vertebral column. See page 417.

A patient is admitted to the hospital with osteoporosis and lower back pain. The patient loses balance when trying to stand and walk. The patient has a nursing diagnosis of body imbalance. What instructions does the nurse give the patient? Select all that apply. 1 Instruct the patient to widen the base of support by separating the feet. 2 Instruct the patient to bring the knees closer together to maintain a broad base. 3 Instruct the patient to lower the center of gravity closer to the base of support. 4 Instruct the patient to keep the center of gravity away from the base of support. 5 Instruct the patient to maintain a vertical line from the center of gravity through the base of support.

1, 3, 5 To maintain body balance, the patient must attain a posture that requires the least muscular work and places the least strain on muscles, ligaments, and bones. To do this, the patient must first separate the feet to a comfortable distance to widen the base of support. Then the patient must try to increase balance by bringing the center of gravity closer to the base of support. The body posture is adjusted such that the vertical line from the center of gravity falls through the base of support to attain body balance. The knees should not be kept closer, because this could decrease the width of the base of support and impair balance. Increasing the distance between the center of gravity and the base of support would also impair the balance of the patient. Knees should be kept wide. Keeping the center of gravity away from the base of support will result in a loss of balance while standing or walking.

A patient with a body mass index (BMI) of 36 has a sedentary job. The patient states that she has never exercised. The patient has been advised to reduce weight. What actions should the nurse advise the patient to do to promote reduction of weight? Select all that apply. 1 Advise her to discuss her diet with a dietitian. 2 Advise her to undergo gastric banding. 3 Advise her to undergo an intensive exercise training program. 4 Advise her to have realistic goals such as losing 4 pounds over 2 weeks. 5 Advise her to resign from her job immediately because it is the cause of her obesity.

1, 4 A dietitian can help the patient plan a diet for weight reduction. The patient should be advised to set realistic goals for weight reduction. A reduction of 4 pounds over 2 weeks is acceptable. Gastric banding is the surgical procedure used for morbidly obese patients, if dietary measures and medications do not help them. Exercise is a healthy way to lose weight, but it should be gradual. A patient who has never exercised should not start with high-intensity exercises. The patient should start with a mild intensity exercise and gradually increase the intensity. Although her job is one of the reasons for her sedentary lifestyle and weight gain, it is not the only reason. Resigning from the job will not help the patient.

What are the signs and symptoms of orthostatic hypotension? Select all that apply. 1 Pallor 2 Fainting 3 Diarrhea 4 Dizziness 5 Bradycardia

1. 2. 4 Pallor, fainting, and dizziness are the signs and symptoms of orthostatic hypotension. Diarrhea and bradycardia may indicate other disorders.

Nursing care principles for care of the cognitively impaired older adults

1. Institue medical measures to correct underlying physiological alterations. 2. Maximize safe function. Keep a routine, limit choices, allow for rest 3. Provide unconditional positive regard. be respectful. Non verbal communication should be positive 4. Use behaviors to gauge activity and stimulation.. Watch for facial signs of anxiety 5. Teach caregivers to listen to the behaviors that show stress (verbalizations such as repetition) 6. Modify the environment 7. Promote social interaction based on abilities. Make sure that the environment is safe for mobility and promote way finding with pictures or cues. Try to identify patients who wande and remove the cause (pain, thirst, unfamiliar surroundings, new noises) 8. compensate for any sensory deficits (hearing aids, glasses, dentures) 9. encourage fluid intake (make sure fluids are accessible) and avoid long periods of giving nothing orally 10. Be vigilant for drug reactions or interactions, consider onset of new symptoms as an adverse reaction 11. Activate bed alarm and chair alarms 12. Provide ongoing assistance to family caregivers, educate them in nursing care techniques and inform them about community resources

What are the developmental tasks for older adults?

1. adjusting to decreasing health and physical strength 2. adjusting to retirement and reduced or fixed income 3. adjusting to death of a spouse, children, siblings, friends 4. accepting self as aging person 5. maintaining satisfactory living arrangements 6. redefining relationships with adult children and siblings 7. finding ways to maintain quality of life

When speaking to the older patient with a hearing impairment you should:

1. face the patient 2. avoid covering your mouth 3. make sure the room is quiet 4. make sure the room is well lit (so patient can see your lips move) 5. minimize background sounds (turn off TV and close the door)

What are age related changes for the older patient's cardiovascular system?

1. orthostatic hypotension 2. increased arterial resistance 3. decreased cardiac output (loss of 30-40%) 4. increased time for heart rate to return to resting rate after exercise or activity 5. occasional ectopic beats 6. S4 7. increased heart size and weight 8. decreased myocardial perfusion up to 35%

When a person has visual impairment use these communication techniques:

1. sit or stand at eye level, in front of the patient in full view 2. face the older adult while speaking; do not cover your mouth 3. provide diffuse, bright, non glare light 4. encourage the older adult to use his or her familiar assisitive devices such as glasses or magnifiers

5 key points to ensure age specific nursing assessment

1. the interrelation between physical and psychosocial aspects of aging 2. the effects of disease and disability on functional status 3. the decreased efficiency of homeostatic mechanisms 4. the lack of standards for health and illness norms 5. altered presentation and response to a specific disease

For what duration should a patient contract the biceps and triceps muscles while performing isometric exercises? Record your answer using a whole number. _________seconds

10 When performing isometric exercises of the biceps and triceps, the patient contracts each muscle group for 10 seconds at a time.

transdermal fentanyl

100 times more potent than morphine in predetermined doses that provide analgesic for 48-72 hours; useful when unable to take oral medications

In a tripod stance, at what distance are crutches placed from the side of each foot? Record your answer using a whole number. ___cm

15 A patient should be informed about the tripod position used during crutch walking. The tripod position is formed when crutches are placed 15 cm (6 inches) in front of and to the side of each foot. This position provides maximum stability when starting to walk.

A nurse is conducting and admission interview with a patient. To maintain the patient's territoriality and maximize communication, the nurse should sit

18 inches to 4 feet away.

The nurse is starting an exercise program for a patient who is 27 years old. What is the approximate maximum heart rate of this patient during exercise? Record your answer using a whole number. _________ bpm

193 The maximum heart rate of a patient during exercise is obtained by subtracting the patient's age from 220. Therefore, 220 - 27 = 193 bpm.

What nursing intervention should the nurse provide to a patient who has impaired gas exchange related to decreased cardiac output? 1 Teach the patient how to restrict fluid intake 2 Administer oxygen at 2 L/min via the nasal cannula 3 Record activity of the patient in an exercise log daily along with the response 4 Ask the patient to perform a 2-to 3-mile brisk walk and isometric exercises three to four times a week

2 A patient should be administered oxygen at a rate of 2 L/min via the nasal cannula if the patient has impaired gas exchange related to decreased cardiac output. A patient who is diagnosed with decreased cardiac output related to decreased myocardial contractility should be taught how to restrict the intake of fluids. The nurse should record the activity of the patient in exercise log daily along with the response in case of activity intolerance related to physical deconditioning. The nurse should guide a patient who is diagnosed with activity intolerance related to physical deconditioning to take brisk walks and perform isometric exercise three to four times a week.

If a patient with crutches is in a perfect tripod position, what is the distance between the crutches? 1 15 cm 2 30 cm 3 45 cm 4 60 cm

2 A tripod position is formed when the crutches are placed 15 cm to the side of each foot. Therefore, the distance between the crutches is 30 cm. For a tripod position, 15 cm is too close, and 45 cm and 60 cm are too far.

Which environmental issue is a hindrance to activity and exercise? 1 Hormonal changes and increased osteoclastic activity with increasing age 2 Work sites reluctant in motivating employees for physical fitness regimens 3 A patient's decisions to change his or her behavior to include a daily exercise routine 4 A patient's knowledge, values, and beliefs about exercise in relation to health

2 Activity and exercise promotion (or lack thereof) at work sites is an environmental factor that affects a patient's ability to exercise. Hormonal changes and increased osteoclastic activity with increasing age are developmental factors that affects activity and exercise. A patient's decision to change his or her behavior to include a daily exercise routine and the patient's knowledge, values, and beliefs about exercise in relation to health are behavioral factors that influence activity and exercise.

Which measure should the nurse adopt to reposition a patient in bed? 1 When pulling a patient up in bed, the bed should be in anti-Trendelenburg's position. 2 For patients with stage III or IV pressure ulcers, care should be taken to avoid shearing force. 3 If the patient weighs less than 200 lb (91 kg), friction-reducing devices should be avoided. 4 If the caregiver needs to lift about 55 lb (25 kg) of a patient's weight, the patient is considered fully dependent.

2 For patients with stage III or IV pressure ulcers, care should be taken to avoid shearing forces. When pulling a patient up in bed, the bed should be flat or in a Trendelenburg's position. If the patient weighs less than 200 lb (91 kg), friction reducing devices and two to three caregivers are needed. If the caregiver needs to lift more than 35 lb (16 kg) of a patient's weight, then the patient is considered fully dependent and assistive devices should be used.

Which activity is least appropriate for an older adult patient's exercise program? 1 Stretching 2 High-intensity interval training 3 Agility training 4 Weight-bearing and other resistance exercises

2 High-intensity interval training is inappropriate for older adult patients. Stretching is ideal for enhancing circulation. Agility training may help prevent falls. Weight-bearing and other resistance exercises help slow bone loss.

The nurse is caring for a patient who has a lack of coordination and weakness of both lower limbs. The patient is able to bear weight on both limbs but is unable to walk independently. Which gait does the nurse teach the patient? 1 A two-point gait 2 A four-point gait 3 A three-point gait 4 A three-point alternating gait

2 In a four-point gait, the patient bears his or her weight on both legs, which provides stability when walking. The patient then moves each leg alternately with each opposing crutch. The patient is able to bear weight but is unable to walk independently, thus the nurse should teach the four-point gait to the patient. This gait helps in maintaining stability while walking. Once the patient has mastered the four-point gait pattern, the patient should be taught the two-point gait, wherein the patient moves the crutch and opposing leg at the same time. In a three-point or three-point alternating gait, the patient bears the weight on both crutches first and then on the uninvolved leg alternately. This gait pattern is taught to those patients who lack function of one limb.

Which statement if made by a nurse is correct? 1 "Permanent cartilage is ossified." 2 "Ligaments connect bones to cartilage." 3 "Cartilage is a vascular supporting connective tissue." 4 "The Achilles tendon is the thinnest tendon in the body."

2 Ligaments connect bones to cartilage. Permanent cartilage is unossified, except in adults with advanced age and diseases such as osteoarthritis. Cartilage is a nonvascular supporting connective tissue. The Achilles tendon is the thickest tendon in the body.

Which is a congenital defect? 1 Arthritis 2 Scoliosis 3 Osteoporosis 4 Osteomalacia

2 Scoliosis is a structural curvature of the spine associated with vertebral rotation; it is a congenital defect. Arthritis is an inflammatory joint disease that causes systemic signs of inflammation and destruction of the synovial membrane and articular cartilage. Osteoporosis is an aging disorder that results in the reduction of bone density or mass. Osteomalacia is an uncommon metabolic disease characterized by inadequate and delayed mineralization, resulting in compact and spongy bones.

A patient on bed rest for several days attempts to walk with assistance. He becomes dizzy and nauseated. His pulse rate jumps from 85 beats/minute to 110 beats/minute. Of what are these most likely symptoms? 1 Rebound hypertension 2 Orthostatic hypotension 3 Dysfunctional proprioception 4 Central nervous system (CNS) rebound hypotension

2 Signs and symptoms of orthostatic hypotension include dizziness, light-headedness, nausea, tachycardia, pallor, and even fainting. Rebound hypertension is caused by abruptly discontinuing certain drugs such as beta blockers. Dysfunctional proprioception is the patient's lack of awareness of the position of certain body parts. CNS rebound hypotension can by caused by cerebrospinal fluid leakage or certain drugs.

Which group of patients is most at risk for severe injuries related to falls? 1 Adolescents 2 Older adults 3 Toddlers 4 Young children

2 Some older adults walk more slowly and are less coordinated. They also take smaller steps, keeping their feet closer together, which decreases the base of support. Thus, body balance is unstable, and they are at greater risk for falls and injuries.

What group of muscles contract to accomplish the same movement? 1 Skeletal muscles 2 Synergistic muscles 3 Antigravity muscles 4 Antagonistic muscles

2 Synergistic muscles contract to accomplish the same movement. Skeletal muscles are attached to the skeleton by tendons. Antigravity muscles continuously oppose the effect of gravity on the body and permit a person to maintain an upright posture. Antagonistic muscles relax when active mover muscles contract.

The nurse is assessing a patient who reports joint pain during walking. Which is the most appropriate question to be asked by the nurse to assess the severity of pain in the patient? 1 "Which activities trigger your pain?" 2 "How far do you walk before the pain in your legs begins?" 3 "What prevents you from exercising 30 minutes each day?" 4 "Do you experience muscular or joint pain during or after exercise?"

2 The nurse should use different questions, including open-ended and closed-ended ones, when assessing a patient. A patient who reports pain should be assessed for severity of the pain, and the most appropriate question to be asked would be, "How far do you walk before the pain in your legs begins?" If the patient is able to cover only a short distance, then it indicates that the patient's pain is severe. "Which activities trigger your pain?" and "What prevents you from exercising 30 minutes each day?" are questions that should be asked to gather information about the precipitating factors of pain. "Do you experience muscular or joint pain during or after exercise?" is a question that should be asked while assessing the extent to which the pain acts as a barrier to exercise.

The nurse measures the distance between the greater trochanter muscle of the patient and the floor and finds it to be 3 feet. How long should the patient's cane be? 1 2 ft 2 3 ft 3 4 ft 4 5 ft

2 The patient's cane length should be 3 ft, because a patient's cane length should be equal to the distance between the greater trochanter muscle and the floor. A 2-ft cane is too short, and a cane that is 4 ft or 5 ft is too long.

A patient with a right knee replacement is prescribed no weight bearing on the right leg. You reinforce crutch walking knowing that which crutch gait is most appropriate for this patient? 1 A two-point gait 2 A three-point gait 3 A four-point gait

2 The three-point alternating, or three-point gait requires the patient to bear all of the weight on one foot. In a three-point gait, the patient bears weight on both crutches and then on the uninvolved leg, repeating the sequence.

Which is the correct gait when a patient is ascending stairs on crutches? 1 The affected leg is advanced between the crutches to the stairs in a modified two-point gait. 2 The unaffected leg is advanced between the crutches to the stairs in a modified three-point gait. 3 A swing-through gait 4 Both legs advance between the crutches to the stairs in a modified four-point gait.

2 When ascending stairs on crutches, the patient usually uses a modified three-point gait.

A patient is admitted to the hospital with injury to the knee joint following a fall. The nurse notices an increased mobility of the joint while assessing the range of motion (ROM). What could be the reason for the increased mobility of the knee joint? 1 Arthritis of the joint 2 Ligament tears in the joint 3 Contractures of the joint 4 Fluid collection in the joint

2 While assessing the ROM of the patient, if increased mobility is noticed, it indicates that there is a possibility of ligament tears. Arthritis is an inflammation of the joint resulting in decreased mobility and stiffness. Contractures and fluid collection in the joint may decrease joint mobility and cause stiffness.

Signs and symptoms of orthostatic hypotension include dizziness, light-headedness, nausea, tachycardia, pallor, and even fainting. Rebound hypertension is caused by abruptly discontinuing certain drugs such as beta blockers. Dysfunctional proprioception is the patient's lack of awareness of the position of certain body parts. CNS rebound hypotension can by caused by cerebrospinal fluid leakage or certain drugs.

2 While determining the height and placement of the handgrips, the distance between the crutch pad and the patient's axilla should be approximately 2 inches.

The nurse is assessing a patient whose right leg is injured and uses a modified three-point gait to climb upstairs. The patient stands at the bottom of the stairs and transfers body weight to the crutches. The patient then advances the right leg between the crutches to the stairs, and then shifts weight from the crutches to the left leg. Finally, the patient aligns both of the crutches on the stairs and repeats this sequence. According to the nurse, which step followed by the patient requires correction? 1 Standing at the bottom of the stairs and transferring body weight to the crutches 2 Advancing the right leg between the crutches to the stairs 3 Shifting the weight from the crutches to the left leg after advancing the right leg 4 Aligning both of the crutches on the stairs

2 While using the modified three-point gait when climbing up the stairs on crutches, the patient should first move the uninjured (left limb) to the stairs followed by the injured (right) limb. This is done so that the body weight is first transferred to the uninjured side. Advancing the right leg first and bearing weight on the limb during transfer would aggravate the injury. The patient should follow the steps in a particular order. These steps include standing at the bottom of the stairs and transferring body weight to the crutches. Then the unaffected leg should be advanced between the crutches to the stairs, followed by shifting weight from the crutches to the unaffected leg. Finally, the patient should align both of the crutches on the stairs. This sequence should be repeated until the patient reaches the top of the stairs. Therefore, the step that is not appropriate in this scenario is advancing the right leg, which is injured. The leg may not be able to support the patient's weight.

Average fluid intake for healthy adults

2 - 3 liters

Chronologically arrange the steps a nurse should take to prepare for and react to a syncopal episode. 1. Bend the knees to lower the body as the patient slides to the floor. 2. Stand with feet apart with one foot in front of the other. 3. Extend one leg of the patient and let the patient slide against the leg. 4. Gently lower the patient to the floor protecting the patient's head.

2, 3, 4, 1 First, the nurse stands with his or her feet apart with one foot in front of the other. This provides a wide base of support and helps in supporting the patient's body weight. Then, the nurse extends one leg of the patient and lets the patient slide against the leg. Next, the patient is gently lowered to the floor while protecting the patient's head. Finally, the knees are bent to lower the body as the patient slides to the floor.

The nurse works at an occupational therapy clinic. A patient who is suffering from type 1 diabetes mellitus has recovered from a fractured tibia. The patient wishes to join a regular exercise program. What advice should the nurse give this patient? Select all that apply. 1 Perform high-intensity exercises. 2 Get a physical examination before starting the program. 3 Wear a medical alert bracelet. 4 Carry sugar packets or hard candy. 5 Monitor blood glucose levels before and after exercises.

2, 3, 4, 5 A physical examination before starting the exercise program helps to evaluate potential risks. Wearing a medical alert bracelet informs others about the patient's problem. It is easier for other people to help the patient in case of an emergency such as hypoglycemia. Sugar packets or hard candy help to treat hypoglycemia if it occurs. The blood sugar levels should be monitored before and after exercise to determine the fluctuations. The patient should not engage in high-intensity exercise. Low or moderate intensity exercises are preferred.

A patient is learning crutch walking. Before starting to walk, the patient assumes a tripod position, extends the head and neck, straightens the vertebral column, extends the hips, and flexes the knees. What does the nurse tell the patient? Select all that apply. 1 "The axillae should bear some weight." 2 "The vertebral column is in a correct position." 3 "Keep the head and neck in an erect position." 4 "Keep the knees extended before advancing the limb." 5 "Keep the hips in an extended position while crutch walking."

2, 3, 5 When a patient is learning to use crutches for walking, the patient should be informed about the basic crutch stance in the tripod position. This position includes a straight vertebral column, an erect head and neck, and extended hips and flexed knees. This posture is useful for promoting even weight distribution across all the joints of the body. The axillae should not bear any weight while assuming this position. Excessive force on the axilla can cause compression of the brachial plexus and the axillary blood vessels. The knees should be flexed and not extended to start crutch walking. A flexed position of the knee would cause excessive weight-bearing forces to act on the joints.

While the nurse is talking to a patient, the patient faints and starts to fall. Arrange the steps the nurse takes in the appropriate order to protect the patient from head injury. 1. Extend one leg and let the patient slide down against the leg. 2. Assume a wide base of support. 3. Gently lower the patient to the floor, protecting the head. 4. Put one foot in front of the other to support the patient's body weight.

2, 4, 1, 3 When the nurse finds that a patient is having a fainting episode and is about to fall, it is important to protect the patient from head injury. The first step by the nurse should be to assume a wide base of support by having one foot in front of the other to support the patient's body weight. The nurse should then extend one leg and let the patient slide down against this leg. The final step is to gently lower the patient to the floor, protecting the head.

While assessing a patient with a head injury, the nurse suspects damage to the central nervous system (CNS). Why should the nurse assess the patient's voluntary movements? Select all that apply. 1 Damage to any part of the central nervous system (CNS) that regulates voluntary movement causes fractures. 2 Damage to any part of the central nervous system (CNS) that regulates voluntary movement causes impaired mobility. 3 Damage to any part of the central nervous system (CNS) that regulates voluntary movement causes joint degeneration. 4 Damage to any part of the central nervous system (CNS) that regulates voluntary movement causes articular disruption. 5 Damage to any part of the central nervous system (CNS) that regulates voluntary movement causes impaired body alignment.

2, 5 Central nervous system (CNS) damage may cause impaired body alignment and immobility because the CNS regulates voluntary and involuntary activities. Fractures, joint degeneration, and articular disruption are caused by musculoskeletal trauma.

A patient has a body mass index (BMI) of 36. Her work requires her to sit all day. The patient has been advised to lose weight. The patient follows an exercise program to lose weight. What are the benefits of a well-designed exercise program? Select all that apply. 1 Increased cardiac output and decreased venous return 2 Reduced bone loss and improved muscle tone 3 Decreased gastric motility, and increased triglyceride breakdown 4 Increased effort when breathing and improved alveolar ventilation 5 Decreased fatigue and improved tolerance to stress

2, 5 Exercise decreases demineralization of bones resulting in reduced bone loss. The muscle tone improves due to regular conditioning of the muscles. Due to increased consumption of oxygen, the patient feels less fatigued and develops increased tolerance to stress. Cardiac output and venous return increase with exercise due to improved circulation. Gastric motility increases and triglycerides are well broken down to be absorbed. The effects of exercise on the respiratory system include improved alveolar ventilation and decreased effort when breathing.

What is the minimum patient weight that requires the use of friction reducing devices and at least three caregivers to handle and position the patient? Record your answer in pounds using a whole number.___________________________ lb

200 If the patient weighs more than 200 lb, then friction reducing devices and at least three caregivers are needed to handle and position the patient.

CO2 normal range

22-30 mmol/L

MCH normal range

26-34

Which nursing intervention is appropriate for a patient who is diagnosed with decreased cardiac output related to decreased myocardial contractility? 1 Take steps to reduce the number of interruptions during sleep. 2 Administer oxygen to the patient at 2 L/min via the nasal cannula. 3 Provide the patient with a low-calorie, low-sodium, and high-protein diet. 4 Instruct the patient to take a brisk walk for 2 to 3 miles and perform isometric exercises three to four times a week.

3 A patient who has decreased cardiac output related to decreased myocardial contractility should consume a low-calorie, low-sodium, and high-protein diet. A patient who has fatigue related to poor physical condition should have reduced sleep interruptions. The nurse should administer oxygen to the patient at 2 L/min via the nasal cannula in case of impaired gas exchange related to decreased cardiac output. A patient who has activity intolerance related to physical deconditioning should be instructed to take a brisk walk for 2 to 3 miles and perform isometric exercises three to four times a week.

Which statement is true about the different forms of exercise? 1 Isotonic exercises promote osteoclastic activity. 2 Push-ups and hip lifting are examples of isotonic exercises. 3 A patient who is immobilized can perform isometric exercises. 4 Resistive isometric exercises involve tensing muscles without moving body parts.

3 A patient who is immobilized in bed can perform isometric exercises. Isotonic exercises promote osteoblastic activity rather than osteoclastic activity. Push-ups and hip lifting are examples of resistive isometric exercises. Isometric exercises involve tensing muscles without moving body parts.

Which term is used to explain the relationship of one body part to another along a horizontal or vertical line? 1 Friction 2 Body balance 3 Body alignment 4 Coordinated body movement

3 Body alignment refers to the relationship of one body part to another along a horizontal or vertical line. Friction is a force that opposes movement. Body balance is a technique in which a relatively low center of gravity is balanced over a wide, stable base of support and a vertical line falls from the center of gravity through the base of support. Coordinated body movement is a result of weight, center of gravity, and balance.

When caring for a patient who can assist with positioning, what should the nurse keep in mind? 1 If the center of gravity is higher, the nurse can have more stability. 2 If the base of support is narrower, the nurse can have more stability. 3 If the balancing activity is divided between the arms and legs, there is a reduced risk of back injury. 4 If the nurse's face is towards the direction opposite to movement, this positioning prevents abnormal twisting of the spine.

3 Dividing the balancing activity between the arms and legs reduces the risk of back injury. The lower the center of gravity, the greater the stability of the nurse. The wider the base of support, the greater the stability of the nurse. Facing the direction of movement prevents abnormal twisting of the spine.

The nurse is teaching a four-point alternating gait to a patient. If the patient has understood the teaching completely, what will be the pattern of the patient's gait? 1 The patient will advance both the left crutch and right foot at the same time. 2 The patient will advance both the right crutch and left foot at the same time. 3 The patient will move the right crutch forward first and then the left foot forward. 4 The patient will move the right leg forward first and then the right crutch forward.

3 In a four-point alternating or four-point gait, the patient bears the weight on both legs to provide stability. In this gait, once a crutch is moved and again bearing weight, the opposite leg is then moved so that at all times there are three points of support on the floor. Therefore, the most appropriate pattern would be to move the right crutch first and then the left foot. Moving the opposite crutch and foot (such as left foot and right crutch) at the same time describes the two-point gait. Moving the right leg forward first and then the right crutch forward will not provide support.

How is the body alignment and posture of a patient in a standing position different from the body alignment and posture of a patient in a sitting position? 1 The head is erect. 2 The spine is straight. 3 The arms hang at the sides. 4 The feet are flat on the floor.

3 In a standing position, the arms of the patient hang comfortably at the sides. In a sitting position, the forearms of the patient are supported on the armrest, in the lap, or on a table in front of the chair. In both the positions, the head is erect, the spine is straight, and the feet are flat on the floor.

A patient with a history of coronary heart disease and chronic obstructive pulmonary disease (COPD) has blood pressure of 180/98 mm Hg and a body mass index (BMI) of 28. The nurse is educating the patient on the benefits of exercise. Which point regarding exercise does the nurse keep in mind when educating the patient? 1 Exercise increases diastolic blood pressure in hypertensive patients. 2 Exercise aggravates systolic blood pressure in hypertensive patients. 3 Exercise helps in preventing recurrence of coronary heart disease. 4 Exercise can worsen chronic obstructive pulmonary disease.

3 Physical activity and exercise improve the cardiac function of an individual. Thus, exercise helps in secondary prevention or recurrence of coronary heart disease. It is proven that exercise can improve the health of patients with hypertension and chronic pulmonary disorders by decreasing the diastolic blood pressure as well as systolic blood pressure. Patients with COPD should be supported and encouraged to increase activity and exercise in a safe environment. The progress of patients with COPD should be monitored in pulmonary rehabilitation.

In a health care setting, the nurse is caring for four patients with musculoskeletal disorders. Which patient's crutch movements are similar to the arm motions of normal walking? 1 Patient 1 2 Patient 2 3 Patient 3 4 Patient

3 The patient moves the crutch at the same time as the opposite leg while using a two-point crutch gait. Therefore, the arm movements are similar to arm motions during normal walking. Therefore, patient 3 with arthritis in the knees using a two-point crutch gait has movements similar to the arm motions of normal walking. Patient 1 with a four-point crutch gait requires weight bearing on both legs. Therefore, it does not resemble the arm motions used during normal walking. Patient 2 with a three-point crutch gait requires the patient to bear all of the weight on one foot. The amputated leg does not touch the ground. Therefore, the crutch movements are not similar to arm motions during normal walking. Patient 4 using a swing-through gait places the crutches one stride in front and swings the body through them.

The nurse is performing assessments to measure the cane size for a patient. Which measurement is appropriate in determining the correct size of the cane? 1 The length from the floor to the hip joint 2 The length from the floor to the iliac crest 3 The length from the floor to the greater trochanter 4 The length from the great toe to the lesser trochanter

3 The patient's cane length should be equal to the distance between the greater trochanter and the floor. This provides maximum support while walking. If the length of the cane were equal to the distance from the floor to the hip joint, the cane would be too long and might not support the patient's movements. If the cane length were equal to the distance from the floor to the iliac crest, it would result in a shorter cane. A cane length equal to the distance from the great toe to the lesser trochanter will also result in a shorter cane, which might make the patient unstable while walking.

The patient who has a severe left leg injury needs to avoid weight bearing on the affected leg. Which crutch gait is appropriate for the patient? 1 Two-point gait 2 Four-point gait 3 Three-point gait 4 Swing-through gait

3 The three-point gait is appropriate for this patient because in a three-point gait, the patient bears all of the weight on the unaffected foot. In a two-point gait, partial weight is placed on each foot. In a four-point gait, weight is placed on both the legs. In a swing-through gait, weight is placed on the supported legs, which have weight-supporting braces.

A toddler has awkward posture because of a slight swayback and protruding abdomen. The legs and feet are far apart, and the feet are slightly averted. By what age does the child becomes slimmer, taller, and better balanced? Record your answer using a whole number. _ years

3 Toddlers usually have a protruding abdomen and a slight swayback. They usually walk with their legs and feet far apart, and the feet are slightly averted. The posture changes by the third year, and the child's gait becomes more balanced.

What height of the bed is used to transfer and handle the patient safely? 1 Knee level 2 Hand level 3 Elbow level 4 Shoulder level

3 While transferring and handling a patient, the height of the bed should be at elbow level for the purpose of safety.

What does the nurse teach a patient about a walker and its proper use? 1 "Hold the handgrips on the lower bars of the walker." 2 "A walker has four widely placed sturdy legs and two open sides." Correct3 "Each time you take a step, move the walker forward and take another step." 4 "Your elbows should be flexed at about 45 degrees when standing inside the walker."

3 While walking, each time the patient takes a step, the patient should move the walker forward and then take another step. The patient should hold the handgrips on the upper bars of the walker, not on the lower bars. A walker has four widely placed sturdy legs and one open side. The patient should flex the elbows at about 15 to 30, not 45, degrees when standing inside the walker.

The Dietary Supplement and Health Education Act states that: 1.) The FDA must evaluate all herbal therapies 2.) Herbs, vitamins, and minerals may be sold with their therapeutic advantages listed on the label 3.) Herbs, vitamins, and minerals may be sold as long as no therapeutic claims are made on the label 4.) In conjunction with the FDA, all supplements are considered safe for use

3.) Herbs, vitamins, and minerals may be sold as long as no therapeutic claims are made on the label

The nurse is caring for a patient with dysphagia and is feeding her a pureed chicken diet when she begins to choke. What is the priority nursing intervention? 1. Suction her mouth and throat 2. Turn her in their side 3. Put on oxygen at 2L nasal cannula 4. Stop feeding her and place NPO

4

A patient reports sweating and shortness of breath while walking. On examination, the patient's respiratory rate is found to be 30 breaths/minute and the oxygen saturation of blood (SpO2) is 83%. What is the most appropriate intervention? 1 Assess the blood pressure. 2 Assess the blood glucose levels. 3 Administer 25% dextrose via an intravenous (IV) catheter. 4 Administer oxygen at 2 L/min via the nasal cannula.

4 A respiratory rate of 30 breaths/minute and an oxygen saturation of blood of 83% are indicative of decreased gas exchange due to decreased cardiac output. In this case, oxygen should be administered at the rate of 2 L/min via the nasal cannula. This is done to improve oxygen saturation in the blood. Assessing the blood pressure and blood glucose levels may not relieve shortness of breath. Administering 25% dextrose via an IV catheter helps to reverse hypoglycemia but has no effect on cardiac output.

A patient with paraplegia wants to sit in a chair. The patient's right side is stronger than the left. What does the patient do when trying to sit? 1 Hold one crutch in each hand and bear body weight on the crutches. 2 Hold one crutch in each hand and bear body weight on both the legs and the crutches. 3 Hold both crutches in the left hand and bear body weight on the left side and the crutches. 4 Hold both crutches in the right hand and bear body weight on the right side and the crutches.

4 In this patient with paraplegia, the right side is stronger than the left side. Thus, while sitting the patient should hold both of the crutches in the right hand and bear body weight on the right side and the crutches. The stronger side is more capable of holding the body weight while lowering the body to sit, and thus falling would be prevented. The patient should hold the chair with the left arm while sitting. Thus, holding the crutches in each hand would not allow the patient to hold onto the chair and should be avoided. If the patient holds both crutches in the left hand and bears body weight on the left side and the crutches, the patient is very likely to fall. The left side is weaker and would not be able to bear weight while lowering the body for sitting.

Which statement is true regarding exercise and activity? 1 There are four categories of exercise. 2 Isotonic exercises cause muscle relaxation. 3 Examples of resistive isometric exercise are walking and swimming. 4 Isometric exercises involve tensing muscles without moving body parts.

4 Isometric exercises involve tightening or tensing muscles without moving body parts. There are three categories of exercise: isotonic, isometric, and resistive isometric. Isotonic exercises cause muscle contraction and changes in muscle length. Examples of resistive isometric exercises are push-ups and hip lifting.

How is the isotonic form of exercise different from the isometric form? 1 Isotonic exercises promote osteoblastic activity. 2 Isotonic exercises enhance circulatory functioning. 3 Isotonic exercises increase muscle mass, tone, and strength. 4 Isotonic exercises cause muscle contraction and changes in muscle length.

4 Isotonic exercises cause muscle contraction and changes in muscle length, whereas isometric exercise involves tightening or tensing muscles without moving the body parts. Both isotonic and isometric forms of exercise promote osteoblastic activity. Both forms of exercise enhance circulatory functioning. Both forms of exercise increase muscle mass, tone, and strength.

What is the normal state of balanced muscle tension? 1 Muscle tension 2 Isotonic contraction 3 Isometric contraction 4 Muscle tone/tonus

4 Muscle tone, or tonus, is the normal state of balanced muscle tension. Muscle tension can be in various states. Muscle tone helps maintain functional positions such as sitting or standing, without excess muscle fatigue; this tone is maintained through the continual use of muscles. Isotonic (dynamic) contraction is a combination of concentric and eccentric muscle actions for active movement. Isometric (static) contraction causes an increase in muscle tension or muscle work but no shortening or active movement of the muscle.

You are transferring a patient who weighs 320 lb (145.5 kg) from his bed to a chair. The patient has an order for partial weight bearing because of bilateral reconstructive knee surgery. Which is the best technique for transfer? 1 Use a transfer board. 2 Obtain a stand assist device. 3 Implement a three-person carry. 4 Use the ceiling-mounted lift.

4 The use of patient-handling equipment helps prevent injury to health care workers and patients. In this situation, the ceiling-mounted lift would be the best choice for transferring this patient. A transfer board is utilized when transferring a patient from a bed to another bed or cart. The stand assist device would be used when getting the patient out of the chair. Manual lifting should be used as a last resort. A three-person carry could cause injury to the health care workers and possibly even the patient.

Before discharge of a bedridden patient to home, the nurse taught the patient's caregiver about repositioning the patient every 2 hours to prevent development of pressure ulcers. Four days after discharge, the patient developed skin breakdown at the sacral region with redness and edema. What does the nurse say in order to evaluate the caregiver's understanding of the repositioning techniques taught during discharge? 1 "I suspect the patient is developing pressure ulcers." 2 "You have been careless in not following my instructions." 3 "I shall refer the patient to the primary health care provider for an antibiotic prescription." 4 "Have you been repositioning the patient every 2 hours?"

4 When evaluating the nursing interventions, the nurse should compare the actual outcomes with the expected outcomes. If the expected outcomes are not met, the nurse should try to explore the reason behind it and make changes in the teaching strategy. Therefore, the most important step would be to ask for the reason behind the development of pressure ulcers, and if the caregiver had been following the repositioning regimen. Stating that the patient may have developed pressure ulcers may not help in evaluating the nursing intervention. When talking to the patient, the nurse should avoid judgments or use demeaning words such as "careless." Referring the patient to a primary health care provider would be helpful in obtaining a prescription for antibiotics but would not help in evaluating the nursing interventions.

A patient has paraplegia and wears weight-supporting braces. Which crutch gait pattern should the patient be trained to use during ambulation? 1 A two-point gait 2 A four-point gait 3 A three-point gait 4 A swing-through gait

4 While using the swing-through gait pattern, the patient places the crutches one stride in front and then swings to or through them while they support his or her weight. This gait pattern does not require weight bearing on the legs; therefore, it is the correct gait pattern for the patient. In a two-point gait pattern, the patient moves a crutch at the same time as the opposing leg that resembles arm motion during normal walking. It requires weight bearing on one leg, and may not be possible in paraplegia. A four-point crutch gait requires weight bearing on both legs. Each leg is moved alternately with each opposing crutch. Therefore, it is not appropriate for this patient. A three-point gait requires the patient to bear all of the weight on one foot. The affected foot does not touch the ground. This gait pattern may not be suitable for this patient.

A nurse is teaching about the transtheoretical model of change. In which order will the nurse place the progression of the stages from beginning to end? 1. Action 2. Preparation 3. Maintenance 4. Contemplation 5. Precontemplation

5, 4, 2, 1, 3

BUN normal range

5-25 mg/dL

VITAL SIGNS - HEART RATE

60-100 beats per minute (bpm) regular rate/rhythm

calcium normal range

8.5-10.5 mg/dL

MCV normal range

80-100

CLUBFOOT

95%: Medial deviation and plantar flexion of foot (equinovarus) 5%: Lateral deviation and dorsiflexion (calcaneovalgus)

VITAL SIGNS - PULSE OXIMETERY

95-100% on room air

serum chloride normal range

95-105 mmol/L

VITAL SIGNS - TEMPERATURE

96.8 - 100.4 F 36 - 38 C

RDW normal range

<14.5

A nurse is describing a patient's perceived ability to successfully complete a task. Which term should the nurse use to describe this attribute? a.Self-efficacy b.Motivation c.Attentional set d.Active participation

A

A nurse is preparing to teach a kinesthetic learner about exercise. Which technique will the nurse use? a.Let the patient touch and use the exercise equipment. b.Provide the patient with pictures of the exercise equipment. c.Let the patient listen to a video about the exercise equipment. d.Provide the patient with a case study about the exercise equipment.

A

A nurse is teaching a patient about the Speak Up Initiatives. Which information should the nurse include in the teaching session? a.If you still do not understand, ask again. b.Ask a nurse to be your advocate or supporter. c.The nurse is the center of the health care team. d.Inappropriate medical tests are the most common mistakes.

A

A nurse needs to teach a young woman newly diagnosed with asthma how to manage her disease. Which of the following topics does the nurse teach first? A. How to use an inhaler during an asthma attack B. The need to avoid people who smoke to prevent asthma attacks C. Where to purchase a medical alert bracelet that says she has asthma D. The importance of maintaining a healthy diet and exercising regularly

A

A patient had a stroke and must use a cane for support. A nurse is preparing to teach the patient about the cane. Which learning objective/outcome is most appropriate for the nurse to include in the teaching plan? a.The patient will walk to the bathroom and back to bed using a cane. b.The patient will understand the importance of using a cane. c.The patient will know the correct use of a cane. d.The patient will learn how to use a cane.

A

A patient who is going to surgery has been taught how to cough and deep breathe. Which evaluation method will the nurse use? a.Return demonstration b.Computer instruction c.Verbalization of steps d.Cloze test

A

A patient with chest pain is having an emergency cardiac catheterization. Which teaching approach does the nurse use in this situation? A. Telling approach B. Selling approach C. Entrusting approach D. Participating approach

A

After a teaching session on taking blood pressures, the nurse tells the patient, "You took that blood pressure like an experienced nurse." Which type of reinforcement did the nurse use? a.Social acknowledgment b.Pleasurable activity c.Tangible reward d.Entrusting

A

The patient receiving total parenteral nutrition (TPN) asks the nurse why his blood glucose is being checked since he does not have diabetes. What is the best response by the nurse? A. TPN can cause hyperglycemia, and it is important to keep your blood glucose level in an acceptable range. B. The high concentration of dextrose in the TPN can give you diabetes; thus you need to be monitored closely. C. Monitoring your blood glucose level helps to determine the dose of insulin that you need to absorb the TPN. D. Checking your blood glucose level regularly helps to determine if the TPN is effective as a nutrition intervention.

A

Which action is initially taken by the nurse to verify correct position of a newly placed small-bore feeding tube? A. Placing an order for x-ray film examination to check position B. Confirming the distal mark on the feeding tube after taping C. Testing the pH of the gastric contents and observing the color D. Auscultating over the gastric area as air is injected into the tube

A

While preparing a teaching plan, the nurse describes what the learner will be able to accomplish after the teaching session about healthy eating. Which action is the nurse completing? a.Developing learning objectives b.Providing positive reinforcement c.Presenting facts and knowledge d.Implementing interpersonal communication

A

a nurse assesses four patients. which patient has the greatest risk for hypomagnesemia? A. a 72 year old with chronic alcoholism B. a 79 year old with bone cancer C. a 41 year old with hypernatremia D. a 46 year old with respiratory acidosis

A

the health care providers order is 500 ml 0.9% NaCl intravenously over 4 hours. which rate does a nurse program into the infusion pump? A. 125 ml/hr B. 167 ml/hr C. 200 ml/hr D. 1000 ml/hr

A

what assessment does a nurse make before hanging an intravenous fluid that contains potassium? A. urine output B. arterial blood gases C. fullness of neck veins D. level of consciousness

A

Electrolyte

A compound that contains mineral salts that separates into ions when dissolved in water.

Atrial natriuretic peptide

A hormone that opposes the action of aldosterone and promote vasodialation. Promotes sodium and Water excretion in the urine.

The nurse is admitting a patient with uncontrolled diabetes mellitus. It is the fourth time the patient is being admitted in the last 6 months for high blood sugars. During the admission process, the nurse asks the patient about employment status and displays a nonjudgmental attitude. What is the rationale for the nurse's actions?

A person's compliance is affected by economic status.

types of theories

A prescriptive theory details nursing interventions (meditation) for a specific phenomenon (migraine headaches) and the expected outcome of the care. Grand theories are broad in scope and complex and require further specification through research; it does not provide guidance for specific nursing interventions. Descriptive theories do not direct specific nursing activities but help to explain patient assessment. A middle-range theory tends to focus on a concept found in 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.

Type of dependence: Addiction

A primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. Addictive behaviors include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.

Reticular Formation

A small cluster of neurons in the brainstem and spinal cord, continuously monitors the physiological status of the body through sensory and motor tracks.

Type of dependence: drug tolerance

A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time.

Type of dependence: physical dependence

A state of adaptation that is manifested by a drug class-specific withdrawal syndrome produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.

General Adaptation Syndrome (GAS)

A three stage reaction to stress, describes how the body responds to stressors through the alarm reaction, the resistance stage and the exhaustion stage.

A nurse is asked by a co-worker why patient education/teaching is important. Which statements will the nurse share with the co-worker? (Select all that apply.) a."Patient education is an essential component of safe, patient-centered care." b."Patient education is a standard for professional nursing practice." c."Patient teaching falls within the scope of nursing practice." d."Patient teaching is documented and part of the chart." e."Patient education is not effective with children." f."Patient teaching can increase health care costs."

A, B, C, D

A nurse is preparing to teach patients. Which patient finding will cause the nurse to postpone a teaching session? (Select all that apply.) a.The patient is hurting. b.The patient is fatigued. c.The patient is mildly anxious. d.The patient is asking questions. e.The patient is febrile (high fever). f.The patient is in the acceptance phase.

A, B, E

The nurse is teaching a program on healthy nutrition at the senior community center. Which points should be included in the program for older adults? (Select all that apply.) A. Avoid grapefruit and grapefruit juice, which impair drug absorption. B. Increase the amount of carbohydrates for energy. C. Take a multivitamin that includes vitamin D for bone health. D. Cheese and eggs are good sources of protein. E. Limit fluids to decrease the risk of edema.

A, C, D

a patient has severe hypercalcemia. what are the priority nursing interventions? (select all that apply) A. fall prevention interventions B. teaching regarding sodium restrictions C. encouraging increased fluid intake D. monitoring for constipation E. explaining hot to take daily weights

A, C, D

The nurse is caring for a patient experiencing dysphagia. Which interventions help decrease the risk of aspiration during feeding? (Select all that apply.) A. Sit the patient upright in a chair. B. Give liquids at the end of the meal. C. Place food in the strong side of the mouth. D. Provide thin foods to make it easier to swallow. E. Feed the patient slowly, allowing time to chew and swallow. F. Encourage patient to lie down to rest for 30 minutes after eating.

A, C, E

a patient has hypokalemia with stable cardiac function. what are the priority nursing interventions? (select all that apply) A. fall prevention interventions B. teaching regarding sodium restrictions C. encouraging increased fluid intake D. monitoring for constipation E. explaining how to take daily weights

A, D

an intravenous fluid is infusing more slowly than ordered. the infusion pump is set correctly. which factors could cause this slowing? (select all that apply) A. infiltration at vascular access device site (VAD) B. patient lying on tubing C. roller clamp wide open D. tubing kinked in bedrails E. circulatory overload

A,B,D

Successful ethical discussion depends on people who have a clear sense of personal values. When a group of people share many of the same values, it may be possible to refer for guidance to philosophical principals of utilitarianism. This philosophy proposes which of the following? A. The value of something is determined by its usefulness to society. B. People's values are determined by religious leaders. C. The decision to perform a liver transplant depends on a measure of the moral life that the patient has led so far. D. The best way to determine the solution to an ethical dilemma is to refer the case to the attending physician or health care provider.

A. The value of something is determined by its usefulness to society.

Resolution of an ethical dilemma involves discussion with the patient, the patient's family, and participants from all health care disciplines. Which of the following describes the role of the nurse in the resolution of ethical dilemmas? A. To articulate his or her unique point of view, including knowledge based on clinical and psychosocial observations B. To await new clinical orders from the physician C. To limit discussions about ethical principals D. To allow the patient and the physician to resolve the dilemma without regard to personally held values or opinions regarding the ethical issues

A. To articulate his or her unique point of view, including knowledge based on clinical and psychosocial observations

The nurse is attempting to start an exercise program in a local community as a health promotion project. In explaining the purpose of the project, the nurse explains to community leaders that a. A sedentary lifestyle contributes to the development of health-related problems. b. The recommended frequency of workouts should be twice a day. c. An exercise prescription should incorporate aerobic exercise only. d. The purpose of weight training is to bulk up muscles.

ANS: A A sedentary lifestyle contributes to the development of health-related problems. A holistic approach is taken to develop overall fitness and includes warm-ups, aerobic exercise, resistance training, weight training, and so forth. The recommended frequency of aerobic exercise is 3 to 5 times per week or every other day for approximately 30 minutes. Cross-training is recommended for the patient who prefers to exercise every day. Some patients use weight training to bulk up their muscles. However, the purposes of weight training from a health perspective are to develop tone and strength and to simulate and maintain healthy bone

26. The nurse is preparing a patient for a surgical procedure on the right great toe. Which of the following actions would be most important to include in this patient's preparation? a. Ascertain that the surgical site has been correctly marked. b. Ascertain where the family will be located during the procedure. c. Place the patient in a clean surgical gown. d. Ask the patient to remove all hairpins and cosmetics.

ANS: A Because errors have occurred in the past with patients undergoing the wrong surgery on the wrong site, the universal protocol has been implemented and is used with all invasive procedures. Part of this protocol includes marking the operative site with indelible ink. Knowing where the family is during a procedure, placing the patient in a clean gown, and asking the patient to remove all hairpins and cosmetics are important but are not most important in this list of items.

The nurse is preparing to reposition a patient. Before doing so, the nurse must a. Assess the weight to be lifted and the assistance needed. b. Attempt to manually lift the patient alone before asking for assistance. c. Attempt a manual lift only when lifting most or all of the patient's weight. d. Not use the agency lift team if a mechanical lift is available

ANS: A Before lifting, assess the weight to be lifted and determine the assistance needed and the resources available. Manual lifting is the last resort, and it is used when the task at hand does not involve lifting most or all of the patient's weight. Use safe patient handling equipment in conjunction with agency lift teams to reduce the risk of injury to the patient and members of the health care team.

Isotonic, isometric, and resistive isometric are three categories of exercise. They are classified according to the type of muscle contraction involved. Of the following exercises, which are considered isotonic? a. Bicycling, swimming, walking, jogging, dancing b. Tightening or tensing of muscles without moving body parts c. Push-ups, hip lifting, pushing feet against a footboard on the bed d. Quadriceps set exercises and contraction of the gluteal muscles

ANS: A Examples of isotonic exercises are walking, swimming, dance aerobics, jogging, bicycling, and moving arms and legs with light resistance. Isometric exercises involve tightening or tensing of muscles without moving body parts. Examples include quadriceps set exercises and contraction of the gluteal muscles. Examples of resistive isometric exercises are push-ups and hip lifting, as well as placing a footboard on the foot of the bed for patients to push against with their feet.

23. During preoperative assessment for a 7:30 case, the patient indicates to the nurse that he had a cup of coffee this morning. The nurse reports this information to the anesthesia provider anticipating a. A delay in or cancellation of surgery. b. Questions regarding components of the coffee. c. Additional questions about why the patient had coffee. d. Instructions to determine what education was provided in the preoperative visit.

ANS: A For fatty, fried, and meat sources, the recommended fast is 8 hours. Fasting from intake of a light meal or from nonhuman milk for 6 or more hours, breast milk for 4 or more hours, and clear liquids for 2 to 3 hours before elective procedures requiring general anesthesia, regional anesthesia, or sedation is recommended. A delay in or cancellation of surgery will be in order for this case. Questions regarding components of the coffee (e.g., milk; can determine the length of time for a delay), asking why, and evaluating the preoperative education may all be items to be addressed, especially from a performance improvement perspective, but at this time in caring for this patient, a delay or cancellation is in order.

12. The nurse is caring for a preoperative patient. The nurse teaches the principles and demonstrates leg exercises for the patient. The patient is unable to perform leg exercises correctly. What is the nurse's best next step? a. Assess for the presence of anxiety, pain, or fatigue. b. Ask the patient why he does not want to do the exercises. c. Encourage the patient to practice at a later date. d. Assess the educational methods used to educate the patient.

ANS: A If the patient is unable to perform leg exercises after sound educational principles and demonstration are provided, the nurse should look for circumstances that may be impacting the patient's ability to learn. In this case, the patient can be anticipating the upcoming surgery and may be experiencing anxiety. The patient may also be in pain or may be fatigued; both of these can affect the ability to learn. Assessment of educational methods may be needed, but in this case, sound principles and demonstration are being utilized. Asking anyone why can cause defensiveness and may not help in attaining the answer. In this case, the patient really may want to participate and may not know why he is unable to learn. The nurse is aware that the patient is unable to do the exercises. Moving forward without ascertaining that learning has occurred will not help the patient in meeting goals.

25. The nurse has completed a preoperative assessment for a patient going to surgery and gathers assessment data. Of the following, which would be the most important next step? a. Notify the operating suite that the patient has a latex allergy. b. Document that the patient had a bath at home this morning. c. Ask the nursing assistant to obtain vital signs. d. Administer the ordered preoperative intravenous antibiotic.

ANS: A Innumerable products that contain latex are used in the operating suite and the postanesthesia care unit (PACU). When preparing for a patient with this allergy, special considerations are required from preparation of the room to the types of tubes, gloves, drapes, and instruments utilized. To ensure that the patient has a safe environment takes time, and if the correct supplies are not available, awaiting their arrival may cancel or delay the case. Obtaining vital signs, documenting, and administering medications are all part of the process and should be done—with the latex allergy in mind. However, making sure that the patient has a safe environment is the first step.

31. The nurse is caring for a postoperative patient with a history of obstructive sleep apnea. The nurse monitors for which of the following? a. Choking and noisy, irregular respirations b. Shallow respirations c. Moaning and reports of pain d. Disorientation

ANS: A One of the greatest concerns after general anesthesia is airway obstruction. Choking and noisy, irregular respirations are classic signs and symptoms of airway obstruction. A number of factors contribute to obstruction, including a history of obstructive sleep apnea; weak pharyngeal/laryngeal muscle tone from anesthetics; secretions in the pharynx, bronchial tree, or trachea; and laryngeal or subglottic edema. In the postanesthetic patient, the tongue is a major cause of airway obstruction. Shallow respirations are indicative of respiratory depression. Moaning and reports of pain are common in all surgical patients and are an expected event. Disorientation is common when first awakening from anesthesia but can be a sign of hypoxia.

The patient has just started on enteral feedings but is complaining of abdominal cramping. The nurse should a. Slow the rate of tube feeding. b. Instill cold formula to "numb" the stom-ach. c. Place the patient in a supine position. d. Change the tube feeding to a high-fat formula.

ANS: A One possible cause of abdominal cramping is a rapid increase in rate or volume. Lowering the rate of delivery may increase tolerance. Another possible cause of abdominal cramping is use of cold formula. The nurse should warm the formula to room temperature. The nurse should maintain the head of the bed at least 30 degrees. High-fat formulas are also a cause of abdominal cramping.

17. The nurse is preparing to assist the patient in using the incentive spirometer. Which nursing intervention should the nurse provide first? a. Perform hand hygiene. b. Place in reverse Trendelenburg position. c. Explain use of the mouthpiece. d. Instruct the patient to inhale slowly.

ANS: A Performing hand hygiene reduces microorganisms. Placing the patient in the correct position such as high Fowler's or reverse Trendelenburg for the bariatric patient would be the next step in the process. Demonstration of use of the mouthpiece followed by the instruction to inhale slowly would be the last step in this scenario.

1. The nurse is precepting a student nurse and explains that perioperative nursing care occurs a. Before, during, and after surgery. b. In preadmission testing. c. During the surgical procedure. d. In the postanesthesia care unit.

ANS: A Perioperative nursing care occurs before, during, and after a surgery. Preadmission testing occurs before surgery and is considered preoperative. Nursing care provided during the surgical procedure is considered intraoperative, and in the postanesthesia care unit, it is considered postoperative. All of these are parts of the perioperative phase, but each individual phase does not explain the term completely.

13. Which nursing assessment would indicate that the patient is performing diaphragmatic breathing correctly? a. Hands placed on border of rib cage with fingers extended will touch as chest wall contracts. b. Hands placed on chest wall with fingers extended will separate as chest wall contracts. c. The patient will feel upward movement of the diaphragm during inspiration. d. The patient will feel downward movement of the diaphragm during expiration.

ANS: A Positioning the hands along the borders of the rib cage allows the patient to feel movement of the chest and abdomen as the diaphragm descends and the lungs expand. As the patient takes a deep breath and slowly exhales, the middle fingers will touch while the chest wall contracts. The fingers will separate as the chest wall expands. The patient will feel normal downward movement of the diaphragm during inspiration and normal upward movement during expiration.

The nurse is providing care to a patient who is bedridden. To prevent fatigue, the nurse raises the height of the bed. The nurse understands that balance is maintained by raising the bed to a. Prevent a shift in the nurse's base of support. b. Narrow the base of support. c. Allow the nurse to bring his or her feet close together. d. Shift the center of gravity further away from the base of support

ANS: A Raising the height of the bed when performing a procedure prevents bending too far at the waist and causing a shift in the base of support. Balance is maintained by maintaining proper body alignment and posture through two simple techniques. First, widen the base of support by separating the feet to a comfortable distance. Second, increase balance by bringing the center of gravity closer to the base of support.

In determining the nutritional status of a patient and developing a plan of care, it is important to evaluate the patient according to a. Published standards. b. Nursing professional standards. c. Absence of family input. d. Patient input only.

ANS: A Referring to professional standards for nutrition is especially important during this step because published standards are based on scientific findings. Nursing standards cannot be used alone. Other health care professionals must be consulted to adopt interventions that reflect the patient's needs. Family should be involved in evaluation and design of interventions. Although patient input is important, synthesis of patient information from multiple sources is necessary to devising an individualized approach to care that is relevant to the patient's needs.

22. The nurse is reviewing the surgical consent with the patient during preoperative education. The patient indicates that he does not understand what procedure will be completed. What is the nurse's best next step? a. Notify the physician about the patient's question. b. Explain the procedure that will be completed. c. Ask the patient to sign the form. d. Continue with preoperative education.

ANS: A Surgery cannot be legally or ethically performed until the patient understands the need for a procedure, the steps involved, the risks, expected results, and alternative treatments. It is the surgeon's responsibility to explain the procedure and obtain informed consent. It is important for the nurse to pause to notify the physician of the patient's questions. It is not within the nurse's scope to explain the procedure for the first time. The nurse can certainly reinforce what the physician has explained, but the information needs to come from the physician. It is not prudent to ask a patient to sign a form for a procedure that he/she does not understand.

7. The nurse is preparing a patient for surgery. Aims of assessment before surgery include a. Establishing a patient's baseline of normal function. b. Planning for care after the procedure. c. Educating the patient and family about the procedure. d. Gathering appropriate equipment for the patient's needs.

ANS: A The aim of assessment of the patient before surgery is to establish the patient's normal preoperative function to prevent and minimize possible postoperative complications. Gathering appropriate equipment, planning care, and educating the patient and family are all important interventions that must be provided for the surgical patient; they are part of the nursing process but are not the reason for completing an assessment of the surgical patient.

The energy needed to maintain life-sustaining activities for a specific period of time at rest is known as a. BMR. b. REE. c. Nutrients. d. Nutrient density.

ANS: A The basal metabolic rate (BMR) is the energy needed to maintain life-sustaining activities for a specific period of time at rest. The resting energy expenditure (REE), or resting metabolic rate, is the amount of energy an individual needs to consume over a 24-hour period for the body to maintain all of its internal working activities while at rest. Nutrients are the elements necessary for body processes and function. Nutrient density is the proportion of essential nutrients to the number of kilocalories. High-nutrient density foods provide a large number of nutrients in rela-tion to kilocalories.

The patient weighs 450 lbs (204.5 kg) and complains of shortness of breath with any exertion. His health care provider has recommended that he begin an exercise program. He states that he can hardly get out of bed and just cannot do anything around the house. To focus on the cause of the patient's complaints, the nurse devises which of the following nursing diagnoses? a. Activity intolerance related to excessive weight b. Activity intolerance related to bed rest c. Impaired gas exchange related to shortness of breath d. Imbalanced nutrition: less than body requirements

ANS: A The diagnostic label directs nursing interventions. This requires the correct selection of related factors. For example, Activity intolerance related to excess weight gain requires very different interventions than if the related factor is prolonged bed rest. In this case, the intolerance is related to the patient's excessive weight. He is not on bed rest, although he claims that it is difficult for him to get out of bed. Shortness of breath is a symptom, not a cause, of Impaired gas exchange, making this nursing diagnosis ineffective. The patient certainly has an imbalance of nutrition, but it is more than body requirements

The patient is being admitted for elective knee surgery. While the nurse is admitting the patient, she will a. Begin to develop a discharge plan. b. Plan to wait until after the surgery to plan for discharge. c. Place a generalized discharge plan in the record for later use. d. Address immediate needs of the patient only and address other needs later

ANS: A The nurse needs to begin discharge planning when the patient enters the health care system. The nurse cannot wait until after surgery to begin to plan for discharge. In addition, the discharge plan is always individualized to the patient and directed at meeting the actual and/or potential needs of the patient

19. The nurse is providing preoperative teaching for the ambulatory surgery patient who will be having a cyst removed from the right arm. Which would be the best explanation for diet progression after surgery? a. "Start with clear liquids, soup, and crackers. Advance to a normal diet as you tolerate." b. "There is no limitation on your diet. You can have whatever you want." c. "Stay on clear liquids for 24 hours. Then you can progress to a normal diet." d. "Start with clear liquids for 2 hours, then full liquids for 2 hours. Then progress to a normal diet."

ANS: A The type of surgery that patients undergo determines how quickly they can resume normal physical activity and regular eating habits. It is normal to progress gradually in activity and eating, and if the patient tolerates activity and diet well, he/she can progress more quickly. A common complication after surgery is nausea and vomiting. This can be caused by the anesthesia, fluid imbalance from being NPO, and pain. The gastrointestinal tract may be hypoactive owing to anesthesia. It is best to start with a clear liquid to see if the patient can tolerate the liquid without vomiting. If so, progressing to soup and crackers and advancing as the patient tolerates is appropriate. Starting with a heavy, greasy meal could cause nausea and vomiting. There is no need to stay on clear liquids for 24 hours after this procedure. Putting a time frame on the progression is too prescriptive. Progression should be adjusted for the patient's needs.

When expected nutritional outcomes are not being met, the nurse should a. Revise the nurse measures or expected outcomes. b. Alter the outcomes based on nursing standards. c. Ensure that patient expectations are con-gruent with the nurse's expectations. d. Readjust the plan to exclude cultural be-liefs.

ANS: A When expected outcomes are not met, the nurse should revise the nursing measures or expected outcomes based on the patient's needs or preferences, not solely on the basis of nursing stand-ards. Expectations and health care values held by nurses frequently differ from those held by pa-tients. Working closely with patients enables the nurse to redefine expectations that are realisti-cally met within the limits of conditions and treatments and to identify their dietary preferences and cultural beliefs.

Despite working in a highly stressful nursing unit and accepting additional shifts, a new nursing graduate has a strategy to prevent burnout. The best strategy would be for the new nurse to a. Identify limits and scope of work responsibilities. b. Write for 10 minutes in a journal every day. c. Use progressive muscle relaxation. d. Delegate complex nursing tasks to licensed professional nurses.

ANS: A An important step in preventing burnout is acknowledging one's own limitations, as well as what one's scope of work is while on the job. By doing this, the person will help to prevent emotional exhaustion and will limit the effects of chronic stress. Journaling and muscle relaxation are good stress-relieving techniques but are not directed at the cause of the workplace stress. Delegating if not applicable is an inappropriate coping mechanism.

The purpose of unconscious ego defense mechanisms is to do which of the following for the individual? a. Protect against feelings of worthlessness and anxiety. b. Facilitate the use of problem-focused coping. c. Evaluate an event for its personal meaning. d. Trigger the stress control functions of the medulla oblongata.

ANS: A Ego defense mechanisms offer the individual psychological protection from emotional stress. They are used unconsciously to protect against worthlessness and feelings of anxiety. Problem-focused coping is a coping strategy rather than an ego defense mechanism. Evaluation of an event for its personal meaning is primary appraisal. The medulla oblongata controls heart rate, blood pressure, and respirations and is not triggered by ego defense mechanisms.

While giving a lecture on attention-deficit/hyperactivity disorder, the nurse encourages which of the following to reduce children's stress regarding homework assignments? a. Time management skills b. Prevention of iron deficiency anemia c. Routine preventative health visits d. Speech articulation skills

ANS: A Time management skills are most related to homework assignment completion. Anemia prevention will improve energy levels but not stress. Routine health visits are important but do not directly affect ability to complete homework. Speech and other developmental aspects need to be developed if the child is to be successful, but skill development will not directly reduce homework-related stress.

When assessing the activity tolerance of a patient, the nurse would evaluate which of the following? (Select all that apply.) a. Skeletal abnormalities b. Emotional factors c. Age d. Pregnancy status e. Race

ANS: A, B, C, D Factors influencing activity tolerance include physiological factors such as skeletal abnormalities, emotional factors such as anxiety/depression, developmental factors such as age and gender, and pregnancy status. Race is not a factor because people of all races are faced with similar factors that affect their activity tolerance.

When developing a plan of care for a patient with altered nutritional needs, the nurse must assess the patient for which of the following? (Select all that apply.) a. What is the condition now? b. Is the condition stable? c. Will the condition get worse? d. Will the disease process accelerate deteri-oration? e. Which single objective measure will pre-dict the course of action?

ANS: A, B, C, D Nutritional screening tools must gather data based on four main principles: What is the condition now? Is the condition stable? Will the condition get worse? And will the disease process acceler-ate nutritional deterioration? Using a single objective measure is ineffective in predicting risk of nutritional problems.

3. The nurse is caring for a postoperative patient with an incision. Which of the following nursing interventions have been found to decrease wound infections? (Select all that apply.) a. Perform hand hygiene before and after contact with the patient. b. Maintain normoglycemia. c. Use hair clippers to remove hair. d. Administer antibiotics within 30 to 60 minutes of incision time. e. Provide bath and linen change daily. f. Perform first dressing change 1 week postoperatively.

ANS: A, B, C, D Performing hand hygiene before and after contact with the patient helps to decrease the number of microorganisms and break the chain of infection. Maintaining blood glucose levels at less than 150 mg/dL has resulted in decreased wound infection. Removing unwanted hair by clipping instead of shaving decreases the numbers of nicks and cuts caused by a razor and the potential for the introduction of microbes. Administration of an antibiotic within 30 to 60 minutes of incision time supports the defense against infection. Providing a bath and linen change is positive but is not necessarily important daily for infection control unless copious body fluids are present. The physician usually is the person who changes a dressing the first time to inspect the condition of the site, but this is done well before 7 days postoperatively.

7. The nurse is caring for a patient in the operating suite. The nurse assists in positioning the patient to (Select all that apply.) a. Gain access to the operative site. b. Sustain adequate circulatory and respiratory function. c. Ensure patient safety and skin integrity. d. Support the use of equipment. e. Maintain neuromuscular structures. f. Provide warmth and comfort.

ANS: A, B, C, E Ideally the patient's position provides good access to the operative site, sustains adequate circulatory and respiratory function, and ensures patient safety and skin integrity. It should not impair neuromuscular structures. Warmth and comfort are always concerns, but the other options are more important because they relate to positioning. Positioning does not support the use of equipment, rather the use of equipment complements the position of the patient to maintain patient safety.

A nurse meets the following goals: helps a patient maintain health and helps a patient with an illness. Which factors assist the nurse in achieving these goals? (Select all that apply.) a. Understands the challenges of today's health care system b. Identifies actual and potential risk factors c. Has coined the term "illness behavior" d. Minimizes the effects of illnesses e. Experiences compassion fatigue

ANS: A, B, D

Dietary reference intakes (DRIs) present evidence-based criteria for an acceptable range of amounts of vitamins and nutrients for each gender and age group. Components of DRIs include which of the following? (Select all that apply.) a. Estimated average requirement (EAR) b. Recommended dietary allowance (RDA) c. The Food Guide Pyramid d. Adequate intake (AI) e. The tolerable upper intake level (UL)

ANS: A, B, D, E Dietary reference intakes (DRIs) present evidence-based criteria for an acceptable range of amounts of vitamins and nutrients for each gender and age group. DRIs have four components. The estimated average requirement (EAR) is the recommended amount of a nutrient that appears sufficient to maintain a specific body function for 50% of the population based on age and gen-der. The recommended dietary allowance (RDA) indicates the average needs of 98% of the pop-ulation, not the exact needs of the individual. Adequate intake (AI) is the suggested intake for individuals based on observed or experimentally determined estimates of nutrient intakes and is used when evidence is insufficient to allow the RDA to be set. The tolerable upper intake level (UL) is the highest level that likely poses no risk of adverse health events. It is not a recom-mended level of intake. The food guide pyramid is not a component of the DRIs.

To create a new nutritional plan of care for a patient, the nurse needs to do which of the following? (Select all that apply.) a. Utilize the characteristics of a normal nu-tritional status. b. Evaluate previous patient responses to nursing interventions. c. Exclude established expected outcomes to evaluate patient responses. d. Design innovative interventions to meet the patient's needs. e. Follow through with evaluation and counseling.

ANS: A, B, D, E To create a new nutritional plan of care, the nurse must utilize characteristics of a normal nutri-tional status to gauge effectiveness of the plan. The nurse must be aware of previous patient re-sponses to nursing interventions for altered nutrition to determine the probability of success. The nurse must use established expected outcomes to evaluate the patient's response to care (e.g., patient's weight increases by 0.5 kg/week). The nurse must also be creative when designing in-novative nursing interventions to meet the patient's nutritional needs and must demonstrate re-sponsibility by following through with evaluation and counseling to successfully reach goals.

4. The nurse is preparing for a patient who will be going to surgery. The nurse screens for risk factors that can increase a person's risks in surgery. What risk factors are included in the nurse's screening? (Select all that apply.) a. Age b. Nutrition c. Race d. Obesity e. Pregnancy f. Ambulatory surgery

ANS: A, B, D, E Very young and old patients are at risk during surgery because of immature or declining physiological status. Normal tissue repair and resistance to infection depend on adequate nutrients. Obesity increases surgical risk by reducing respiratory and cardiac function. During pregnancy, the concern is for the mother and the developing fetus. Because all major systems of the mother are affected during pregnancy, risks for operative complications are increased. Race and ambulatory surgery are not risks associated with a surgical procedure.

5. The nurse is providing preoperative education and reviews with the patient what it will be like to be in the surgical environment. What points should the nurse include? (Select all that apply.) a. The surgical area is cold but warm blankets will be provided. b. The surgical staff will be dressed in special clothing with hats and masks. c. The operative suite will be very dark. d. Families are not allowed in the operating suite. e. The operating table or bed will be comfortable and soft. f. The nurses will be there to assist you through this process.

ANS: A, B, D, F The operating suite itself is kept cool to decrease microbial growth, so it can be very cold to patients as they enter the suite, particularly with limited clothing. The surgical staff is dressed in special clothing, hats, and masks—all for infection control. Families are not allowed in the operating suite for several reasons, which include infection control and the emotional effect of seeing a loved one in that condition. The nurse is there as the coordinator and patient advocate during a surgical procedure. The rooms are very bright so everyone can see, and the operating table is very uncomfortable for the patient.

Bones perform five functions in the body: support, protection, movement, mineral storage, and hematopoiesis. In the discussion of body mechanics, which are the most important? (Select all that apply.) a. Support b. Protection c. Movement d. Mineral storage e. Hematopoiesis

ANS: A, C Bones perform five functions in the body: support, protection, movement, mineral storage, and hematopoiesis. In the discussion of body mechanics, two of these functions—support and movement—are most important. In support, bones serve as the framework and contribute to the shape, alignment, and positioning of body parts. In movement, bones together with their joints constitute levers for muscle attachment. As muscles contract and shorten, they pull on bones, producing joint movement. Protection involves encasing the soft tissue organs in a protective cage. Mineral storage helps to strengthen bones but also helps regulate blood levels of certain nutrients. Hematopoiesis is the formation of blood cells

32. The nurse is caring for a patient in the operating suite who is experiencing hypercarbia, tachypnea, tachycardia, premature ventricular contractions, and muscle rigidity. The nurse suspects that this patient may be experiencing a. Hypoxia. b. Malignant hyperthermia. c. Fluid imbalance. d. Hemorrhage.

ANS: B A life-threatening, rare complication of anesthesia is malignant hyperthermia. Malignant hyperthermia causes hypercarbia, tachycardia, tachypnea, premature ventricular contractions, unstable blood pressure, cyanosis, skin mottling, and muscular rigidity. It often occurs during induction. Hypoxia would manifest with decreased oxygen saturation as one of its signs and symptoms. Fluid imbalance would be assessed with intake and output and can manifest with tachycardia and blood pressure fluctuations but does not have muscle rigidity. Hemorrhage can manifest with tachycardia and decreased blood pressure, along with a thread pulse. Usually some sign or symptom of blood loss is noted (e.g., drains incision, orifice, and abdomen).

The patient with cardiovascular disease must be taught how to reduce the risk of cardiovascular disease by balancing calorie intake with exercise to maintain a healthy body weight. In addition to this, the nurse instructs the patient to a. Eat fish at least 5 times per week. b. Limit saturated fat to less than 7%. c. Limit cholesterol to less than 200 mg/day. d. Avoid high-fiber foods.

ANS: B AHA guidelines recommend limiting saturated fat to less than 7%, trans fat to less than 1%, and cholesterol to less than 300 mg/day. Diet therapy includes eating fish at least 2 times per week and eating whole grain high-fiber foods.

30. The nurse is concerned about the skin integrity of the patient in the intraoperative phase of surgery. Which of the following actions helps to minimize skin breakdown? a. Encouraging the patient to bathe before surgery b. Securing attachments to the operating table with foam padding c. Periodically adjusting the patient during the surgical procedure d. Measuring the time a patient is in one position during surgery

ANS: B Although it may be necessary to place a patient in an unusual position, try to maintain correct alignment and protect the patient from pressure, abrasion, and other injuries. Special mattresses, use of foam padding, and attachments to the operating suite table provide protection for the extremities and bony prominences. Bathing before surgery helps to decrease the number of microbes on the skin. Periodically adjusting the patient during the surgical procedure is impractical and can present a safety issue with regard to maintaining sterility of the field and maintaining an airway. Measuring the time the patient is in one position may help with monitoring the situation but does not prevent skin breakdown.

The patient is brought to the emergency department with possible injury to his shoulder. To help determine the degree of injury, the nurse should evaluate a. The patient's gait. b. The patient's range of motion. c. Fine motor coordination. d. Activity tolerance

ANS: B Assessing range of motion is one assessment technique used to determine the degree of damage or injury to a joint. Gait is the manner or style of walking. It may have little bearing on the shoulder damage. Assessing fine motor coordination would be beneficial in helping to assess the patient's ability to perform tasks but would not help in evaluating the shoulder. Activity tolerance refers to the type and amount of exercise or activity a person is able to perform. Damage to the shoulder would affect this, but this would not have a direct bearing on the amount of damage done to the shoulder.

The patient is to receive multiple medications via the nasogastric tube. The nurse is concerned that the tube may become clogged. To prevent this, the nurse a. Irrigates the tube with 60 mL of water af-ter all medications are given. b. Checks with the pharmacy to find out if liquid forms of the medications are avail-able. c. Instills nonliquid medications without di-luting. d. Mixes all medications together to decrease the number of administrations.

ANS: B Avoid crushed medication if liquid is available. Irrigate with 30 mL of water before and after each medication per tube. Dilute crushed medications if not liquid. Read pharmacological infor-mation on compatibility of drugs and formula before mixing medications.

Before giving the patient an intermittent tube feeding, the nurse should a. Make sure that the tube is secured to the gown with a safety pin. b. Have the tube feeding at room temperature. c. Inject air into the stomach via the tube and auscultate. d. Place the patient in a supine position.

ANS: B Cold formula causes gastric cramping and discomfort because the mouth and the esophagus do not warm the liquid. Do not use safety pins. Safety pins can become unfastened and may cause harm to the patient. Auscultation is no longer considered a reliable method for verification of tube placement because a tube inadvertently placed in the lungs, pharynx, or esophagus transmits sound similar to that of air entering the stomach. Place the patient in high-Fowler's position, or elevate the head of the bed at least 30 degrees to help prevent aspiration.

When teaching a patient about current dietary guidelines for the general population, the nurse explains referenced daily intakes (RDIs) and daily reference values (DRVs), otherwise known as daily values. In providing this information, the nurse understands that daily values a. Have replaced recommended daily al-lowances (RDAs). b. Have provided a more understandable format of RDAs for the public. c. Are based on percentages of a diet con-sisting of 1200 kcal/day. d. Are not usually easy to find computer ex-perience is required.

ANS: B Daily values did not replace RDAs but provided a separate, more understandable format for the public. Daily values are based on percentages of a diet consisting of 2000 kcal/day; these values constitute the daily values used on food labels, which are easy for anyone to find. Computer ex-perience is not required.

The nurse is developing an exercise plan for someone diagnosed with congestive heart failure and exercise intolerance. In doing so, the nurse should a. Plan for 20 minutes of continuous aerobic activity and increase as tolerated. b. Perform 6-minute walks at the patient's pace at least 2 times a day. c. Instruct the patient that he should not take his beta blocker medication on exercise days. d. Encourage a high-calorie diet to plan for extra calorie expenditure

ANS: B For the diagnosis of exercise intolerance, the patient should begin by performing 6-minute walks at his own pace at least twice a day. The patient would not be able to tolerate 20 minutes of continuous aerobic activity. Patients should be instructed to take medications as ordered. Low-calorie, low-sodium, and high-protein diets are best for this type of patient

The nurse is ambulating a patient in the hall when she notices that he is beginning to fall. The nurse should a. Grab the patient and hold him tight to prevent the fall. b. Gently lower the patient to the floor. c. Jump back and let the patient fall naturally. d. Push the patient against the wall and guide him to the floor

ANS: B If the patient has a fainting episode or begins to fall, assume a wide base of support with one foot in front of the other, thus supporting the patient's body weight. Then extend one leg and let the patient slide against the leg, and gently lower the patient to the floor, protecting the patient's head. Grabbing the patient will shift the nurse's center of gravity and may lead to a back injury. Allowing the patient to fall could lead to head injury for the patient. Pushing the patient against the wall could also cause the patient to hit his head and cause injury.

The nurse is examining a patient who is admitted to the emergency department with severe elbow pain. Of the following situations, which would cause the nurse to suspect a ligament tear or joint fracture? a. Range of motion of the elbow is limited. b. Joint motion is greater than normal. c. The patient has arthritis. d. The elbow cannot be moved (frozen).

ANS: B Increased mobility (beyond normal) of a joint may indicate connective tissue disorders, ligament tears, or possible joint fractures. Limited range of motion often indicates inflammation such as arthritis, fluid in the joint, altered nerve supply, or contractures (frozen joints).

The nurse is developing a plan of care for a patient diagnosed with activity intolerance. Of the following strategies, which has the best chance of maintaining patient compliance? a. Performing 20 minutes of aerobic exercise daily with 10 minute warm-up and cool-down periods b. Instructing the patient to use an exercise log to record day, time, duration, and responses to exercise activity c. Instructing the patient on the evils of not exercising, and getting her to take responsibility for her current health status d. Arranging for the patient to join a gym that she will have to pay, for so that she does not need to depend on insurance

ANS: B Keeping a log may increase adherence to an exercise prescription. Cross-training (combination of exercise activities) provides variety to combat boredom and increases the potential for total body conditioning as opposed to daily aerobic exercise. "Blaming" a patient for his or her health status is usually counterproductive. Instead, the nurse should instruct the patient about the physiological benefits of a regular exercise program. Developing a plan of exercise that the patient may perform at home may improve compliance

5. The patient has presented to the ambulatory surgery center to have a colonoscopy. The patient is scheduled to receive moderate sedation (conscious sedation) during the procedure. Moderate sedation is used routinely for procedures that require a. Performance on an outpatient basis. b. A depressed level of consciousness. c. Loss of sensation in an area of the body. d. The patient to be immobile.

ANS: B Moderate sedation (conscious sedation) is used routinely for procedures that do not require complete anesthesia, but rather a depressed level of consciousness. Not all patients who are treated on an outpatient basis receive moderate sedation. Regional anesthesia such as local anesthesia provides loss of sensation in an area of the body. General anesthesia is used for patients who need to be immobile and to not remember the surgical procedure.

In providing diet education for a patient on a low-fat diet, it is important for the nurse to understand that with few exceptions a. Saturated fats are found mostly in vegeta-ble sources. b. Saturated fats are found mostly in animal sources. c. Unsaturated fats are found mostly in ani-mal sources. d. Linoleic acid is a saturated fatty acid.

ANS: B Most animal fats have high proportions of saturated fatty acids, whereas vegetable fats have higher amounts of unsaturated and polyunsaturated fatty acids. Linoleic acid, an unsaturated fatty acid, is the only essential fatty acid in humans.

2. The nurse is caring for a patient who is scheduled to undergo a surgical procedure. The nurse is completing an assessment and reviews the patient's laboratory tests and allergies. In which perioperative nursing phase would this work be completed? a. Perioperative b. Preoperative c. Intraoperative d. Postoperative

ANS: B Reviewing the patient's laboratory tests and allergies is done before surgery in the preoperative phase. Perioperative means before, during, and after surgery. Intraoperative means during the surgical procedure in the operating suite; postoperative means after the surgery and could occur in the postanesthesia care unit, in the ambulatory surgical area, or on the hospital unit.

Dysphagia refers to difficulty when swallowing. Of the following causes of dysphagia, which is considered neurogenic? a. Myasthenia gravis b. Stroke c. Candidiasis d. Muscular dystrophy

ANS: B Stroke is the only cause of dysphagia in this list that is considered neurogenic. Myasthenia gravis and muscular dystrophy are considered myogenic in origin, whereas candidiasis is considered obstructive.

14. The nurse is caring for a postoperative patient with an abdominal incision. A pillow is used during coughing to provide a. Pain relief. b. Splinting. c. Distraction. d. Anxiety reduction.

ANS: B Surgical incisions cut through muscles, tissues, and nerve endings. Deep breathing and coughing exercises place additional stress on the suture line and cause discomfort. Splinting incisions with hands and a pillow provides firm support and reduces incisional pull. Providing a pillow during coughing does not provide distraction or reduce anxiety. Providing a pillow does not provide pain relief. Coughing can increase anxiety because it can cause pain.

36. The postanesthesia care unit (PACU) nurse transports the inpatient surgical patient to the medical-surgical floor. Before leaving the floor, the medical-surgical nurse obtains a complete set of vital signs. What is the rationale for this nursing action? a. The first action in a head-to-toe assessment is vital signs. b. This is done to compare and monitor for vital sign variation during transport. c. This is done to ensure that the medical-surgical nurse checks on the postoperative patient. d. This is done to follow hospital policy and procedure for care of the surgical patient.

ANS: B The PACU nurse reviews the patient's information with the medical-surgical nurse, including the surgical and PACU course, physician orders, and the patient's condition. Before leaving the medical-surgical unit, the PACU nurse waits while the medical-surgical nurse obtains a complete set of vital signs to compare with PACU findings. Minor vital sign variations normally occur after the patient is transported. Vital signs may or may not be the first action in a head-to-toe assessment. Following policy or ascertaining that the floor nurse checks on the patient is not a reason to obtain vital signs.

In planning a physical activity program for a patient, the nurse must understand that a. Isotonic exercises cause contraction without changing muscle length. b. The best program includes a combination of exercises. c. Isometric contraction involves the movement of body parts. d. Resistive isometric exercises can lead to bone wasting

ANS: B The best program of physical activity includes a combination of exercises that produce different physiological and psychological benefits. Isotonic exercises cause muscle contractions and changes in muscle length. Isometric exercises involve tightening or tensing of muscles without moving body parts. Resistive isometric exercises help promote muscle strength and provide sufficient stress against bone to promote osteoblastic activity

18. The nurse and the nursing assistant are caring for a group of postoperative patients who need turning, coughing, deep breathing, incentive spirometer, and leg exercises. The nurse directs the nursing assistant to a. Teach and demonstrate postoperative exercises. b. Inform the nurse if the patient is unwilling to perform exercises. c. Document in the medical record when exercises are completed. d. Do nothing associated with postoperative exercises.

ANS: B The nurse may delegate activities to individuals who are competent, within their scope of practice, and willing to be legally responsible—all while maintaining responsibility for follow-up and outcome. The nurse can delegate to a nursing assistant to encourage patients to practice postoperative exercises regularly after instruction, and to inform the nurse if the patient is unwilling to perform these exercises. The skills of demonstrating and teaching postoperative exercises and documenting are not within the scope of practice for the nursing assistant. Doing nothing is not appropriate.

33. The nurse is caring for a postoperative patient who has had a carpel tunnel repair. The patient has a temperature of 97° F and is shivering. Which of the following is the best reason for this condition? a. The patient is dressed only in a gown. b. Anesthesia lowers metabolism. c. The surgical suite has laminar flow. d. The open body cavity contributed to heat loss.

ANS: B The operating suite and recovery room environments are cool. The patient's anesthetically depressed level of body function results in lowering of metabolism and a fall in body temperature. The patient being dressed in a gown and laminar flow in the surgical suite can contribute to a decrease in temperature, but the length of time required for this procedure would minimize this effect. Also, the patient in this type of case does not have a large open body cavity to contribute to heat loss.

The patient is eager to begin his exercise program with a 2-mile jog. The nurse instructs the patient to warm up with stretching exercises. The patient states that he is ready and does not want to waste time with a "warm-up." The nurse explains that the warm-up a. Allows the body to readjust gradually to baseline functioning. b. Prepares the body and decreases the potential for injury. c. Should not involve stretching exercises because they can lead to injury. d. Should be performed with high intensity to prepare for the coming challenge

ANS: B The warm-up activity prepares the body for activity and decreases the potential for injury. It usually lasts about 5 to 10 minutes and may include stretching, calisthenics, and/or aerobic activity performed at a lower intensity. The cool-down period allows the body to readjust gradually to baseline functioning and provides an opportunity to combine movement such as stretching with relaxation-enhancing mind-body awareness.

The nurse is assessing a patient for nutritional status. In doing so, the nurse must a. Choose a single objective tool that fits the patient's condition. b. Combine multiple objective measures with subjective measures. c. Forego the assessment in the presence of chronic disease. d. Use the Mini Nutritional Assessment for pediatric patients.

ANS: B Using a single objective measure is ineffective in predicting risk of nutritional problems. Combine multiple objective measures with subjective measures related to nutrition to adequately screen for nutritional problems. Chronic disease and increased metabolic requirements are risk factors for the development of nutritional problems; these patients may be in critical need of this assessment. The Mini Nutritional Assessment was developed to use for screening older adults in home care programs, nursing homes, and hospitals.

9. The nurse is caring for a potential surgical patient in the preadmission testing unit. The medication history indicates that the patient is currently taking warfarin (Coumadin). Which of the following actions should the nurse take? a. Consult with the physician regarding a radiological examination of the chest. b. Consult with the physician regarding an international normalized ratio (INR). c. Consult with the physician regarding blood urea nitrogen (BUN). d. Consult with the physician regarding a complete blood count (CBC).

ANS: B Warfarin is an anticoagulant that is utilized for different maladies, but its action is to increase the time it takes for the blood to clot. This action can put the surgical patient at risk for bleeding tendencies. Typically, if at all possible, this medication is held several days before a surgical procedure to decrease this risk. INR, PT (prothrombin time), APTT (activated partial thromboplastin time), and platelet counts reveal the clotting ability of the blood. Chest x-ray, BUN, and CBC are diagnostic screening tools for surgery but are not specific to warfarin.

Knowing that protein is required for tissue growth, maintenance, and repair, the nurse must understand that for optimal tissue healing to occur, the patient must be in a. Negative nitrogen balance. b. Positive nitrogen balance. c. Total dependence on protein for kcal pro-duction. d. Neutral nitrogen balance.

ANS: B When intake of nitrogen is greater than output, the body is in positive nitrogen balance. Positive nitrogen balance is required for growth, normal pregnancy, maintenance of lean muscle mass and vital organs, and wound healing. Negative nitrogen balance occurs when the body loses more nitrogen than the body gains. Neutral nitrogen balance occurs when gain equals loss and is not optimal for tissue healing. Protein provides energy, but because of the essential role of protein in growth, maintenance, and repair, a diet needs to provide adequate kilocalories from nonprotein sources.

The patient is admitted with a stroke. The outcome of this disorder is uncertain, but the patient is unable to move his right arm and leg. The nurse understands that a. Active range of motion is the only thing that will prevent contractors from forming. b. Passive range of motion must be instituted to help prevent contracture formation. c. Range-of-motion exercises should be started 2 days after the patient is stable. d. Range-of-motion exercises should be done on major joints only.

ANS: B When patients cannot participate in active range of motion, the nurse must institute passive range of motion to maintain joint mobility and prevent contractures. Passive range of motion can be substituted for active when needed. For the patient who does not have voluntary motor control, passive range-of-motion exercises are the exercises of choice. Unless contraindicated, the nursing care plan includes exercising each joint (not just major joints) through as nearly a full range of motion as possible. Initiate passive range-of-motion exercises as soon as the patient loses the ability to move the extremity or joint.

A young adult's chief complaint is "seizure fits." A chart review shows a negative EEG report and a normal neurological consultation report. A psychosocial history reveals increased family stress, bankruptcy, and a recent divorce. The nurse recognizes that this young man's pseudo-seizures most likely are an example of which unconscious coping mechanism? a. Compensation b. Conversion c. Dissociation d. Denial

ANS: B A conversion reaction is an ego defense mechanism that involves repressing an anxiety-producing conflict and transforming it into a nonorganic symptom such as difficulty sleeping, loss of appetite, or sudden blindness without medical cause. Compensation is making up for a deficiency in one aspect of self-image by strongly emphasizing a feature considered an asset. Dissociation involves experiencing a subjective sense of numbing and a reduced awareness of one's surroundings. Denial is seen as avoiding emotional conflicts by refusing to consciously acknowledge anything that causes intolerable emotional pain.

A senior college student contacts the college health clinic about a freshman student living on the same dormitory floor. The senior student reports that the freshman is crying and is not adjusting to college life. The clinic nurse recognizes this as a combination of situational and maturational stress factors. The best comment to the senior student would be a. "I'd better call 911 because your friend is suicidal." b. "Give her this list of university and community resources." c. "You must make an appointment for the student to obtain medications." d. "I'd recommend you help the student pack her bags to go home."

ANS: B A health care provider can help to reduce situational stress factors for individuals. Providing the student with a list of resources is one way to begin this process, as part of secondary prevention strategies. This is not a medical or psychiatric emergency, so calling 911 is not necessary. Not everyone who has sadness needs medications; some need counseling only. Not enough information is given to know whether the student would be best suited to leave college.

After a natural disaster occurred, an emergency worker referred a family for crisis intervention services. One family member refused to attend the services, stating "No way, I'm not crazy." The best response the nurse can give is which of the following? a. "Many times disasters can create mental health problems, so you really should participate with your family." b. "Crisis intervention is a short-term problem-solving type of help, and seeking this help does not mean that you have a mental illness." c. "Don't worry now. The psychiatrists are well trained to help." d. "Crisis intervention will help your family communicate better."

ANS: B Crisis intervention is a type of brief therapy that is more directive than typical psychotherapy or counseling. It focuses on problem solving and involves only the problem created by the crisis. The goal of crisis intervention is to create stability for the person involved in the crisis while promoting self-reliance. The other options do not properly reassure the patient and build trust.

A woman who was sexually assaulted a month ago presents to the emergency department with complaints of recurrent nightmares, fear of going to sleep, repeated vivid memories of the sexual assault, and inability to feel much emotion. The nurse recognizes the signs and symptoms of which medical problem? a. General adaptation syndrome b. Posttraumatic stress disorder c. Developmental crisis d. Alarm reaction

ANS: B Posttraumatic stress disorder is characterized by vivid recollections of the traumatic event and emotional numbing and often is accompanied by nightmares. General adaptation syndrome is the expected reaction to a major stressor. Developmental crisis occurs as a person moves through life stages rather than in response to a trauma. Alarm reaction involves physiological events such as increased activation of the sympathetic nervous system that would have occurred at the time of the sexual assault.

Pediatric stressors related to self-esteem and changes in family structure reflect which maturational school age category? a. Elementary school age b. Preadolescence c. Adolescence d. Early adulthood

ANS: B The preadolescent age category experiences stress related to self-esteem issues, changing family structure due to divorce or death of a parent, or hospitalization. Adolescent stressors include identity issues with peer groups and separation from parents. Elementary school age stressors include friends, family, and school relations. Adult stressors centralize around life events.

In developing a nursing care plan for increasing activity tolerance in a patient, the nurse should (Select all that apply.) a. Use generalized therapies because they work for everyone. b. Consult with members of the health care team. c. Avoid goals published by the American College of Sports Medicine. d. Involve the patient and the patient's family in designing an exercise plan. e. Consider the patient's ability to increase activity level.

ANS: B, D, E When planning care, the nurse should consult/collaborate with members of the health care team to increase activity, involve the patient and family in designing an activity and exercise plan (especially if family members are also providers of care), and consider the patient's ability to increase activity level. Therapies should be individualized to the patient's activity tolerance. Information from the American College of Sports Medicine serves as a standard that the nurse should use when applying activity and exercise goals

1. The nurse is precepting a new nurse in the perioperative area. The nurse explains that perioperative nursing is based on certain principles and includes (Select all that apply.) a. Purchasing the correct equipment. b. Providing high-quality and patient safety-focused care. c. Scheduling the right types of patients. d. Conducting multidisciplinary teamwork. e. Ensuring effective therapeutic communication. f. Providing advocacy for the patient.

ANS: B, D, E, F Perioperative nursing is a fast-paced, changing, and challenging field and is based on the nurse's understanding of several important principles, including high-quality, patient safety-focused care; multidisciplinary teamwork; effective therapeutic communication and collaboration with the patient, the patient's family, and the surgical team; effective and efficient assessment and intervention in all phases of surgery; advocacy for the patient and the patient's family; and understanding of cost containment. Purchasing the correct equipment is important in any specialty of nursing. Perioperative nursing cares not only for the "right" types of patients, but for all patients with surgical needs.

4. The nurse is caring for a patient in preadmission testing. The patient has been assigned a physical status classification by the American Society of Anesthesiologist of P3. Which of the following assessments would support this classification? a. Denial of any major illnesses or conditions b. Normal, healthy patient c. History of hypertension, 80 pounds overweight, history of asthma d. History of myocardial infarction that limits activity

ANS: C A P3 is a patient with a severe systemic disease. Patients with hypertension, obesity, diabetes mellitus, and asthma fit into this category. A P1 is a normal healthy patient. A P2 is a patient with mild systemic disease. A P4 is a patient with severe systemic disease that is a constant threat to life.

34. The nurse is monitoring a patient in the postanesthesia care unit (PACU) for postoperative fluid and electrolyte imbalance. Which of the following actions would be most appropriate for this patient? a. Encourage copious amounts of water. b. Weigh the patient and compare with preoperative weight. c. Measure and record all intake and output. d. Start an additional intravenous (IV) line.

ANS: C Accurate recording of intake and output assesses renal and circulatory function. Measure and record all sources of intake and output. Encouraging copious amounts of water in a postoperative patient might encourage nausea and vomiting. In the PACU, it is impractical to weigh the patient while waking from surgery, but in the days afterward, it is a good assessment parameter for fluid imbalance. Starting an additional IV is not necessary and is not important at this juncture.

To counter obesity in adolescents, increasing physical activity is often more important than curbing intake. Sports and regular, moderate to intense exercise necessitate dietary modifications to meet increased energy needs for adolescents. The nurse understands that these modifications include a. Decreasing carbohydrates to 25% to 30% of total intake. b. Decreasing protein intake to .75 g/kg/day. c. Ingesting water before and after exercise. d. Providing vitamin and mineral supple-ments.

ANS: C Adequate hydration is very important for all athletes. They need to ingest water before and after exercise to prevent dehydration, especially in hot, humid environments. Carbohydrates, both simple and complex, are the main source of energy, providing 55% to 60% of total daily kilocal-ories. Protein needs increase to 1.0 to 1.5 g/kg/day. Vitamin and mineral supplements are not re-quired, but intake of iron-rich foods is required to prevent anemia.

3. The nurse is caring for a patient in the postanesthesia care unit. The patient has developed profuse bleeding from the surgical site, and the surgeon has determined the need to return to the operative area. This procedure would be classified as a. Elective. b. Urgent. c. Emergency. d. Major.

ANS: C An emergency procedure must be done immediately to save life or preserve function of a body part. An example would be repair of a perforated appendix, repair of a traumatic amputation, or control of internal hemorrhaging. An urgent procedure is necessary for a patient's health and often prevents additional problems form developing. An example would be excision of a cancerous tumor, removal of a gallbladder for stones, or vascular repair for obstructed artery. An elective procedure is performed on the basis of the patient's choice; it is not essential and is not always necessary for health. An example would be a bunionectomy, plastic surgery, or hernia reconstruction. A major procedure involves extensive reconstruction or alteration in body parts; it poses great risks to well-being. An example would be a coronary artery bypass or colon resection.

At present, the most reliable method for verification of placement of small-bore feeding tubes is a. Auscultation. b. Aspiration of contents. c. X-ray. d. pH testing.

ANS: C At present, the most reliable method for verification of placement of small-bore feeding tubes is x-ray examination. Aspiration of contents and pH testing are not infallible. The nurse would need a more precise indicator to help differentiate the source of tube feeding aspirate. Auscultation is no longer considered a reliable method for verification of tube placement because a tube inad-vertently placed in the lungs, pharynx, or esophagus transmits sound similar to that of air entering the stomach.

The coordinated efforts of the musculoskeletal and nervous system maintain balance, posture, and body alignment. Body alignment refers to a. A low center of gravity balanced over a wide base of support. b. The result of weight, center of gravity, and balance. c. The relationship of one body part to another. d. The force that occurs in a direction to oppose movement

ANS: C Body alignment refers to the relationship of one body part to another body part along a horizontal or vertical line. Body balance occurs when a relatively low center of gravity is balanced over a wide, stable base of support. Coordinated body movement is a result of weight, center of gravity, and balance. Friction is a force that occurs in a direction to oppose movement.

Many patients find it difficult to incorporate an exercise program into their daily lives because of time constraints. For these patients, it is beneficial to reinforce that many ADLs are used to accumulate the recommended 30 minutes or more per day of moderate-intensity physical activity. When instructing these patients, the nurse explains that a. Housework is not considered an aerobic exercise. b. To strengthen back muscles, the patient should bend using back muscles. c. Daily chores should begin with gentle stretches. d. The patient should stick to one chore until it is done before beginning a new one

ANS: C Daily chores should begin with gentle stretches. Housework is considered aerobic exercise. To make it more aerobic, work faster and scrub harder. Bend your legs rather than your back to prevent back injury. Alternate cleaning activities to prevent overworking the same muscle groups.

The patient has been diagnosed with cardiovascular disease and placed on a low-fat diet. The patient asks the nurse, "How much fat should I have? I guess the less fat, the better." The nurse needs to explain that a. Fats have no significance in health and the incidence of disease. b. All fats come from external sources so can be easily controlled. c. Deficiencies occur when fat intake falls below 10% of daily nutrition. d. Vegetable fats are the major source of saturated fats and should be avoided.

ANS: C Deficiency occurs when fat intake falls below 10% of daily nutrition. Various types of fatty acids have significance for health and for the incidence of disease and are referred to in dietary guidelines. Linoleic acid and arachidonic acid are important for metabolic processes but are manufactured by the body when linoleic acid is available. Most animal fats have high proportions of sat

35. The nurse is caring for a patient in the postanesthesia care unit. The patient asks for a bedpan and states to the nurse, "I feel like I need to go to the bathroom, but I can't." Which of the following nursing interventions would be most appropriate? a. Encourage the patient to wait a minute and try again. b. Call the physician and obtain an order for catheterization. c. Assess the patient's intake and the patient for bladder distention. d. Inform the patient that everyone feels this way after surgery.

ANS: C Depending on the surgery, some patients do not regain voluntary control over urinary function for 6 to 8 hours after anesthesia. Assess the amount of fluid that the patient obtained while in surgery, and palpate the lower abdomen just above the symphysis pubis for bladder distention. If fluid intake is not excessive and the bladder is nondistended, allowing some time might be appropriate. Not everyone feels as if they need to go but can't after surgery. If the bladder is distended and the patient is unable to void, a catheter might be in order.

The nurse is caring for a patient who will be receiving PN. To reduce the risk of developing sepsis, the nurse a. Takes down a running bag of TPN after 36 hours. b. Runs lipids for no longer than 24 hours. c. Wears a sterile mask when changing the CVC dressing. d. Wears clean gloves when changing the CVC dressing.

ANS: C During CVC dressing changes, always use a sterile mask and gloves, and assess insertion sites for signs and symptoms of infection. To avoid infection, change the TPN infusion tubing every 24 hours, and do not hang a single container of PN for longer than 24 hours or lipids longer than 12 hours.

10. The nurse is encouraging the postoperative patient to utilize diaphragmatic breathing. Reasons for this intervention include a. Management of pain. b. Decreased healing time. c. Prevention of atelectasis. d. Decreased thrombus formation.

ANS: C During general anesthesia, the lungs are not fully inflated during surgery and the cough reflex is suppressed, so mucus collects within airway passages. After surgery, patients may have reduced lung 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. Diaphragmatic breathing, except for the components of distraction, minimal increased level of oxygen, and minimal chest wall movement, does not influence pain, healing time, or thrombus formation. Better, more effective interventions are available for these situations.

To provide successful nutritional therapies to patients, the nurse must understand that a. Patients will have to change diet prefer-ences drastically to be successful. b. The patient will tell the nurse when to change the plan of care. c. Expectations of nurses frequently differ from those of the patient. d. Nurses should never alter the plan of care regardless of outcome.

ANS: C Expectations and health care values held by nurses frequently differ from those held by patients. Successful interventions and outcomes depend on recognition of this concept, in addition to nursing knowledge and skill. If ongoing nutritional therapies are not resulting in successful out-comes, patients expect nurses to recognize this fact and alter the plan of care accordingly. Work-ing closely with patients enables the nurse to redefine expectations that are realistically met within the limits of conditions and treatments and to identify their dietary preferences and cultural beliefs.

Approximately what percentage of all back pain is associated with manual lifting tasks? a. 10% b. 25% c. 50% d. 75%

ANS: C Half of all back pain is associated with manual lifting tasks

15. The nurse is encouraging a reluctant postoperative patient to deep breathe and cough. What explanation can the nurse provide that may encourage the patient to cough more effectively? a. "If you don't deep breathe and cough, you will get pneumonia." b. "Deep breathing and coughing will clear out the anesthesia." c. "Coughing will not harm the incision if done correctly." d. "You will need to cough only a few times during this shift."

ANS: C If coughing is done correctly with proper support of the incision, it will not harm the incision. Deep breathing and coughing help to clear out mucus in the respiratory system that has been caused by the anesthesia. Although it is correct that a patient may experience atelectasis and pneumonia if deep breathing and coughing are not performed, the way this is worded sounds threatening and could be communicated in a more therapeutic manner. Deep breathing and coughing is encouraged every 2 hours while the patient is awake.

In general, when energy requirements are completely met by kilocalorie (kcal) intake in food a. Weight increases. b. Weight decreases. c. Weight does not change. d. Kilocalories are not a factor.

ANS: C In general, when energy requirements are completely met by kilocalorie (kcal) intake in food, weight does not change. When kilocalories ingested exceed a person's energy demands, the indi-vidual gains weight. If kilocalories ingested fail to meet a person's energy requirement, the indi-vidual loses weight. Kilocalories are a factor.

Unlike arthritis, joint degeneration a. Occurs only from noninflammatory disease. b. Occurs only from inflammatory disease. c. Involves overgrowth of bone at the articular ends. d. Affects mostly non-weight-bearing joints

ANS: C Joint degeneration, which can occur with inflammatory and noninflammatory disease, is marked by changes in articular cartilage combined with overgrowth of bone at the articular ends. Degenerative changes commonly affect weight-bearing joints.

In creating a plan of care to meet the nutritional needs of the patient, the nurse needs to explore the patient's feelings about weight and food. The nurse must do this to a. Determine which category of plan to use. b. Set realistic goals for the patient. c. Mutually plan goals with patient and team. d. Prevent the need for a dietitian consult.

ANS: C Mutually planned goals negotiated by patient, registered dietitian, and nurse ensure success. In-dividualized planning cannot be overemphasized. Preplanned and categorical care plans are not effective unless they are individualized to meet patient needs. It is important to explore patients' feelings about weight and food to help them set realistic and achievable goals. The nurse does not set goals for the patient. The plan should reflect the combined effort of patient, nurse, and dietitian, so a dietitian consult is required.

24. The nurse has administered an anxiolytic as a preoperative medication to the patient going to surgery. Which of the following is the best next step? a. Waste any unused medication according to policy. b. Notify the operating suite that the medication has been given. c. Instruct the patient to call for help to go to the restroom. d. Ask the patient to sign the consent for surgery.

ANS: C Once a medication has been administered, instruct the patient to call for help when getting out of bed to prevent falls. For patient safety, explain the purpose of a preoperative medication and its effects. Reinforce to the patient to stay in the bed or on the stretcher. Raise the side rails and keep the bed or stretcher in the low position. Place the call light within easy reach of the patient. Notifying the operating suite that the medication has been given may be part of a facilities procedure but is not the best next step. It is important to have the patient sign consents before the patient has received medication that may make him/her drowsy. Wasting unused medication according to policy is important but is not the best next step.

20. The nurse explains the pain relief measures available after surgery during preoperative teaching for a surgical patient. Which of the following comments from the patient indicates the need for additional education on this topic? a. "I will take the pain medication as the physician prescribes it." b. "I will be asked to rate my pain on a pain scale." c. "I will have minimal pain because of the anesthesia." d. "I will take my pain medications before doing postoperative exercises."

ANS: C Pain after surgery is expected and is one of the patient's fears. Anesthesia will be provided during the procedure itself, and the patient should not experience pain during the procedure. Pain management is utilized after the postoperative phase. Inform the patient of interventions available for pain relief, including medication, relaxation, and distraction. The patient needs to know and understand how to take the medications that the physician will prescribe postoperatively. During the stay in the facility, the level of pain is frequently assessed by the nurses. Coordinating pain medication with postoperative exercises helps to minimize discomfort and allows the exercises to be more effective.

The patient is on PN and is lethargic. He has been complaining of thirst and headache and has had increased urination. Which of the following problems would cause these symptoms? a. Electrolyte imbalance b. Hypoglycemia c. Hyperglycemia d. Hypercapnia

ANS: C Signs and symptoms of hyperglycemia are thirst, headache, lethargy, and increased urination. Electrolyte imbalance is marked by changes in Na, Ca, K, Cl, PO4, Mg, and CO2 levels. These have to be monitored closely when patients are on PN. Hypercapnia increases oxygen consump-tion and increases CO2 levels. Ventilator-dependent patients are at greatest risk for this. Hypo-glycemia is characterized by diaphoresis, shakiness, confusion, and loss of consciousness.

The patient is having at least 75% of his nutritional needs met by enteral feeding, so the physician has ordered the PN to be discontinued. However, the nurse notices that the PN infusion has fallen behind. The nurse should a. Increase the rate to get the volume caught up before discon-tinuing. b. Stop the infusion and hang a normal saline drip in place. c. Taper the PN infusion gradually. d. Hang 5% dextrose if the PN runs out.

ANS: C Sudden discontinuation of PN can cause hypoglycemia. PN must be tapered off. Usually, 10% dextrose is infused when PN solution is suddenly discontinued. The same is true if the PN runs out. Too rapid administration of hypertonic dextrose (PN) can result in an osmotic diuresis and dehydration. If an infusion falls behind schedule, the nurse should not increase the rate in an at-tempt to catch up.

The nurse is providing nutrition teaching to a Korean patient. In doing so, the nurse must understand that the focus of the teaching should be on a. Changing the patient's diet to a more conventional American diet. b. Discouraging the patient's ethnic food choices. c. Food preferences of the patient, including racial and ethnic choices. d. Comparing the patient's ethnic preferences with American dietary choices.

ANS: C The nurse needs to make sure to consider the food preferences of different racial and ethnic groups, vegetarians, and others when planning diets. Initiation of a balanced diet is more im-portant than conversion to what may be considered an American diet. Ethnic food choices may be just as nutritious as "American" choices. Foods should be chosen for their nutritive value and should not be compared with the "American" diet.

28. The nurse is caring for a patient in the preoperative holding area of an ambulatory surgery center. Which nursing action would be most appropriate for this area? a. Monitor vital signs every 15 minutes. b. Empty the urinary drainage bag. c. Apply a warm blanket. d. Check the surgical dressing.

ANS: C The temperature in the preoperative holding area and in adjacent operating suites is usually cool. Offer the patient an extra warm blanket. The main activities in this area include verification of the patient, the surgery to be performed, and physical and emotional readiness for the procedure. The intravenous catheter is usually inserted, and the preoperative checklist is reviewed. Vital signs are not normally monitored unless there is a specific reason, such as a medication being administered. Typically, ambulatory surgery patients will not come to the holding area with a urinary drainage bag or a surgical dressing. These activities if appropriate are performed in the postanesthesia care unit.

The patient is an 80-year-old male who is visiting the clinic today for his routine physical examination. The patient's skin turgor is fair, but he has been complaining of fatigue and weakness. The skin is warm and dry, pulse rate is 126 beats per minute, and urinary sodium level is slightly elevated. After assessment, the nurse should recommend that the patient a. Decrease his intake of milk and dairy products to decrease the risk of osteoporosis. b. Drink more grapefruit juice to enhance vitamin C intake and medication absorption. c. Drink more water to prevent further dehydration. d. Eat more meat because meat is the only source of usable protein.

ANS: C Thirst sensation diminishes, leading to inadequate fluid intake or dehydration. Symptoms of de-hydration in older adults include confusion, weakness, hot dry skin, furrowed tongue, and high urinary sodium. Milk continues to be an important food for older woman and men, who need adequate calcium to protect against osteoporosis. After age 70, osteoporosis equally affects men and women. Caution older adults to avoid grapefruit and grapefruit juice because these will de-crease absorption of many drugs. Some older adults avoid meats because of cost, or because they are difficult to chew. Cream soups and meat-based vegetable soups are nutrient-dense sources of protein.

Identify a sociocultural factor that can lead to developmental problems. a. Family relocation b. Childhood obesity c. Prolonged poverty d. Loss of stamina

ANS: C Environmental and social stressors are believed to lead to developmental problems. Sociocultural refers to societal or cultural factors; poverty is a sociocultural factor. Stamina loss and obesity are health problems, and family relocation is a situational factor.

A nurse is teaching guided imagery to a prenatal class. Identify an example of guided imagery from the options below. a. Singing b. Back massage c. Sensory peaceful words d. Listening to music

ANS: C Guided imagery is used as a means to create a relaxed state through the person's imagination, often using sensory words. Imagination allows the person to create a soothing and peaceful environment. Singing, back massage, and listening to music are other types of stress management techniques.

In a natural disaster relief facility, the nurse observes that an elderly man has a recovery plan, while a 25-year-old man is still overwhelmed by the disaster situation. These different reactions to the same situation would be explained best by which of the following? a. Restorative care b. Strong financial resources c. Maturational and sociocultural factors d. Immaturity and intelligence factors

ANS: C Maturational factors and sociocultural factors can affect people differently depending on their life experiences. An older individual would have more life experiences to draw from and to analyze on why he was successful, whereas a younger individual would have fewer life experiences based on chronological age to analyze for patterns of previous success. Nothing in the scenario implies that either man is in restorative care, has strong financial resources, or is immature or intelligent.

A teen with celiac disease continues to eat food she knows will make her ill several hours after ingestion. Given appropriate tertiary level interventions, the nursing intervention would be to a. Teach the patient about the food pyramid. b. Administer antidiarrheal medications with meals. c. Assist the teen in meeting dietary restrictions while eating foods similar to those eaten by her friends. d. Admonish the teen and her parents regarding her consistently poor diet choices.

ANS: C Tertiary level interventions have the purpose of assisting the patient in readapting to life with an illness. By adjusting the diet to meet dietary guidelines and also addressing adolescent emotional needs, the nurse will help the teen to eat an appropriate diet without health complications and see herself as a "typical and normal" teenager. Teaching about the food pyramid will not address the real issue, which is that the teen is still eating what she knows will make her ill. Administering antidiarrheal medications may help but is not a tertiary level intervention. Admonishing the teen and parents is not a tertiary level intervention, and because this approach is nontherapeutic, it may cause communication problems.

The nurse teaches stress reduction and relaxation training to a health education group of patients after cardiac bypass surgery. The nurse is performing which level of intervention? a. Primary b. Secondary c. Tertiary d. Quad level

ANS: C Tertiary level interventions have the purpose of assisting the patient in readapting to life with an illness. Tertiary prevention focuses on the person who already has the disease and is recovering or rehabilitating. Tertiary prevention goals are to slow down the disease process, prevent further damage or pain from the disease, and prevent the current disease from creating other health problems. Primary level consists of stress prevention, promotion of wellness, and risk factor reduction before illness occurs. Secondary level occurs after symptoms appear and assists the person to develop resources to manage illness and stress. Quad level does not exist.

An adult male reports new-onset seizurelike activity. An EEG and a neurology consultant's report rule out a seizure disorder. When considering the ego defense mechanism of conversion, the nurse's next best action would be to a. Recommend acupuncture. b. Confront the patient on malingering. c. Obtain history of any recent life stressors. d. Recommend a regular exercise program.

ANS: C The purpose of an ego defense mechanism is to help regulate emotional stress. By regulating emotional stress, the individual gains some protection from anxiety and stress. A conversion reaction involves repressing an anxiety-producing conflict and transforming it into a nonorganic symptom such as difficulty sleeping, appetite loss, or sudden blindness without medical cause. The nurse must assess the patient fully before implementing any nursing interventions. Although the patient may be malingering, confrontation is non therapeutic because the patient is using this type of defense mechanism in response to some type of stressor.

11. The nurse is caring for a postoperative patient on the medical-surgical floor. To prevent venous stasis and the formation of thrombus after general anesthesia, the nurse encourages a. Coughing. b. Diaphragmatic breathing. c. Incentive spirometry. d. Leg exercises.

ANS: D After general anesthesia, circulation slows, and when the rate of blood slows, a greater tendency for clot formation is noted. Immobilization results in decreased muscular contractions in the lower extremities; these promote venous stasis. Coughing, diaphragmatic breathing, and incentive spirometry are utilized to decrease atelectasis.

In assisting the patient to exercise, the nurse should a. Expect that pain will occur with exercise of unused muscle groups. b. Set the pace for the exercise class. c. Force muscles or joints to go just beyond resistance. d. Stop the exercise if pain is experienced

ANS: D Assess for pain, shortness of breath, or a change in vital signs. If present, stop exercise. Let each patient exercise at his or her own pace. Assess for joint limitations, and do not force a muscle or a joint during exercise.

The patient has a calculated body mass index (BMI) of 34. This would classify the patient as a. Unclassifiable. b. Normal weight. c. Overweight. d. Obese.

ANS: D BMI greater than 30 is defined as obesity. BMI between 25 and 30 is classified as overweight. BMI less than 25 is considered normal or underweight. All patients can be classified by dividing their weight in kilograms by their height in meters squared.

The nurse is preparing to position an immobile patient. Before doing so, the nurse must understand that a. Manual lifting is the easier method and should be tried first. b. Following body mechanics principles alone will prevent back injury. c. Body mechanics can be ignored when patient handling equipment is used. d. Body mechanics alone are not sufficient to prevent injuries

ANS: D Body mechanics alone are not sufficient to prevent musculoskeletal injuries when positioning or transferring patients. The use of patient-handling equipment in combination with proper body mechanics is more effective than either one in isolation. Body mechanics cannot be ignored even when patient handling equipment is being used. Manual lifting is the last resort, and it is only used when it does not involve lifting most or all of the patient's weight

In teaching mothers-to-be about infant nutrition, the nurse instructs patients to a. Give cow's milk during the first year of life. b. Supplement breast milk with corn syrup. c. Add honey to infant formulas for in-creased energy. d. Remember that breast milk or formula is sufficient for the first 4 to 6 months.

ANS: D Breast milk or formula provides sufficient nutrition for the first 4 to 6 months of life. Infants should not have regular cow's milk during the first year of life. Cow's milk causes gastrointesti-nal bleeding, is too concentrated for the infant's kidneys to manage, increases the risk of milk product allergies, and is a poor source of iron and vitamins C and E. Honey and corn syrup are potential sources of botulism toxin and should not be used in the infant diet.

Patients who are unable to digest or absorb enteral nutrition benefit from parenteral nutrition (PN). However, the goal to move toward use of the GI tract is constant because PN a. Can be given only in the hospital setting. b. Cannot be used in patients in highly stressed situations. c. Can be given only by way of a peripheral IV line. d. Can lead to villous atrophy and cell shrinkage.

ANS: D Disuse of the GI tract has been associated with villous atrophy and generalized cell shrinkage. Translocation of bacteria from the local gut to systemic regions has been noted in relation to GI cell shrinkage, resulting in gram-negative septicemia. PN is administered in a variety of settings, including the patient's home. Patients in highly stressed physiological states such as sepsis, head injury, or burns are candidates for PN therapy. Safe administration of this form of nutrition de-pends on meticulous management of a central venous catheter.

The nurse is developing an exercise program for elderly patients living in a nursing home. To develop a beneficial health promotion program, the nurse needs to understand that when dealing with the elderly a. Exercise is of very little benefit because the patients are old. b. It is important to disregard their current interests in favor of exercise. c. No physical benefit can be gained without a formal exercise program. d. Adjustments to exercise programs may have to be made to prevent problems.

ANS: D Exercise is extremely beneficial for older adults, but adjustments to an exercise program may have to be made for those of advanced age to prevent problems. When developing an exercise program for any older adult, consider not only the person's current activity level, range of motion, muscle strength and tone, and response to physical activity, but also the person's interests, capacities, and limitations. Older adults who are unable to participate in a formal exercise program are able to achieve the benefits of improved joint mobility and enhanced circulation by simply stretching and exaggerating movements during performance of routine activities of daily living.

The patient is elderly and has been diagnosed with Imbalanced nutrition: less than body requirements. Her treatment regimen should include having the nurse a. Encourage weight gain as rapidly as pos-sible. b. Encourage large meals three times a day. c. Decrease fluid intake to prevent feeling full. d. Encourage fiber intake.

ANS: D Increasing fiber intake deters constipation and enhances appetite. Weight gain should be slow and progressive. Frequent small meals should be encouraged to increase dietary intake and to help offset anorexia. Older adults need eight 8-ounce glasses of fluid per day from beverage and food sources.

16. The nurse and the nursing assistant are assisting a postoperative patient to turn in the bed. To assist in minimizing discomfort, which instruction should the nurse provide to the patient? a. "Close your eyes and think about something pleasant." b. "Hold your breath and count to three." c. "Hold my shoulders with your hands." d. "Place your hand over your incision."

ANS: D Instruct the patient to place right hand over incisional area to splint it, providing support and minimizing pulling during turning. Closing one's eyes, holding one's breath, and holding the nurse's shoulders do not help support the incision during a turn.

The nurse is working with the patient in developing an exercise plan. The patient tells the nurse that she just will not participate in a formal exercise program. The nurse then suggests that exercise activities can be incorporated into activities of daily living. The patient seems to be agreeable to that concept. Of the following activities, which would be considered a moderate-intensity activity? a. Doing laundry b. Making the bed c. Ironing d. Folding clothes

ANS: D Low-intensity ADLs include doing the laundry, making the bed, ironing, and washing dishes. Moderate-intensity ADLs include sweeping the kitchen or sidewalk, washing windows, folding clothes, and vacuuming.

The nurse is preparing to insert a nasogastric tube in a patient who is semiconscious. To determine the length of the tube needed to be inserted, the nurse measures from the a. Tip of the nose to the xiphoid process of the sternum. b. Earlobe to the xiphoid process of the sternum. c. Tip of the nose to the earlobe. d. Tip of the nose to the earlobe to the xiphoid process.

ANS: D Measure distance from the tip of the nose to the earlobe to the xiphoid process of the sternum. This approximates the distance from the nose to the stomach in 98% of patients. For duodenal or jejunal placement, an additional 20 to 30 centimeters is required.

The patient is admitted with facial trauma, including a broken nose, and has a history of esophageal reflux and of aspiration pneumonia. Given this information, which of the following tubes is appropriate for this patient? a. Nasogastric tube b. Percutaneous endoscopic gastrostomy (PEG) tube c. Nasointestinal tube d. Jejunostomy tube

ANS: D Patients with gastroparesis or esophageal reflux or with a history of aspiration pneumonia may require placement of tubes beyond the stomach into the intestine. The nasogastric tube and the PEG tube are placed in the stomach, and placement could lead to aspiration. The nasointestinal tube and the nasogastric tube may be contraindicated by facial trauma and the broken nose. The jejunostomy tube is the only tube in the list that is beyond the stomach and is not contraindicated by facial trauma.

An active lifestyle is important for maintaining and promoting health. In developing an exercise program, the nurse understands that a. Physical exercise is contraindicated for patients with chronic illnesses. b. Regular physical activity is beneficial only for the body part that is exercised. c. Physical exercise has no effect on psychological well-being. d. Physical activity enhances functioning of all body systems.

ANS: D Regular physical activity and exercise enhance the functioning of all body systems, including cardiopulmonary functioning, musculoskeletal fitness, weight control and maintenance, and psychological well-being. It is also essential in treatment for chronic illness.

The patient has been in bed for several days and needs to be ambulated. Before ambulation, the nurse a. Removes the gait belt to allow for unrestricted movement. b. Has the patient get up from bed before he has a chance to get dizzy. c. Has the patient look down to watch his feet to prevent tripping. d. Dangles the patient on the side of the bed.

ANS: D Some patients experience orthostatic hypotension—a drop in blood pressure that occurs when the patient changes from a horizontal to a vertical position. Assist the patient to a position of sitting at the side of the bed, and dangle for 1 to 2 minutes before standing. The nurse needs to provide support at the waist so that the patient's center of gravity remains midline. This is achieved with the use of a gait belt. A gait belt encircles the patient's waist and may have handles attached for the nurse to hold while the patient ambulates. The patient should maintain as normal a walking posture as possible with the head erect.

The ChooseMyPlate program was developed to replace MyFoodPyramid as a basic guide for buying food and meal preparations. This system was developed by the a. Food and Drug Administration. b. 1990 Nutrition Labeling and Education Act. c. Referenced daily intakes (RDIs). d. U.S. Department of Agriculture.

ANS: D The ChooseMyPlate program was developed by the U.S. Department of Agriculture to replace the MyFoodPyramid program. ChooseMyPlate serves as a basic guide for making food choices for a healthy lifestyle. The Food and Drug Administration (FDA) created daily values for food labels in response to the 1990 Nutrition Labeling and Education Act (NLEA). The FDA first es-tablished two sets of reference values: referenced daily intakes (RDIs) and daily reference values (DRVs).

Which of the following exercise activities would most likely provide the opportunity for mind-body awareness? a. Warm-up activity b. Resistance training c. Aerobic exercise d. Cool-down activity

ANS: D The cool-down period allows the body to readjust gradually to baseline functioning and provides an opportunity to combine movement such as stretching with relaxation-enhancing mind-body awareness. The warm-up activity prepares the body and decreases the potential for injury. Aerobic exercise includes running, bicycling, jumping rope, and so forth, and is the main portion of exercise activity; it precedes the cool-down period. Resistance training increases muscle strength and endurance and is associated with improved performance of daily activities but not with enhancing mind-body awareness.

In measuring the effectiveness of nutritional interventions, the nurse should a. Expect results to occur rapidly. b. Not be concerned with physical measures such as weight. c. Expect to maintain a course of action re-gardless of changes in condition. d. Evaluate outcomes according to the pa-tient's expectations and goals.

ANS: D The nurse should measure the effectiveness of nutritional interventions by evaluating the pa-tient's expected outcomes and goals of care. Nutrition therapy does not always produce rapid results. Ongoing comparisons need to be made with baseline measures of weight, serum albumin or prealbumin, and protein and kilocalorie intake. Changes in condition may indicate a need to change the nutritional plan of care.

Some proteins are manufactured in the body, but others are not. Those that must be obtained through diet are known as a. Amino acids. b. Dispensable amino acids. c. Triglycerides. d. Indispensable amino acids.

ANS: D The simplest form of protein is the amino acid. The body does not synthesize indispensable amino acids, so these need to be provided in the diet. The body synthesizes dispensable amino acids. Triglycerides are made up of three fatty acids attached to a glycerol

The nurse is teaching the patient about dietary guidelines. In discussing the four components of dietary reference intakes (DRIs), it is important to understand that a. The estimated average requirement (EAR) is appropriate for 100% of the population. b. The recommended dietary allowance (RDA) meets the needs of the individual. c. Adequate intake (AI) determines the nu-trient requirements of the RDA. d. The tolerable upper intake level (UL) is not a recommended level of intake.

ANS: D The tolerable upper intake level (UL) is the highest level that likely poses no risk of adverse health events. It is not a recommended level of intake. The EAR is the recommended amount of a nutrient that appears sufficient to maintain a specific body function for 50% of the population based on age and gender. The RDA reflects the average needs of 98% of the population, not the exact needs of the individual. AI is the suggested intake for individuals based on observed or experimentally determined estimates of nutrient intakes and is used when evidence is insufficient for setting of the RDA.

The patient has been bedridden for several months owing to severe congestive heart disease. In determining a plan of care for this patient that will address his activity level, the nurse formulates which of the following nursing diagnoses? a. Fatigue related to poor physical condition b. Impaired gas exchange related to decreased cardiac output c. Decreased cardiac output related to decreased myocardial contractility d. Activity intolerance related to physical deconditioning

ANS: D When activity and exercise are problems for a patient, nursing diagnoses often focus on the individual's ability to move. The diagnostic label directs nursing interventions. In this case, physical deconditioning must be addressed relative to activity level, perhaps leading to 6-minute walks twice a day. Physical deconditioning is the cause of fatigue as well, so it would take priority over that diagnosis. Decreased cardiac output and myocardial contractility are serious concerns that must be addressed before activity intolerance to keep the patient safe and to help determine the level of exercise that the patient can tolerate, but reconditioning of the patient's body will help improve contractility and cardiac output

The nursing student gave a wellness lecture on the importance of accurate assessment and intervention from a personal, family, and community perspective. The other nursing students enjoyed the lecture about which nursing theory? a. Ego defense model b. Situational model c. Evidence-based practice model d. Neuman systems model

ANS: D The Neuman systems model is based on an individual's/family's/community's relationship to stress and the reaction to stress. This model promotes wellness on primary, secondary, and tertiary levels. The other items listed as models are not nursing theories. Ego defense mechanisms are unconscious coping mechanisms. Situational refers to factors such as relocation or family job changes that are stressors. Evidence-based practice consists of relying on data or other reputable information sources to guide nursing care.

Neuropathic pain

Abnormal processing of sensory input by the peripheral or central nervous system; treatment usually includes adjuvant analgesics.

Hyperchloremia

Abnormally high blood chloride level which occurs with some types of acidosis, some renal conditions, and other electrolyte imbalances.

As nurses, you will certainly deal with ethical issues related to access to care

Access to care

Answerable to oneself and others for one's own actions

Accountability

Identify the spiritual factors that can influence pain

Active searching for meaning, concerns of loss of independence and becoming a burden to the family

PRIORITY SETTING - LOW PRIORITY

Actual or potential problems that are not directly related to a patient's illness or disease often related to developmental needs or long-term health care needs For example: preparing patients for discharge with teaching/info for self-care at home

Is curving and compression of the spinal column an age related change or pathology changes?

Age related. Mineral loss in the bones causes aging vertebrae to become thinner. this combined with fluid loss in the disks leads to shortening and curvature of the spinal column.

Explain the following movement therapies *Feldenkrais method*

Alternative therapy based on establishment of good self-image through awareness and correction of body movements; integrates he understanding of the physics of body movement patterns with an awareness of the way people learn to move, behave and interact

Stress

An experience to which a person is exposed through stimulus or stressor. This is subjective and varies from person to person.

PRIORITY SETTING - HIGH PRIORITY

An immediate threat to a patient's survival or safety For example: obstructed airway loss of consciousness anxiety attack.

Pressure ulcer prevention

Anesthetic agents lower BP, altering tissue perfusion. Careful positioning of patients and use of pressure-relieving devices intraoperatively helps reduce pressure on bony prominences. Careful skin assessments should be performed frequently.

Review questions A substance that can cause analgesia when it attaches to opiate receptors in the brain is: 1. Endorphin 2. Bradykinin 3. Substance P 4. Prostaglandin

Answer is: 1. Rationale: Once the brain perceives pain, there is a release of inhibitory neurotransmitters such as endogenous opioids (e.g., endorphins) which hinder the transmission of pain and help produce an analgesic effect.

Review questions To adequately assess the quality of a client's pain, which question would be appropriate? 1. "Is it a sharp or a dull pain?" 2. "Tell me what your pain feels like." 3. "Is your pain a crushing sensation?" 4. "How long have you had this pain?"

Answer is: 2. Rationale: A client's self-report of pain is the single most reliable indicator of the existence and intensity of pain.

Review questions Pain is a protective mechanism warning of tissue injury and largely a (an): 1. Objective experience 2. Subjective experience 3. Acute symptom of short duration 4. Symptom of a severe illness or disease

Answer is: 2. Rationale: Only the client knows whether pain is present and what the experience is like.

Review questions The use of client distraction in pain control is based on the principle that: 1. Small C fibers transmit impulses via the spinothalamic tract 2. The reticular formation can send inhibitory signals to gating mechanisms 3. large A fibers compete with pain impulses to close gates to painful stimuli 4. Transmission of pain impulses from the spinal cord to the cerebral cortex can inhibited

Answer is: 2. Rationale: The reticular activating system inhibits painful stimuli if a person receives sufficient or excessive sensory input; with sufficient sensory stimulation a person is able to ignore or become unaware of pain.

Review questions Teaching a child about painful procedures is best achieved by: 1. Early warnings of the anticipated pain 2. Storytelling about the upcoming procedure 3. Relevant play directed toward procedure activities 4. Avoiding explanations until the pain is experienced

Answer is: 3. Rationale: Developmental differences are found between age groups; therefore, the nurse needs to adapt approaches for assessing a child's pain and how to prepare a child for a painful procedure.

You are caring for a 65-year-old patient 2 days after surgery and helping him walk down the hallway. The surgeon has ordered exercise as tolerated. Your assessment indicates that the patient's heart rate at baseline is 88. After walking down approximately 30 yards down the hallway, the heart rate is 110. What should be your next action?

Ask him how he feels; determine if there is any discomfort or shortness of breath; and, if not, continue exercise.

Explain the following manipulative and body-based methods *Craniosacral therapy*

Assessing the craniosacral motion for rate, amplitude,symmetry, and quality and attuning/aligning the spinal column, cerebrospinal fluid, and rhythmic processes releasing restrictions or abnormal barriers to motion

Sympathetically maintained pain

Associated with dysregulation of the autonomic nervous system. Examples: pain associated with reflex sympathetic dystrophy/causalgia (complex regional pain syndrome, type I, type II).

Commitment to include patients in decisions

Autonomy

A nurse is assessing the ability to learn of a patient who has recently experienced a stroke. Which question/statement will best assess the patient's ability to learn? a."What do you want to know about strokes?" b."Please read this handout and tell me what it means." c."Do you feel strong enough to perform the tasks I will teach you?" d."On a scale from 1 to 10, tell me where you rank your desire to learn."

B

A nurse is teaching a patient about heart failure. Which environment will the nurse use? a.A darkened, quiet room b.A well-lit, ventilated room c.A private room at 85° F temperature d.A group room for 10 to 12 patients with heart failure

B

A nurse is trying to help a patient begin to accept the chronic nature of diabetes. Which teaching technique should the nurse use to enhance learning? a.Lecture b.Role play c.Demonstration d.Question and answer sessions

B

A patient has heart failure and kidney failure. The patient needs teaching about dialysis. Which nursing action is most appropriate for assessing this patient's learning needs? a.Assess the patient's total health care needs. b.Assess the patient's health literacy. c.Assess all sources of patient data. d.Assess the goals of patient care.

B

A patient needs to learn how to administer a subcutaneous injection. Which of the following reflects that the patient is ready to learn? A. Describing difficulties a family member has had in taking insulin B. Expressing the importance of learning the skill correctly C. Being able to see and understand the markings on the syringe D. Having the dexterity needed to prepare and inject the medication

B

A patient who is hospitalized has just been diagnosed with diabetes. He is going to need to learn how to give himself injections. Which teaching method does the nurse use? A. Simulation B. Demonstration C. Group instruction D. One-on-one discussion

B

The home care nurse is seeing the following patients. Which patient is at greatest risk for experiencing inadequate nutrition? A. A 55-year-old obese man recently diagnosed with diabetes mellitus B. A recently widowed 76-year-old woman recovering from a mild stroke C. A 22-year-old mother with a 3-year-old toddler who had tonsillectomy surgery D. A 46-year-old man recovering at home following coronary artery bypass surgery

B

The nurse sees the nursing assistive personnel (NAP) perform the following for a patient receiving continuous enteral feedings. What intervention does the nurse need to address immediately with the NAP? The NAP: A. Fastens the tube to the gown with tape. B. Places the patient supine while giving a bath. C. Performs oral care for the patient. D. Elevates the head of the bed 45 degrees.

B

The nurse suspects that the patient receiving parenteral nutrition (PN) through a central venous catheter (CVC) has an air embolus. What action does the nurse need to take first? A. Raise head of bed to 90 degrees B. Turn patient to left lateral decubitus position C. Notify health care provider immediately D. Have patient perform the Valsalva maneuver

B

The nurse is organizing a disease prevention program for a specific cultural group. To effectively meet the needs of this group the nurse will: Select all that apply. a. Assess the needs of the community in general. b. Involve those affected by the problem in the planning process. c. Develop generalized goals and objectives for the program. d. Use educational materials that are simplistic and have many pictures. e. Assess commonly held health beliefs among the cultural group. f. Educate the specific cultural group about Western concepts of health and illness. g. Include cultural practices that are relevant to the specific community.

B, E, G

When an ethical dilemma occurs on your unit, can you resolve the dilemma by taking a vote? A. Yes because ethics is essentially a democratic process, with all participants sharing an equal voice B. No because an ethical dilemma involves the resolution of conflicting values and principals rather than simply the identification of what people want to do C. Yes because ethical dilemmas otherwise take up time and energy that is better spent at the bedside performing direct patient care D. No because most ethical dilemmas are resolved by deferring to the medical director of the ethics department

B. No because an ethical dilemma involves the resolution of conflicting values and principals rather than simply the identification of what people want to do

A nurse is working in the preoperative holding area and is assigned to care for a patient who is having a prosthetic aortic valve placed. The nurse inserts an intravenous (IV) line and obtains vital signs. The patient has a temperature of 39°C (102°F), heart rate of 120, blood pressure (BP) of 84/50, and an elevated white blood cell (WBC) count. The nurse immediately notifies the surgeon of the patient's vital signs because:

B. The surgery may need to be delayed to check the patient's WBC count and investigate the source of fever before surgery The patient has a fever, elevated WBC count, tachycardia, and hypotension, which are all signs of a potential infection. The surgery may need to be delayed until the source of the fever is treated.

Explain the following biofield energy therapies *Reiki therapy*

Biofield therapy derived from ancient Buddhist rituals; practitioners place hands on or above a body area and transfers "universal life energy", provides strength harmony, and balance to treat a patient's health disturbances

Explain the following biofield energy therapies *Therapeutic touch*

Biofield therapy involving direction of a practitioner's balanced energies in an intentional manner toward those of a patient, practitioner's hands lay on or close to a patient's body

Explain the following biofield energy therapies *Healing touch*

Biofield therapy; used gentle touch directly on or close to the body to influence and support the human energy system and bring balance to the whole body

Hemolysis

Breakdown of red blood cells

A nurse attends a seminar on teaching/learning. Which statement indicates the nurse has a good understanding of teaching/learning? a."Teaching and learning can be separated." b."Learning is an interactive process that promotes teaching." c."Teaching is most effective when it responds to the learner's needs." d."Learning consists of a conscious, deliberate set of actions designed to help the teacher."

C

A nurse is preparing to teach a patient about smoking cessation. Which factors should the nurse assess to determine a patient's ability to learn? a.Sociocultural background and motivation b.Stage of grieving and overall physical health c.Developmental capabilities and physical capabilities d.Psychosocial adaptation to illness and active participation

C

A nurse is teaching a patient about healthy eating habits. Which learning objective/outcome for the affective domain will the nurse add to the teaching plan? a.The patient will state three facts about healthy eating. b.The patient will identify two foods for a healthy snack. c.The patient will verbalize the value of eating healthy. d.The patient will cook a meal with low-fat oil.

C

A nurse is teaching a patient about hypertension. In which order from first to last will the nurse implement the steps of the teaching process? 1. Set mutual goals for knowledge of hypertension. 2. Teach what the patient wants to know about hypertension. 3. Assess what the patient already knows about hypertension. 4. Evaluate the outcomes of patient education for hypertension. a.1, 3, 2, 4 b.2, 3, 1, 4 c.3, 1, 2, 4 d.3, 2, 1, 4

C

A nurse is teaching an older-adult patient about strokes. Which teaching technique is most appropriate for the nurse to use? a.Speak in a high tone of voice to describe strokes. b.Use a pamphlet about strokes with large font in blues and greens. c.Provide specific information about strokes in short, small amounts. d.Begin the teaching session facing the teaching white board with stroke information.

C

A toddler is going to have surgery on the right ear. Which teaching method is most appropriate for this developmental stage? a.Encourage independent learning. b.Develop a problem-solving scenario. c.Wrap a bandage around a stuffed animal's ear. d.Use discussion throughout the teaching session.

C

When planning for instruction on cardiac diets to a patient with heart failure, which of the following instructional methods would be the most appropriate for someone identified as a visual/spatial learner? A. Printed pamphlets on cardiovascular disease and dietary recommendations from the American Heart Association B. A role-play activity requiring the patient to select proper foods from a wide selection C. Colored visual diagrams that categorize foods according to fat and sodium content D. A lecture-style discussion on heart healthy diet options

C

when delegating input and output (I & O) measurement to nursing assistive personnel, a nurse instructs them to record what information for ice chips? A. the total volume B. two threes of the volume C. one half of the volume D. one quarter of the volume

C

which assessment does a nurse use as a clinical marker of vascular volume in a patient at high risk of extracellular fluid volume (ECV) deficit? A. dryness in the mucous membranes B. presence or absence of edema C. fullness of neck veins when supine D. fullness of neck veins when upright

C

A nurse is recovering a patient who received conscious sedation for cosmetic surgery. Which of the following is an advantage that conscious sedation has over general anesthesia?

C. Amnesia and relief of pain Conscious sedation offers adequate sedation, reduction of fear and anxiety, amnesia, and relief of pain while maintaining airway patency and ventilation independently along with stable vital signs and rapid recovery. Loss of sensation at the surgical site is an effect of local anesthesia. These patients usually only go through phase II recovery.

Which of the following explain how health care reform is an ethical issue? (Select all that apply.) A. Access to care is an issue of beneficence, a fundamental principal in health care ethics. B. Reforms promote the principle of beneficence, a hallmark of health care ethics. C. Purchasing health care insurance may become an obligation rather than a choice, a potential conflict between autonomy and beneficence. D. Lack of access to affordable health care causes harm, and nonmaleficence is a basic principal of health care ethics.

C. Purchasing health care insurance may become an obligation rather than a choice, a potential conflict between autonomy and beneficence. D. Lack of access to affordable health care causes harm, and nonmaleficence is a basic principal of health care ethics.

A client that is visually impaired

Check for glasses, identify self, speak in normal tone, do not rely on gestures or nonverbal communication, use indirect lighting, use 14-font print.

A client that is hearing impaired

Check for hearing aids, reduce environmental noise, get patient's attention, face the patient, do not chew gum, speak in normal voice, rephrase, provide sign language.

Polyneuropathies

Client feels pain along the distribution of many peripheral nerves. Examples: diabetic neuropathy, alcohol-nutritional neuropathy, and Guillain-Barré syndrome.

Verbal communication

Code that convey a special meaning through the combination of words ex: dinner could mean a meal at noon or 7pm to different people vocabulary, connotative and denotative meaning, pacing, intonation, clarity and brevity, timing and relevance ex: don;t

Autologous transfusion

Collection and reinfusion of a patient's own blood

Nurse-healthcare team

Communication with other members of the healthcare team affects patient safety and the work environment. miscommunication risk when moves from one location to another coordination, collaboration, timely follow up after discharge will help Lateral Violence

Explain the following mind-body interventions *Guided imagery*

Concentrating on an image or series of images to treat pathological conditions

examples of barriers to effective pain management Health care system barriers

Concern with creating "addicts,", Ability to fill prescriptions, Absolute dollar restriction on amount reimbursed for prescriptions, Mail order pharmacy restrictions, Nurse practitioners and physician assistants not used efficiently, Extensive documentation requirements, Poor pain policies and procedures regarding pain management, Lack of money, Inadequate access to pain clinics, Poor understanding of economic impact of unrelieved pain

Summarizing

Concise review of key aspects of an interaction.

metabolic acidosis

Condition that results from a deficiency of bicarbonate or an excess of hydrogen. any acids that are not carbonic acids citric acid, lactic acid diarrhea hyperkalemia pH down, PaCO2 normal, HCO3 down

HIPPA(Health Insurance Portability and Accountability Pact)/ Protection of Privacy

Confidentiality

What are examples of altered presentation of illnesses in older adults in a hospital setting:

Confusion can set in. look for an acute illness, neurological events, new medication, or presence of risk factors for delirium. Many hospitalized older adults suffer from chronic dehydration exacerbated by acute illness. Not all older adults have fevers with infection, symptoms instead include increased respiratory rate, falls, incontinence, or confusion

RIGHT CIRCUMSTANCES

Consider the appropriate patient setting, available resources, and other relevant factors. In an acute care setting patients' conditions often change quickly.

Explain the following biologically based therapies *Dietary supplements*

Contains one or more dietary ingredients including vitamins, minerals, herbs, or other botanical products

A female patient has been overweight for most of her life. She has tried dieting in the past and has lost weight, only to regain it when she stopped dieting. The patient is visiting the weight loss clinic/health club because she has decided to do it. She states that she will join right after the holidays, in 3 months. Which stage is the patient displaying?

Contemplation

Osmoreceptors

Continually monitor plasma osmolality when osmolality increases the hypothalamus stimulates thirst.

Identify the limitations of chiropractic therapy.

Contraindications include acute myelopathy, fractures, dislocations, rheumatoid arthritis, and osteoporosis

A nurse is teaching a group of young college-age women the importance of using sunscreen when going out in the sun. Which type of content is the nurse providing? A. Simulation B. Restoring health C. Coping with impaired function D. Health promotion and illness prevention

D

A nurse is teaching a patient who has low health literacy about chronic obstructive pulmonary disease (COPD) while giving COPD medications. Which technique is most appropriate for the nurse to use? a.Use complex analogies to describe COPD. b.Ask for feedback to assess understanding of COPD at the end of the session. c.Offer pamphlets about COPD written at the eighth grade level with large type. d.Include the most important information on COPD at the beginning of the session.

D

A nurse is teaching a patient with a risk for hypertension how to take a blood pressure. Which action by the nurse is the priority? a.Assess laboratory results for high cholesterol and other data. b.Identify that teaching is the same as the nursing process. c.Perform nursing care therapies to address hypertension. d.Focus on a patient's learning needs and objectives.

D

A nurse is teaching a patient's family member about permanent tube feedings at home. Which purpose of patient education is the nurse meeting? a.Health promotion b.Illness prevention c.Restoration of health d.Coping with impaired functions

D

A nurse teaches a patient with heart failure healthy food choices. The patient states that eating yogurt is better than eating cake. Which element represents feedback? a.The nurse b.The patient c.The nurse teaching about healthy food choices d.The patient stating that eating yogurt is better than eating cake

D

A nurse's goal is to provide teaching for restoration of health. Which situation indicates the nurse is meeting this goal? a.Teaching a family member to provide passive range of motion for a stroke patient b.Teaching a woman who recently had a hysterectomy about possible adoption c.Teaching expectant parents about changes in childbearing women d.Teaching a teenager with a broken leg how to use crutches

D

A patient needs to learn to use a walker. Which domain is required for learning this skill? A. Affective domain B. Cognitive domain C. Attentional domain D. Psychomotor domain

D

An older adult is being started on a new antihypertensive medication. In teaching the patient about the medication, the nurse: A. Speaks loudly. B. Presents the information once. C. Expects the patient to understand the information quickly. D. Allows the patient time to express himself or herself and ask questions.

D

a nurse assesses pain and redness at a vascular access device (VAD) site. which action is taken first? A. apply a warm moist compress B. monitor the patients blood pressure C. aspirate the infusing fluid from the VAD D. stop the infusion and discontinue the intravenous infusion

D

a patient is hyperventilating from acute pain and hypoxia. interventions to manage his pain and oxygenation will decrease his risk of which acid-base imbalance? A. metabolic acidosis B. metabolic alkalosis C. respiratory acidosis D. respiratory alkalosis

D

which assessment does a nurse interpret as a transfusion reaction? A. crackles in dependent lobes of lungs B. high fever, severe hypotension C. anxiety, itching, confusion D. chills, tachycardia and flushing

D

Because an older adult is at increased risk for respiratory complications after surgery, the nurse should:

D. Encourage the patient to turn, deep breathe, and cough frequently and ensure adequate pain control. Adequate pain control is important to allow participation in postoperative exercises such as turning, deep coughing, and deep breathing to prevent respiratory complications.

You are a nurse in the postanesthesia care unit (PACU), and you note that your patient has a heart rate of 130 beats/min and a respiratory rate of 32 breaths/min; you also assess jaw muscle rigidity and rigidity of limbs, abdomen, and chest. What do you suspect, and which intervention is indicated?

D. Malignant hyperthermia: Notify surgeon/anesthesia provider immediately, prepare to administer dantrolene sodium (Dantrium), and monitor vital signs frequently. Malignant hyperthermia is a life-threatening complication of general anesthesia. It is a severe hypermetabolic condition that causes rigidity of skeletal muscles caused by an increase in intracellular calcium ion concentration and leads to hypercarbia, tachypnea, and tachycardia. Despite the name, an elevated temperature is a late sign, and an increase in the respiratory rate to eliminate carbon dioxide is one of the first signs. Dantrolene sodium (Dantrium) is a skeletal muscle relaxant that is used to treat this complication.

A nurse is working in an ambulatory care setting and is ready to discharge a patient who is wheelchair dependent. The patient underwent dilation of an esophageal stricture. Her postanesthesia recovery score for ambulatory patients (PARSAP) score is 16. Her family is ready to go and eager to make the long road trip home. In determining if it is safe for the patient to be discharged at this time, the nurse should decide the following:

D. Since the patient was admitted to the surgical center in a wheelchair, she can be discharged with a lower PARSAP score. The PARSAP is an important functional screen to assess the function of the ambulatory surgery patient. The total score must be at least 18 for a patient to be discharged to home, unless the patient is not walking or is unable to use extremities before surgery.

A patient has had emphysema (lung disease) for many years. When approached by the nurse, the patient states "I would be better off dead." The patient supports the family, and now because of oxygen dependency the patient must quit work. The patient's spouse will have to go to work. Which action should the nurse take?

Develop a plan of care for the family

Explain the following biologically based therapies *"The Zone"*

Dietary program that requires eating proteins, carbohydrates and fats in a 30% protein: 40% carbohydrates: 30% fats ratio; used to balance insulin and other hormones for optimal health

OSTEOPOROSIS

Disorder characterized by abnormal rarefaction of bone, occurring most frequently in postmenopausal women, sedentary or immobilized individuals, and patients on long-term steroid therapy.

What are the limitations of relaxation therapy?

During the first few months when the person is learning to focus on body sensations and tensions, there is increased sensitivity in detecting muscle tension. Occasionally, intensification of symptoms or the development of new symptoms can occur

Nursing process: Assessment Identify the ABCDE clinical approach to pain assessment and management E

E: Empower clients and their families. Enable them to control their course to the greatest extent possible.

explain the purpose of topical analgesics

EMLA via a disc or thick cream to the skin for 30 to 60 minutes before minor procedures

Latex sensitivity

Encompasses a range of allergic reactions to the proteins present in natural rubber latex. Latex allergy generally develops after repeated exposure to products containing natural rubber latex.

The study of conduct and character. It is concerned with determining what is good or valuable for individuals and society at large

Ethics

Emphasizes the importance of understanding relationships, especially as they are revealed in personal narratives

Ethics of Care

Infection prevention

Evidence has shown that there is a relationship between wound and tissue infection and blood glucose levels. Poor control of blood glucose levels (specifically hyperglycemia) during surgery and afterwards increases the risk for wound infection and patient mortality in certain types of surgery. Perioperative nurses work with their medical colleagues to maintain normal glucose levels in the postoperative period to reduce the risk for wound and tissue infection.

Interpersonal variables

Factors within both the sender and the receiver that influence communication. cultural sensitivity enables you to explore interpersonal variables: educational and developmental level, sociocultural background, values and beliefs, emotions, gender, physical health status, roles and relationships that may effect how a patient communicates illness interpersonal variables: pain, anxiety, medication

examples of barriers to effective pain management Client

Fear of addiction, Worry about side effects, Fear of tolerance (won't be there when I need it), Take too many pills already, Fear of injections, Concern about not being a "good" client, Don't want to worry family and friends, May need more tests, Need to suffer to be cured, Pain is for past indiscretions, Inadequate education, Reluctance to discuss pain, Pain is inevitable, Pain is part of aging, Fear of disease progression, Primary health care providers and nurses are doing all that they can, Just forget to take analgesics, Fear of distracting primary health care providers from treating illness, Primary health care providers have more important or ill clients to see, Suffering in silence is noble and expected

Intracellular fluid

Fluid within the cells. Approx. 2/3 total body water.

Explain the following mind-body interventions *Yoga*

Focuses on body musculature, posture, breathing mechanisms, and consciousness; goal is attainment of physical and mental well-being through mastery of body achieved through exercise, holding of postures, proper breathing and meditation

PATHOLOGICAL FRACTURES

Fractures resulting from weakened bone tissue frequently caused by osteoporosis or neoplasms

Explain the following biologically based therapies *Mycotherapies*

Fungi-based products (mushrooms)

Family

Group of interacting individuals composing a basic unit of society. is defined biologically, legally, or as a social network with personally constructed ties and ideaologies. created by birth, marriage, and mutual agreements.

The nurse is preparing a smoking cessation class for family members of patients with lung cancer. The nurse believes that the class will convert many smokers to nonsmokers once they realize the benefits of not smoking. Which health care model is the nurse following?

Health belief model

What are examples of altered presentation of illnesses in older adults in a nursing home setting

Health care providers often under treat pain in older adults, especially those with dementia. Look for nonverbal cues of pain such as grimacing or resistance to care Decline in functional ability is the signal of a new illness Residents with less muscle mass-both the frail and the obese are not a much higher risk for toxicity from protein binding drugs such as phenytoin and coumadin New urinary and/or fecal incontinence is often a sign of the onset of a new illness

Identify the clinical applications of herbal therapy.

Herbal therapy can be used for urinary tract infections, sleep and relaxation, mild GI disturbances, and premenstrual symptoms

CONGENITAL HIP DYSPLASIA

Hip instability with limited abduction of hips occasionally adduction contractures - head of femur does not articulate with acetabulum because of abnormal shallowness of acetabulum

The patient is reporting moderate incisional pain that was not relieved by the last dose of pain medication. The patient is not due for another dose of medication for another 2 1/2 hours. The nurse repositions the patient, asks what type of music the patient likes, and sets the television to the channel playing that type of music. Which health care model is the nurse using?

Holistic health model

respiratory alkalosis

Hyperventilation excessive excretion of CO2 through respirations pH up, PaCO2 down, HCO3 normal

respiratory acidosis

Hypoventilation retained CO2 kidneys retain more HCO3 to raise the pH COPD pH down, PaCO2 up, HCO3 normal

Secondary Appraisal

If stress is present, this focuses on possible coping strategies. Balancing factors results in a return to equilibrium.

examples of barriers to effective pain management Health Care Provider

Inadequate pain assessment, Concern with addiction, Opiophobia (fear of opioids), Fear of legal repercussions, No visible cause of pain, Clients must learn to live with pain, Reluctance to deal with side effects of analgesics, Fear of giving a dose that will kill the client, Not believing the client's report of pain, Primary health care provider time constraints, Inadequate reimbursement, Belief that opioids "mask" symptoms, Belief that pain is part of aging, Overestimation of rates of respiratory depression

TORTICOLLIS

Inclining head to affected side sternocleidomastoid muscle is contracted

Explain the following mind-body interventions *Tai chi*

Incorporating breath, movement, and mediation to cleanse, strength, and circulate vital life energy and blood; stimulate the immune system and maintain external and internal balance

Explain the following biologically based therapies *Orthomolecular*

Increased intake of nutrients such as vitamin C and beta-carotene; treats cancer, schizophrenia, autism, and certain chronic diseases such as hypercholesterolemia and coronary artery disease

NURSING DX - IMMOBILITY

Ineffective Airway Clearance Ineffective Coping Impaired Physical Mobility Impaired Urinary Elimination Risk for Impaired Skin Integrity Risk for Disuse Syndrome Social Isolation

Phlebitis

Inflammation of a vein. Redness, tenderness, and warmth along the course of the vein starting at the access site, with possibly a red streak and/or palpable cord along the vein.

Deafferentation pain

Injury to either the peripheral or central nervous system. Examples: Phantom pain reflects injury to the peripheral nervous system; burning pain below the level of a spinal cord lesion reflects injury to the central nervous system.

Preoperative teaching plan

Instruction regarding a patient's anticipated surgery and recovery that is given before surgery. Instruction includes, but is not limited to, dietary and activity restrictions, anticipated assessment activities, postoperative procedures, and pain-relief measures.

Small group

Interaction that occurs with a small number of persons usually goal directed and requires understanding of group dynamics ex: nurse committees, patient-care conference, working with nurses of other disciplines

Public

Interaction with an audience ex: speaking with groups of consumers, presenting scholarly work to colleagues at conferences, lead classroom discussions increases knowledge about health-related topics, health issues, other issues important in the nursing profession

A patient is admitted through the emergency department for multisystem trauma following a motorcycle crash with multiple orthopedic injuries. He goes to surgery for repair of fractures. He is postoperative day 3 from an open reduction internal fixation of bilatory femur fractures and external fixator to his unstable pelvic fracture. Interventions that are necessary for prevention of venous thromboembolism in this high-risk postsurgical patient include:

Intermittent pneumatic compression stockings Subcutaneous heparin or enoxaparin (Lovenox)

PIGEON TOES (METATARSIS VARUS)

Internal rotation of forefoot or entire foot; common in infants

Explain the following movement therapies *Dance therapy*

Intimate and powerful medium because it is a direct expression of the mind and body; treats persons with social, emotional, cognitive or physical problems

Nutrition Risk Factor

Is a surgical risk factor because normal tissue repair and resistance to infection depend on it. At risk patients include: alcoholics, diabetics, anorexics, obese. These patients are likely to have a poor tolerance of anesthesia, negative nitrogen balance, delayed postop recovery, infection, and delayed wound healing.

Pregnancy Risk Factor

Is a surgical risk factor because of the displacement of abdominal organs, anesthetics and medications cause fetal abnormalities during first trimester, and stress because of the fear of fetal loss or deformity. [In an emergency situation you will always treat the mother first].

Fluid and Electrolyte Balance Risk Factor

Is a surgical risk factor because the body views surgery as a form of trauma (stress response). It creates sodium and water retention and potassium loss within the first 2-5 days post surgery. Severe protein breakdown causes a negative nitrogen balance. [A patient who is dehydrated from vomiting preoperatively is at greater risk for hypovolemic shock.]

Obesity Risk Factor

Is a surgical risk factor because the patient has reduced ventilator capacity R/T the pressure of the abdomen on the diaphragm. This increases the patients risk for aspiration, embolisms, atelectasis, and pneumonia. These patients are also at risk for impaired skin integrity, poor wound healing and wound infection because fatty tissue contains a poor blood supply, which slows the delivery of essential nutrients and antibodies needed for healing.

Age Risk Factor

Is a surgical risk factor for very young and older patients because they have difficulty maintaining their body temperature. Infants have a proportionately greater surface area and less subcutaneous fat, placing them at risk for wide temperature variations. In addition, general anesthetics inhibit shivering, a protective reflex to maintain body temperature, and anesthetics cause vasodilation, which results in heat loss. The total blood volume of infants is considerably less than that of older children and adults, creating a risk for both dehydration and over-hydration.

Smoking Risk Factor

Is a surgical risk factor that is associated with postoperative pulmonary complications, specifically pneumonia and atelectasis. This patient has a greater difficulty clearing the airways of mucus and needs to practice deep breathing and coughing exercises. [greater risk for bronchospasm or laryngospasm]

Insensible water loss

Is not visible, it is continuous and occurs through the skin and lungs.

hardiness

Is the internal strengths and durability of the family.

What is the goal of chiropractic therapy?

It aims to normalize the relationship between the structure and function of the spinal cord by by a series of manipulations.

Identify the clinical applications of imagery.

It can be helpful in controlling or relieving pain, decreasing nightmares and improving sleep, and treating chronic disease.

Describe the clinical applications of acupuncture.

It can be used for low back pain, myofasical pain, headaches, sciatica, shoulder pain, tennis elbow, osteoarthritis, whiplash, and musculoskeletal sprains.

Identify some clinical applications for the use of biofeedback.

It can be useful in treating headaches, smoking cessation, strokes, attention deficit hyperactivity, epilepsy, and a variety gastrointestinal and urinary tract disorders.

Therapeutic touch consists of five phases. Explain:*Treatment*

It directs and balances the energy, attempting to rebalance the energy flow

Therapeutic touch consists of five phases. Explain:*Unruffling*

It facilitates the symmetrical and rhythmic flow of energy through the body.

What is imagery?

It is a group of visualization techniques that uses the conscious mind to create mental images to stimulate physical changes in the body, improve perceived well-being, or enhance self-awareness

What is biofeedback?

It is a mind-body technique that uses instruments to teach self-regulation and voluntary self-control specific physiological responses.

Explain what the integrative medicine approach is. (35)

It is a multiple-practitioner treatment group; a pluralistic, complementary health care system; it is consistent with the holistic approach nurses learn to practice.

Explain the cascade of changes that are associated with the stress response

It is associated with increased heart and respiratory rates, tightened muscles, an increased metabolic rate, a general sense of fear, nervousness, irritability, and a negative mood

Identify the limitations of meditation.

It is contraindicated for people who have a strong fear of losing control or who are hypersensitive; medication use

Identify the limitation of therapeutic touch

It is contraindicated in persons who are sensitive to human interaction and touch and who have a sensitivity to energy repatterning.

What is the outcome of relaxation therapy?

It is to lower the heart rate and blood pressure, decreased muscle tension, improved sense of well-being, and reduced symptoms of distress

What is the goal of passive relaxation?

It is to still the mind and body intentionally without the need to tighten and relax any particular body part.

Identify the clinical application of therapeutic touch.

It is used in treatment of pain in adult and children, dementia, and anxiety

Identify the indications for the use of meditation.

It is used to successfully reduce hypertensive risks; reduce relapses in alcohol treatment programs; reduce depression, anxiety, and distress in cancer patients; and benefit people with post-traumatic stress disorder and chronic pain

Identify the clinical applications of chiropractic therapy.

It may improve pain and disability in the short term and pain in the medium term for acute and subacute low back pain as well as joint pain caused by osteoarthritis. It may enhance the effects of conventional treatments in pediatric asthma, headaches, dysmenorrhea, vertigo, tinnitus, and visual disorders.

Being fair

Justice

Activity Tolerance

Kind or amount of exercise or work that a person is able to perform

SCOLIOSIS

Lateral S- or C-shaped spinal column with vertebral rotation, unequal heights of hips and shoulders

Cultural care preservation or maintenance

Leininger defines as a nursing decision and actions mode that assists the patient to retain and or preserve relevant care values so patients maintain their well-being recover illness, or face handicaps and or death.

Hypotonic

Less concentrated than normal blood after their infused. 5% dextrose in water, move water from the extracellular compartment into the cells by osmosis causing them to swell.

Intravascular fluid

Liquid portion of the blood. The plasma

A client that cannot speak clearly

Listen attentively, do not interrupt, ask simple questions, allow time, use visual cues, do not shout, use communication aides.

Explain the following biologically based therapies *Probiotics*

Live microorganisms that are similar to beneficial microorganisms found in the human GI system

Hypochloremia

Low blood chloride level. Frequently associated with alkalosis and conditions that cause loss of hydrochloric acid including vomiting nasogastric section and gastric fistula drainage.

Upon completion of the assessment, the nurse finds that the patient has quit drinking and has been alcohol free for the past 2 years. Which stage best describes the nurse's assessment finding?

Maintenance

You are a nurse in the postanesthsia care unit (PACU), and you note that your patient has a heart rate of 130 beats/min and a respiratory rate of 32 breaths/min; you also assess jaw muscle rigidity and rigidity of limbs, abdomen, and chest. What do you suspect, and which intervention is indicated?

Malignant hyperthermia: Notify surgeon/anesthesia provider immediately, prepare to administer dantroleme sodium (Dantrium), and monitor vital signs frequently.

Explain the following manipulative and body-based methods *Massage therapy*

Manipulating soft tissue through stroking, rubbing, or kneading to increase circulation, improve muscle tone, and provide relaxation

Nurse- community

Many nurses form relationships with community groups by participating in local organizations, volunteering for community service, or becoming politically active. To be effective change agents, nurses need to establish relationships with their communities.

Nurse Family

Many nursing situations, especially those in community and home care settings, require the nurse to form a healthy relationship with entire families. know family dynamics and needs

What classification does a minor surgery fall under ? and what is the description of one

Minimal alteration in body parts ,designed to correct deformities ,involves minimal risk . Example :Facial plastic surgery ,Tooth extraction minor

facial expression

Most expressive part of the body reflects feelings: have intended facial expression on

Referent

Motivates one person to communicate with another. Knowing a stimulus or referent that initiates communication allows you to develop and organize messages better ex: patient request who can't breath well compared to patient request who is hungry

Osmosis

Movement of water across a semipermeable membrane from a compartment of lower particle concentration to one that has a higher particle concentration. Equalizes the concentration of particles on each side of the membrane. Water can cross easily but electrolytes do not. occurs by osmosis.

What classification does a urgent surgery fall under ? and what is the description of one

Necessary for patients health ,Prevent development of additional problems (tissue destruction or impaired organ function) Example :removal of gallbladder for stones vascular repair for obstructed artery urgent

PRIORITY SETTING - INTERMEDIATE PRIORITY

Non-emergency/not life threatening actual or potential needs that a patient and family members are experiencing For example: anticipating teaching needs of patients related to a new drug and taking measures to decrease postoperative complications

Nociceptive pain

Normal processing of stimuli that damages normal tissues or has the potential to do so if prolonged; usually responsive to nonopioids and/or opioids.

You are caring for a patient after surgery who underwent a liver resection. His prothrombin time (PT) or an activated partial thromboplastin time (APTT) is greater than normal. He has low blood pressure; tachycardia; thready pulse; and cool, clammy, pale skin, and he is restless. You assess his surgical wound, and the dressing is saturated with blood. Which immediate interventions should you perform? (select all that apply)

Notify the surgeon Maintain intravenous (IV) fluid infusion and prepare to give volume replacement. Monitor the patient's vital signs every 15 minutes or more frequently until his condition stabilizes.

Family as context

Nursing prospective in which the family is viewed as a unit of interacting members having attributes, functions, and goals separate from those of the individual.

Neuman's Theory

Nursing theory that focuses on stress and a persons response to it.

Burnout

Occurs as a result of chronic stress/ constant changing of an environment.

Trauma

Occurs if symptoms of stress persist beyond the duration of the stressor.

Post-traumatic Stress Disorder (PTSD)

Occurs when a person experiences, witnesses or is confused with a traumatic event and responds with intense fear or helplessness.

Developmental/Maturation Crisis

Occurs when a person moves through stages of life. Ex: Marriage, having a kid

Exhaustion Stage

Occurs when the body is no longer able to resist the effects of the stressor and has depleted the energy necessary to maintain adaptation.

Fight-or-flight Response

Occurs with the arousal of the sympathetic nervous system, and prepares the person for action. The adrenal glands are stimulates and are part of this negative feedback loop.

Intrapersonal

Occurs within an individual self-talk Peoples thoughts and inner communication strongly influence perceptions, feelings, behavior, and self-esteem Positive self-talk allows people to deal with situations more confidently and effectively because they provide a mental rehearsal for difficult tasks and help diminish cognitive distortions

BOWLEGS (GENU VARUM)

One or both legs bent outward at knee, which is normal until 2 to 3 years of age

complementary role relationships

One person holds a higher position than the other in the communication process

Interpersonal

One-to-one interaction between a nurse and another person. most frequent in practice messages received sometimes different than intended necessary to validate or negotiate meaning with those with different experiences, values, opinions and believe systems aka assess understanding clarify meaning

system

Output is the end product of a system and, in the case of the nursing process, it is defined as whether the patient's health status improves or remains stable as a result of nursing care. Input consists of the data that come from a patient's assessment. Feedback serves to inform a system about how it functions. Content is the product and information obtained from the system.

Spontaneous pain

Pain that is unpredictable and not associated with any activity or event

End-of-dose failure pain

Pain that occurs toward the end of the usual dosing interval of a regularly scheduled analgesic

Palliative surgery

Palliative surgery reduces the intensity of the disease or its symptoms but is not intended to be curative. Colostomy, nerve root resection, and debridement of necrotic tissue are examples of palliative surgery. Colostomy is done for diversion of the fecal passage due to obstruction or necrosis of the distal part of the gastrointestinal tract. Nerve root resection is usually done to relieve symptoms related to irritation of the particular nerve. Debridement of necrotic tissue reduces the dead tissues and promotes healing. An appendectomy is an ablative surgery; it removes a diseased body part. A repair of a cleft palate is a constructive surgery to restore the function lost or reduced because of congenital anomalies.

The nurse is working on a committee to evaluate the need for increasing the levels of fluoride in the drinking water of the community. Which concept is the nurse fostering?

Passive health promotion

Diffusion

Passive movement of electrolytes or other particles from an area of higher concentration to one of lower concentration. Electrolytes cannot diffuse across cell membranes unless the membranes have proteins that serve as ion channels. When ion channels are open an electrolyte can diffuse across a membrane, when they are closed no electrolytes pass. Play an important role in nerve and muscle function.

Family forms

Patterns of people considered by family members to be included in the family. nuclear, extended, single-parent, blended, and alternative.

A nurse is assessing internal variables that are affecting the patient's health status. Which area should the nurse assess?

Perception of functioning

What classification does a elective surgery fall under ? and what is the description of one

Performed on the basis of patients choice ,not essential not always necessary . Example Hernia repair ,breast reconstruction,facial plastic surgery urgent

What classification does a cosmetic surgery fall under ? and what is the description of one

Performed to improve person appearance ex;rhinoplasty Purpose

Personal appearance

Physical characteristics, manner of dress and grooming, , facial expression are indicators of well-being, personality, social status, occupation, religion, culture, and self-concept. First impressions are largely based on appearance. Your physical appearance influences a patient's perception of care. (Example: Although your dress may not reflect your abilities, it takes longer to establish trust if your clothing differs from a patient's preconceived image.)

Explain the following biologically based therapies *Herbal medicines*

Plant based therapies used in whole systems of medicine or as individual preparations by allopathic providers and consumers for specific symptoms or issues

Explain the following biologically based therapies *Macrobiotic diet*

Predominately a vegan diet (includes fish); initially used in the management of a variety of cancers; emphasis placed on whole cereal grains, vegetables, and unprocessed foods

colloid osmotic pressure

Pressure that tends to keep fluid in the intravascular compartment

The nurse is working in a clinic that is designed to provide health education and immunizations. Which type of preventive care is the nurse providing?

Primary prevention

Intervention: Teach children not to talk to, go with, or accept any items from a stranger

Rationale: Avoiding strangers reduces the risk of injury and stranger abduction

Intervention: Baby proof home; remove small or sharp objects and toxic or poisonous substances, including plants, install safety locks on floor level cabinets

Rationale: Babies explore their world with their hands and mouth. Choking and poisoning can occur

Intervention: Do not allow children access to firearms or other weapons. Keep all firearms in a locked cabinet

Rationale: Children are often fascinated by firearms and often try to play with them.

Intervention: Remove doors from unused refrigerator and freezers. Instruct children not to play or hide in a car trunk or unused appliance

Rationale: If a child cannot exit freely from appliances and car Trunks Asphyxiation can occur

Intervention: Teach children not to operate electrical equipment while unsupervised

Rationale: If an electrical mishap were to occur, no one would be available to help.

Intervention: Place children in the appropriate car and booster seats based on age and weight

Rationale: In case of a sudden stop or crash, an unrestricted child suffers severs head injuries and death.

Intervention: Never leave crib sides down or babies unattended on changing tables or in infant seats, swings, strollers, or high chairs.

Rationale: Infants and toddlers roll or move and fall from changing tables or out of infants seats or swings.

Intervention:Follow all instructions for preparing and storing formula

Rationale: Prevents contamination, Ensures proper concentration of formula, causes fluid and electrolyte disturbances

Intervention: Teach children proper techniques for specific sports and the need to wear proper safety gear

Rationale: Prevents injury

Intervention: Cover electrical outlets

Rationale: Reduces opportunity for babies to insert objects into the outlet.

Intervention: Teach children not to eat items found in the street or grass

Rationale: Reduces risk of Poisoning.

Intervention: Use large, soft toys without small parts such as buttons

Rationale: Small parts become dislodged, and choking and aspirations may occur.

Intervention: Never leave child alone in the bathroom, tub or near any water source

Rationale: Supervision reduces the risk for accidental drowning.

Intervention: Do not fill cribs with pillows, bumper pads, large stuffed toys, comforters. Use snug fitting sheets

Rationale: These items may cause suffocation, strangulation, or entrapment

Intervention: Discontinue using accessories such as infant seats and swings when the child becomes too active or physically too big and/or according manufacturers directions

Rationale: When Physically active or to big, the child can fall out of or tip over theses accessories and suffer an injury

Intervention: Provide information about the effects of using alcohol and drugs

Rationale: adolescents are prone to risk taking behaviors and are subject to peer pressure.

Intervention: Do not leave the mesh side of playpens lowered, spaces between crib slates need to be less than 2 and 3/8 inches apart

Rationale: child's head may become wedged in the lowered mesh side or between crib slats, and asphyxiation may occur.

Intervention: Refer adolescents to community and school sponsored activities

Rationale: the adolescent needs to socialize with peers, yet need supervision

Intervention: Teach children basic physical safety measures; proper use and safety with scissors, never running with an object in their mouth or hand, an never attempting to use the stove or oven unassisted

Rationale:Risk of Injury is lower if children know basic safety procedures

DISUSE OSTEOPOROSIS

Reductions in skeletal mass routinely accompanying immobility or paralysis.

Hypovolemia

Refers to decreased vascular volume in ECV deficit.

Perioperative nursing

Refers to the role of the operating room nursing during the preoperative, intraoperative, and postoperative phases of surgery.

Ego-Defense Mechanisms

Regulate emotional distress and thus give a person protection from anxiety and stress. This helps a person cope with stress indirectly and offer psychological protection from stressful events.

ADH ( antidiuretic hormone)

Regulates osmolality of body fluids by influencing how much water is x rated in the urine.

Adventitious Crisis

Related to a natural disaster, man made event, crime and violence that change your life. Ex: Hurricane Katrina's effects and 9/11

Situational Crisis

Related to external sources that change your life. Ex: car accident, death of a relative, severe illness.

Aldosterone

Released by the adrenal cortex in response to increased plasma potassium concentration or as the end product of the renin angiotensin aldosterone system . Regulates ECV by influencing how much sodium and water are excreted in the urine.

What classification does a palliative surgery fall under ? and what is the description of one

Relieves or reduces the intensity of the symptoms not necessarily fixing the

What classification does a procurement for transplant surgery fall under ? and what is the description of one

Removal or organs and or tissues from a pronouced brain dead person or a donor ex;kidney heart live purpose

Angiotensin

Renin released by the kidneys acts on the inactive protein in angiotensinogen to produce this. Promotes vasoconstriction to help regulate blood pressure.

Identify the limitations of biofeedback.

Repressed emotions or feelings are sometimes uncovered during biofeedback, and the patient may have difficulty coping.

Specific accountability or liability or associated with performance of duties of a particular role

Responsibility

Clarifying

Restating an unclear or ambiguous message.

Paraphrasing

Restating another's message more briefly using one's owns words.

What classification does a constructive surgery fall under ? and what is the description of one

Restores function loss or reduced as result of congiential anomalies Example repair of cleft pat-let or lip Purpose

What are the psychosocial changes in which older adults have life transitions in which loss is a major component:

Retirement social isolation sexuality housing and environment Death

The operating room (OR) and postanesthsia care unit (PACU) are high-risk environments for all patients with a latex allergy. Which safety measures to prevent a latex reaction should the nurse implement? (select all that apply)

Screening patients about food allergies known to have a cross-reactivity to latex such as kiwis and bananas Having a latex allergy cart available at all times Communicating with the operating room (OR) team as soon as 24 to 48 hours in advance of the surgery when a latex-sensitive patient is identified.

The patient is admitted to the emergency department of the local hospital from home with reports of chest discomfort and shortness of breath. The patient is placed on oxygen, has labs and blood gases drawn, and is given an electrocardiogram and breathing treatments. Which level of preventive care is this patient receiving?

Secondary prevention

Asking relevant questions

Seeking information for decision making.

Explain the following mind-body interventions *Meditation*

Self-directed practice for relaxing the body and calming the mind using focused rhythmic breathing

Environment

Setting for the sender and receiver interaction. Effective communication setting provides physical and emotional safety and comfort Bad: noise, temperature extremes, distractions, lack of privacy

SBAR

Situation-Background-Assessment-Recommendation framework for communication between members of the health care team about a patients condition

Special zones of touch

Social Zone (Permission Not Needed) Hands, arms, shoulders, back Consent Zone (Permission Needed) Mouth, wrists, feet Vulnerable Zone (Special Care Needed) Face, neck, front of body Intimate Zone (Permission and Great Sensitivity Needed) Genitalia, rectum

Parental nutrition

Solution consisting of glucose other nutrients and electrolytes administered through a central venous catheter.

A client that does not speak English

Speak to patient in normal tone, establish a method to signal the desire to communicate, provide and interpreter, avoid using family members, and develop communication aids.

Sharing feelings

Subjective feelings that results from one's thought and perception

Transfusion reaction

Systemic response by the body to the administration of blood incompatible with that of the recipient.

Stressors

Tension producing stimuli operating within or on any system.

A patient is admitted to a rehabilitation facility following a stroke. The patient has right-sided paralysis and is unable to speak. The patient will be receiving physical therapy and speech therapy. Which level of preventive care is the patient receiving?

Tertiary prevention

The referent in the communication process is:

That which motivates one person to communicate with another.

A nurse is working in the preoperative holding area and is assigned to care for a patient who is having a prosthetic aortic valve placed. The nurse inserts an intravenous (IV) line and obtains vital signs. The patient has a temperature of 39 degrees celsius (102 degress fahrenheit), heart rate of 120, blood pressure of 84/50, and an elevated white blood cell count. The nurse immediately notifies the surgeon of the patient's vital signs because:

The Surgery may need to be delayed to check the patient's WBC count and investigate the source of fever before surgery.

family resiliency

The ability to cope with expected and unexpected stressors. It helps to evaluate healthy responses when individuals and families are experiencing stressful events.

Resistance Stage

The body stabilizes and responds in the manner opposite to that of alarm reaction. Hormones levels decrease resulting in decrease heart rate, blood pressure and cardiac output resulting in values returning to normal.

Upon completing a history, the nurse finds that a patient has risk factors for lung disease. How should the nurse interpret this finding?

The chances of getting the disease are increased

Fluid homeostasis

The dynamic interplay of three processes: fluid intake and absorption, fluid distribution, and fluid output.

The nurse is caring for a patient who has been trying to quit smoking. The patient has been smoke free for 2 weeks but had two cigarettes last night and at least two this morning. What should the nurse anticipate?

The patient will return to the contemplation or precontemplation phase.

Therapeutic touch consists of five phases. Explain:*Assessment*

The practitioner moves the hands in a rhythmic and symmetric movement from head to toes, noticing the quality of energy flow

Therapeutic touch consists of five phases. Explain:*Evaluation*

The practitioner reassesses the energy field

Therapeutic touch consists of five phases. Explain:*Centering*

The process whereby the practitioner becomes aware and fully present during the entire assessment.

Therapeutic touch consists of five phases. Explain: *Centering*

The process whereby the practitioner becomes aware and fully present during the entire treatment

Complementary therapies

Therapies used in addition to conventional treatment recommended by the patient's provider

Maslow's Hierarchy

Third Level-love and belonging needs like friendship, social relationships, and sexual love

In demonstrating the method for deep breathing exercises, the nurse places his or her hands on the patient's abdomen to explain diaphragmatic movement.

This technique involves the use of Feedback.

Explain the following mind-body interventions *Art therapy*

Use of art to reconcile emotional conflicts, foster self-awareness, and express patient's unspoken and frequently unconscious concerns about their disease

A client that is cognitively impaired

Use simple sentences, ask one question at a time, allow time for patient to respond, be an attentive listener, and include family and friends.

Focusing

Used to center on key elements or concepts of the message.

Using silence

Useful when people are confronted with decisions that require much thought.

Explain the following mind-body interventions *Breathwork*

Using a variety of breathing patterns to relax, invigorate, or open emotional channels

Cultural imposition

Using one's own values and customs as an absolute guide in interpreting behaviors

Mononeuropathies

Usually associated with a known peripheral nerve injury, and pain is felt at least partly along the distribution of the damaged nerve. Examples: nerve root compression, nerve entrapment, trigeminal neuralgia.

Proposes that the value of something is determined by its usefulness

Utilitarianism

Explain the following mind-body interventions *Healing intention*

Variety of techniques used in multiple cultures that incorporate caring, compassion, love or empathy with the target of prayer

Obesity places patients at an increased surgical risk because of which of the following factors? (select all that apply)

Ventilatory capacity is reduced. Fatty tissue has a poor blood supply.

Hand-off communications that occur between the postanesthesia care unit (PACU) nurse and the nurse on the postoperative nursing unit should be done when a patient returns to the nursing unit. Select appropriate components of a safe and effective hand-off. (select all that apply)

Vital signs, the type of anesthsia provided, blood loss, and level of consciousness. Uninterrupted time to review the recent pertinent events and ask questions.

theorists

When applying Orem's theory, a nurse continually assesses a patient's ability to perform self-care and intervenes as needed to ensure that the patients meet physical, psychological, sociological, and developmental needs. According to Orem, people who participate in self-care activities are more likely to improve their health outcomes. Leiniger's culture care theory focuses on culture diversity and provides culturally specific nursing care. According to Peplau, nurses help patients reduce anxiety by converting it into constructive actions, using therapeutic communication. Nightingale's grand theory is a patient's environment can be manipulated by nurses to restore a patient to health. Neuman views a patient as being an open system that is in constant energy exchange with the environment that the nurse must help cope with stressors. King views a patient as a unique personal system that is constantly interacting/transacting with other systems that the nurse helps with goal attainment. Levine believes nurses promote balance between nursing interventions and patient participation to assist in conserving energy needed for healing. Johnson perceives patients as a collection of subsystems that forms an overall behavioral system focusing on balance.

When an older adult has a memory impairment information can be provided by

a family member or other care giver-sometimes need to supplement the older adult's recollection of past medical events and information such as allergies and immunizations

Food and Drug Administration (FDA)

a federal agency responsible with enforcing regulations regarding the manufacturing, processing, and distributing foods, drugs, and cosmetics to consumers.

Friction

a force that occurs in a direction to oppose movement; reduce friction by reducing surface area, for example, have patient place their arms across their chest when helping them move up in the bed

Dementia is

a generalized impairment of intellectual functioning that interferes with social and occupational functioning.

All medications taken before surgery are automatically discontinued after surgery unless

a health care provider reorders the drugs.

cataracts and symptoms

a loss of the transparency of the lens; blurred vision, sensitivity to glare and gradual loss of vision

Cutaneous Stimulation for Pain

a massage, warm bath, ice bag, and TENS stimulates the skin to reduce pain perception by the release of endorphins, which block the transmission of painful stimuli

Cultural care repatterning or restructuring

a nursing decision and action mode that assists the patient to reorder, change, or greatly modify patients lifestyles for a new different and beneficial health care patterns

CLINICAL CARE COORDINATION

a nursing skill that includes: clinical decision making priority setting organizational skills use of resources time management evaluation

When an older adult has accepted his or her limitations and strengths what view does the older adult have.

a realistic view of aging

self-transendence

a sens of authentically connecting to one's inner self. this contrasts with transcendence, the belief that a force outside of an greater than the person exists beyond the material world.

spiritual distress

a state of suffering related to the impaired ability to experience meaning in life through connections with self, others, the world, or a superior being. spiritual distress also occurs when there is conflict between a person's beliefs and prescribed health regimens or the inability to practice usual rituals.

Motivational Interviewing (MI)

a technique that holds promise for encouraging patients to share their thoughts, beliefs, fears, and concerns with the aim of changing their behavior helps to work with those not ready to change behavior but need to says their health practitioner used to evoke change talk. nonjudgemental, guided communication understand patient motivations and be actively listening communication focuses on recognizing and supporting strengths for positive changes

phenomenon

a term description or label given to describe an idea or responses about an event, situation, process, a group of events or situations.

TRAPEZE BAR

a triangular device that hangs down from a securely fastened overhead bar that is attached to the bedframe It allows a patient to pull with the upper extremities to raise the trunk off the bed, assist in transfer from bed to wheelchair, or perform upper-arm exercises

list of element of professional communication

a) Courtesy b) Use of names: say your title "student nurse" and use their name c) Trustworthiness: communicate with warmth, consistency, reliabilitym competency, respect; enhances expression of feelings, thoughts, needs d) Autonomy of responsibility e) Assertiveness

The process of recording analysis reveals

a) Determine whether he encourages openness and allow the patient to "tell his story" expressing both thoughts and feelings. b) Identify and missed verbal or nonverbal cues or conversational themes c) Examine whether nursing responses blocked or facilitated the patient's efforts to communicate. d) Determine whether nursing responses were positive and supportive or superficial and judgmental. e) Examine the type a number of questions asked. f) Determine the type and number of therapeutic communication techniques used. g) Discover any miss opportunities to use humor, silence, touch.

A list of some challenges communication situations that a nurse may encounter;

a) People who are silent or withdrawn, have difficulty expressing feelings b) People who are sad and depressed with slow mental and motor processes c) People who are angry, confrontational, and cannot listen. d) People who are uncooperative and resent being asked. e) People who are talkative or lonely or want someone with them all of the time f) People who are demanding g) People who are frightened or anxious, having difficulty coping h) People with vision or hearing difficulties i) People with language barriers j) People who are confused k) People who are sexually inappropriate l) people ho require assistance with visual or speech disabilities

A patient is admitted through the emergency department for multisystem trauma following a motorcycle crash with multiple orthopedic injuries. He goes to surgery for repair of fractures. He is postoperative day 3 from an open reduction internal fixation of bilateral femur fractures and external fixator to his unstable pelvic fracture. Interventions that are necessary for prevention of venous thromboembolism in this high-risk postsurgical patient include: (Select all that apply.) a. Intermittent pneumatic compression stockings. b. Vitamin K therapy. c. Subcutaneous heparin or enoxaparin (Lovenox). d. Continuous heparin drip with a goal of an international normalized ratio (INR) 5 times higher than baseline.

a. Intermittent pneumatic compression stockings. c. Subcutaneous heparin or enoxaparin (Lovenox). Combination therapy with mechanical and pharmacological prophylaxis is recommended for high-risk patients. Vitamin K therapy creates a higher risk for clotting, and the goal INR should not be 5 times higher than baseline

The operating room (OR) and postanesthesia care unit (PACU) are high-risk environments for patients with a latex allergy. Which safety measures to prevent a latex reaction should the nurse implement? (Select all that apply.) a. Screening patients about food allergies known to have a cross-reactivity to latex such as kiwis and bananas b. Having a latex allergy cart available at all times c. Communicating with the operating room (OR) team as soon as 24 to 48 hours in advance of the surgery when a latex-sensitive patient is identified d. Scheduling the latex-sensitive patient for the last operative case of the day

a. Screening patients about food allergies known to have a cross-reactivity to latex such as kiwis and bananas b. Having a latex allergy cart available at all times c. Communicating with the operating room (OR) team as soon as 24 to 48 hours in advance of the surgery when a latex-sensitive patient is identified Identifying patients with potential cross-reactivity is important since they may be unaware of their latex sensitivity. Having all necessary equipment easily accessible to staff is necessary to ensure that all items are available when needed. It is important for the operative team to be aware of the case so they can plan appropriate safeguards; scheduling the latex-sensitive patient for the first case means that latex dust from the previous day was removed overnight before the latex-sensitive patients operation

Hand-off communications that occur between the postanesthesia care unit (PACU) nurse and the nurse on the postoperative nursing unit should be done when a patient returns to the nursing unit. Select appropriate components of a safe and effective hand-off. (Select all that apply.) a. Vital signs, the type of anesthesia provided, blood loss, and level of consciousness b. Uninterrupted time to review the recent pertinent events and ask questions c. Verification of the patient using one identifier and the type of surgery performed d. Review of pertinent events occurring in the operating room e. (OR) while at the nurses' station

a. Vital signs, the type of anesthesia provided, blood loss, and level of consciousness A standardized approach or tool for hand-off communication helps providers provide accurate information about the care received in the OR and the PACU before coming to the postoperative nursing unit. Proper identification of the patient requires using a standard of two identifiers and explaining the surgery performed and information about the type of anesthesia provided, blood loss, and level of consciousness. Allowing appropriate time for questions and communication free of distraction improves the quality of the hand-off. It must occur at the patients bedside

Identify the social factors that can influence pain

a. attention b. previous experience c. family and social support.

Explain the following terms related to acupuncture

a.) *Qi*-the vital energy of the body b.) *Meridians*- channels of energy that run in regular patterns through the body and over the surface c.) *Acupoints*- holes through which qi can be influenced by the insertion of needles

classic signs and symptoms of disease are sometimes what in the older patient

absent, blunted or atypical

christianity (health care beliefs, response to illness, and implications for health and nursing)

accepts modern medical science. complementary or alternative medicine often followed. followers use prayer, faith healing. they appreciate visits form clergy. some use laying on of hands. holy communion is sometimes practiced. anointing of the sick is given when patient is ill or near death (catholic). christians usually favor of organ donation. health is important to maintain. allow time for patients to pray by themselves or with family or friends.

Sikhism (health care beliefs, response to illness, and implications for health and nursing)

accepts modern medical science. females are to be examined by females. removing undergarments causes great distress. provide time for devotional prayer. allow use of religious symbols.

Buddhism (health care beliefs and response to illness)

accepts modern medical science. followers sometimes refuse treatment on Holy Days. nonhuman spirits invading body cause illness. followers may want a buddhist priest. followers usually accept death as last stage of life and permit withdrawal of life support. followers of not practice euthanasia. they often do not take time off from work or family responsibilities when sick.

Hinduism (health care beliefs, response to illness, and implications for health and nursing)

accepts modern medical science. past sins cause illness. prolonging life is discouraged. allow time for prayer and purity rituals. allow use of amulets, rituals, and symbols.

THROMBUS

accumulation of platelets, fibrin, clotting factors, and the cellular elements of the blood attached to the interior wall of a vein or artery sometimes occludes the lumen of the vessel

ISOMETRIC EXERCISES

activities that involve muscle tension without muscle shortening can help improve activity tolerance

INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL)

activities to be independent in society - shopping - preparing meals - house cleaning - banking - taking medicine

prescriptive theories

address nursing interventions for a phenomenon, describe the conditions under which nursing interventions occur.

Is seborheic keratosis an age related change to skin or pathology changes?

age related change-brown, black or tan lesion on the face, chest, shoulders, or back common benign skin growth. Has Stuck on apperance

Are fine skin wrinkles an age related change or a pathological change?

age related change. Wrinkles are caused by thinning of the dermis, loss of elasticity, and decrease of sebaceous glands, small lines and creases in the skin. Deep furrows or severe atrophy indicate photo aging caused by effects of UV light exposure.

4 common causes of vision loss in older adults are

age related macular degeneration cataracts glaucoma diabetic retinopathy

What factors contribute to the projected increase in number of older adults?

aging of the baby boomers growth of the population segment over age 85

what is sedative you can offer the patient for anxiety if they cant sleep before surgery

alprazolam (Xanax)

Crutch Gait

alternately bearing weight on one or both legs and on the crutches

Joint

an articulation, where and how bones connect

BED REST

an intervention that RESTRICTS pt to bed for therapeutic reasons. Although it is much less commonly used, healthcare providers most often prescribe this intervention.

Pathogen

any microorganism capable of producing an illness.

Poison

any substance that impairs health or destroys life when ingested, inhaled, or absorbed by the body

CASE MANAGEMENT

approach designed to coordinate and link health care services across all levels of care for patients and their families works to streamline costs while maintaining quality of care

Perceptual biases

are human tendencies that interfere with accurately perceiving and interpreting messages from others people often incorrectly assume they know about an individuals culture perception is based off of the senses tend to ignore information that goes against expectations, preconceptions, stereotypes

Trousseau's sign

arm/carpal spasm associated with hypocalcemia

family member as caregiver

assess the family for the existence of caregivers who provide daily or respite care of older adult family members. caregivers are most often spouses or middle-aged children, especially daughters, assess for caregiver burden, later-life families have a different social network from younger families, take time to individualize and reinforce instruction, abuse of older adults in families may occur across all social classes.

Emotional Intelligence (EI)

assessment and communication technique that allows the nurse to better understand and perceive the emotions of themselves and others enables a nurse to use self-awareness, motivation, empathy, and social skills to build therapeutic relationships with patients

family diversity

attention to uniqueness

Naturalistic practitioners

attribute illness to natural, impersonal, biological forces that cause alternation in the equilibrium of the human body

Obesity places patients at an increased surgical risk because of which of the following factors? (Select all that apply.) a. Risk for bleeding is increased. b. Ventilatory capacity is reduced. c. Fatty tissue has a poor blood supply. d. Metabolic demands are increased.

b. Ventilatory capacity is reduced. c. Fatty tissue has a poor blood supply. A decreased blood supply in adipose tissue slows the delivery of essential nutrients, antibodies, and enzymes needed for wound healing. A decreased ventilatory capacity allows for alveolar collapse, which can lead to pneumonia.

The explanation of all preoperative and postoperative routines and demonstration of postoperative exercises are

basic to preoperative teaching.

connectedness

being interpersonally connected within oneself.

Paternalistic Practitioners

believe that an external agent, which can be human or nonhuman causes health and illness.

Judaism (health care beliefs, response to illness)

believes in sanctity of life. balance between God and medicine. observance of sabbath important. treatments sometimes refused on sabbath. visiting sick is obligation. there is an obligation to seek care, exercise, sleep, eat well, and avoid drug and alcohol abuse. euthanasia is forbidden. life support is discouraged.

GAIT BELT

belt device used to support patients during ambulation when used properly, it supports patient's center of gravity

bradykinin

binds to receptors on peripheral nerves, increasing pain stimuli

Statochastic and nonstochastic theories are what type

biological theories of aging

neuromodulators

body natural supply of morphinelike substances

Care of the postoperative patient centers on the

body systems that anesthesia, immobilization, and surgical trauma most likely affect.

frequent cause of serious injury in health care settings

breakdown in communication, lack of patient education, poor healthcare provider accountability

Aura

bright light , smell or taste that a patient reports just before going into a seizure.

Hospice

care of clients at the end of life, this emphasizes quality of life over quantity

Culturally congruent care

care that fits the persons life patterns values and a set of meanings. Sometimes this differs from the patients perspective on care.

Pallor Parasympathetic stimulation

cause blood supply to shift away from periphery

Isotonic Contractions

cause muscle contraction and change in muscle length e.g. walking, swimming, dancing, aerobics, etc.

how does alcoholism effect patients under anesthesia

causes a unpredictable reaction,people go through withdrawal during and after surgery

The developmental tasks are common to many older adults and are associated with varying degrees of ----------and -----------.

change and loss

external factors outside the patient system

changes in health care policy or an increase in the crime rate.

what are the early indicators of an acute illness in older adults?

changes in mental status, occurrence and reason for falls, dehydration, decrease in appetite, loss of function, dizziness, and incontinence

current trends affecting families

changing economic status, homelessness, family violence, acute or chronic illness.

USE OF WRIST RESTRAINTS

check provider's order application of restraints can be delegated to AP use *QUICK RELEASE TIE* method must be able to insert two fingers between patient's wrist and the restraint padded side should be towards bony prominence of the wrist to prevent friction must be tied to the bed frame

what are the risk factors of a pulmonary embolism?

chest pain dyspenia (Cant breathe) Increase resp rate tachycardia increased anxiety diaphoresis (Perfuse sweating) decreased oreintation decreased blood pressure blood gas changes

what pt are genetically at risk for latex allergy ?

children with spinabifida ,pt with urogenital abnormalities, or spinal cord injuries

Effective messages:

clear, direct, understandable language expressing clearly, directly, in manner familiar to patient

What are examples of altered presentation of illnesses in older adults in an ambulatory care center:

complaints of fatigue or decreased ability to do usual activities are signs of anemia, thyroid, depression, or neurological or cardiac problems. severe gastrointestinal problems in older adults do not always present with the same acute symptoms seen in younger patients. Ask about constipation, cramping sensations, and changes in bowel habits Older adults reporting increased dyspnea and confusion, especially those with a cardiac history, need to go to the emergency room because they are at most risk for manifestations of myocardial infarction Depression is common amoung older adults with chronic illness. Watch for lack of interest in former activities, significant personal losses, or changes in role or home life

TED Hose

compression stockings Thrombo Embolytic Deterent

navajos (health care beliefs, response to illness, and implications for health and nursing)

concepts of health have fundamental place in their concept of humans and their place in the universe. blessing way is practice that attempts to remove ill health by means of stories, songs, rituals, prayers, symbols, and sand paintings.

tetany

condition affecting nerves causing muscle spasms as a result of low amounts of calcium in the blood caused by a deficiency of the parathyroid hormone

transpersonally

connected with God, or an unseen higher power.

interpersonally

connected with other and the environment

Nursing management of older adults with dementia is what

consider the safety and physical and psychosocial needs of the older adult and family. The needs change as the progressive nature of dementia leads to increased cognitive deterioration

islam dietary regulations

consumption of pork and alcohol is prohibited. followers fast during the month of ramadan.

Denotative and Connotative meaning

content of communication people who use common language share denotative meaning: baseball has same meaning for all who speak english but code denotes cardiac arrest primarily to healthcare providers connotative: interpretation of meaning of word influenced by thoughts, feelings, or ideas people have about the words. patients may perceive "serious condition" to near death but nurse meant it as the nature of the illness

Message

content of the communication, verbal and nonverbal expressions of thoughts and feelings

SKELETAL MUSCLES

contract and relax working elements of movment

Synergistic Muscles

contract to accomplish the same movement, for example, when the arm is flexed the strength of the contraction of the biceps brachii is increased by contraction of the synergistic muscle, the brachialis

older adults have to redefine their relationship with their children who have grown and left home as the older adult continues to age what issues come up regarding the children in relation to the aging parent.

control of decision making dependence conflict guilt loss

Diaphoresis Physiological reactions to pain

controls body temp during stress

BODY MECHANICS

coordinated efforts of musculoskelatal and nervous systems; how a person moves during daily activity

What is gerontological nursing?

creative approach for maximizing the potential of older adults.

Effective communication

critical-thinking self-confidence asking for help if something is uncertain Integrity Humility

developmental realm

current family transitions, family stage task completion or progression, individual developmental issues that affect family development, development of health issue and family impact

FACTORS THAT CONTRIBUTE TO THROMBUS FORMATION - VIRCHOW'S TRIAD

damage to vessel wall alterations in blood flow alterations in blood constituents

some older adults deny functional ______ and ______ to ask for help with tasks that place their safety at great risk.

decline; refuse

What are the age related changes for vision in older patients?

decreased ability to adjust to night vision decreased ability to detect moving objects decreased color perception (especially with blues and greens) decreased depth perception decreased pupillary response to light limited upward gaze when assessing extraocular movements arcus senilis (arcus corneus) decreased eye lubrication presbyopia (difficulty focusing)

proprioception

decreased awareness of body positioning in space

What are age related changes for the urinary system?

decreased bladder capacity detrusor muscle instability decreased renal blood flow decreased glomerular filtration rate (HTN, UTI)

What are the age related changes for the musculoskeletal system?

decreased bone mass and density decreased joint mobility decreased height loss (loss of 1 to 3 inches) kyphosis decreasing muscle mass decreasing endurance and agility

calcification on the coastal cartilage causes

decreased mobility of the ribs

What are the age related changes for the gastrointestional system?

decreased olfactory and gustatory function (sweet and salty tastes diminished first) diminished saliva production delayed gastric emptying increased incidence of indigestion, abdominal distension, and flatus decreased anal tone and sensation

What are the age related changes for the integumentary system?

decreased skin elasticity decreased secretions of sweat and sebaceous glands thinning skin increased areas of skin pigmentation increased growth of benign skin lesions (actinic lentigines and seborrheic keratosis) increased fragility of blood vessels in the dermis, (leading to brusing and prupura) diminished wound healing increased variation in hair growth male pattern baldness (2/3 of all men) thinning head hair coarsening of hair in ears, eyebrows, and nose in men coarsening of hair on chin and upper lips in women slower growing, thicker nails longitudinal nail ridges graying hair (often begins in the 30's)

What are the signs and symtoms of hypovolemic shock

decreased urine output decreased blood pressure weak pulse cool clammy skin restlessness increased bleeding Increased thirst ??

METABOLIC CHANGES DUE TO IMMOBILITY

decreases metabolic rate alters metabolism of CHO, fats & proteins causes fluid, electrolyte & calcium imbalance causes GI disturbance - decreased appetite - slowing of peristalsis

NURSING INTERVENTIONS - RESPIRATORY SYSTEM

deep breath/coughing every 1-2 hours controlled coughing chest physiotherapy (CPT) incentive spirometry

DEVELOPMENTAL CHANGES - INFANTS, TODDLERS, & PRESCHOOLERS

delays in the following: gross motor skills intellectual development musculoskeletal development

RIGHT PERSON

delegating the right tasks to the right person to be performed on the right person

macrodrip tubing

delivers large drops; for a solution that needs to be given rapidly - 100 gtt/ml or more

microdrip tubing

delivers small drops; for a solution that needs to be given slowly - 60 gtt/mL

PARENTERAL NUTRITION

delivery of nutritional supplements through a central/peripheral intravenous catheter

GAIT

describes a particular manner/style of walking coordinated action that requires integration of: - sensory function - muscle strength - proprioception - balance - properly functioning CNS

PRIMARY NURSING MODEL

developed to place RNs at the bedside improves accountability of nursing for patient outcomes and the professional relationships among staff members supports the philosophy behind the nurse-patient relationship

five realms of family life that should-be accessed include

developmental,interactive ,integrity,coping.life

SIMS' POSITION

differs from the side-lying position in the distribution of the patient's weight. In Sims' position the patient places the weight on the anterior ileum, humerus, and clavicle.

Distraction for Pain

directs a client's attention to something other than pain and thus reduces the awareness of pain

aging does not inevitablity lead to _________ and __________.

disability and dependence

Gender influences communication, (women)

disclose more personal information and use more active listening

when A person begins to walk monitor for

dyspnea,chest pain or fatigue

In ambulatory surgery, nurses use the limited time available to

educate patients, assess their health status, and prepare them for surgery.

gestures

emphasize, punctuate, and clarify the spoken word pointing with frustrated face vs pointing to pain site

Input

ex.how the patient interacts with the environment and the patients physiological function.

What classification does a major surgery fall under ? and what is the description of one

extensive reconstruction or alteration in body parts ; poses great risk to well being example Coronary artery bypass ,removal of lung lobe Majior

appalachians (health care beliefs, response to illness, and implications for health and nursing)

external locus of control. nature controls life and health. accept folk healers. they dislike hospitals. tend to not follow medical regimens but expect to be helped directly when seeking episodic treatment. they become anxious in unfamiliar settings. encourage communication with family and friends when ill.

Public communication adaptations:

eye contact, gestures, voice inflection, use of media

Nightingales theory

facilitate the reparative processes of the body by manipulating the patients environment. (ex. noise, nutrition, hygiene, light, comfort, socialization, and hope.)

current trends and new family forms

families are smaller, couples are having no children, remarriage results in blended families, homosexual couples are family units, women are delaying childbirth, divorce rates have tripled since the 1950s, single-parent families are prevalent, America is aging.

health realm

family health beliefs and beliefs about health concern or problem, health behaviors of the family, health patterns and health management activities, family care taking responsibilities, disease conditions-treatments-and consequences for the family, family illness stressors, relationship with health care providers and health system access.

interactive realm

family relationships, family communication, family nurturing, intimacy expression, social support, conflict resolution, roles, family leisure life

What do you pay attention to when taking a patients history?

family, social, and community support systems, cognitive impairments, safety issues (fall risk) and functional status and ADL's.

FIBROUS JOINTS

fit closely together and are fixed, permitting little, if any, movement syndesmosis between the tibia and fibula

Fibrous Joints

fit closely together and are fixed, permitting little, if any, movement such as the syndesmosis between the tibia and fibula

Mischel's theory of uncertainty in illness

focuses on patients experiences with cancer while living with continual uncertainty, helps nurses understand how patients cope.

Benner and Wrubel's theory

focuses on patients need for caring as a means of coping with illness. Caring is central to the essence of nursing.

russian orthodox church dietary regulations

followers observe fast days and a no-meat rule on wednesdays and fridays. during lent all animal products, including dairy products and butter, are forbidden.

SHEAR

force exerted against the skin while the skin remains stationary and the bony structures move

AUTONOMY

freedom of choice and responsibility for the choices

Nurse and Physician Communication

frequent occurrence communication across a hierarchy can be intimidating gender or cultural issues may complicate further often named as cause of nurse job dissatisfaction critical for patient safety

what begins during the initial nurse-patient encounter and includes a quick but careful head to toe scan of the older adult that the nurse writes a brief description

general survey

SBAR background

give patients presenting complaint give the patients relevant past medical history brief summary of background

spiritual well being scale (SWB)

has 20 questions that assesses a patient's relationship with God and his or her sense of life purpose and life satisfaction.

hope

has several meanings that vary on the basis of how it is being experienced; it usually refers to an energizing source that has an orientation of future goals and outcomes.

spiritual well-being

has two dimensions; one dimension supports the transcendent relationship between a person and God or a higher power. the other dimension describes positive relationships and connections that people have with others.

Cartilaginous Joints

have little movement but are elastic and use cartilage to unite separate body surfaces such as the synchondrosis that attaches the ribs to the costal cartilage

CARTILAGINOUS JOINTS

have little movement but are elastic and use cartilage to unite separate bony surfaces ribs to the costal cartilage when bone growth is complete, the joints ossify

BODY ALIGNMENT - SITTING

head is erect neck & vertebral column are straight body weight distributed evenly on the buttocks & thighs thighs are parallel and in horizontal plane both feet supported on the floor

BODY ALIGNMENT - STANDING

head is erect and midline shoulders & hips are straight and parallel vertebral column is straight arms at sides abdomen comfortably tucked (in)

SUPPORTED FOWLER'S POSITION

head of the bed is elevated 45 to 60 degrees, and the patient's knees are slightly elevated without pressure to restrict circulation in the lower legs.

The preoperative period may be several days or only a few hours long, with some patients assessed in the

health care provider's office, preadmission clinic, or anesthesia clinic or by telephone.

UNLICENSED ASSISTIVE PERSONNEL (UAP)

health care workers who are not licensed, but provide non-nursing custodial, health-related support to patients work under the direction of an RN includes client care technicians, nurse aides, CNAs, and unit secretaries

Buddhism (cont.) (implications for health and nursing)

health is an important part of life. good health is maintained by caring for self and others. medications are not always accepted because of belief that chemical substances in body are harmful.

what is the point of the preoperative

health maintenance baseline assessment before surgery to compare results

Neuman's theory

help individuals obtain total wellness through interventions. (ex. stress reduction)

NURSING INTERVENTIONS - METABOLIC SYSTEM

high protein/high calorie diet vitamin B supplement - energy metabolism vitamin C supplement - skin integrity/healing

Older adults have difficulty hearing ___________ sounds and distinguising consonants such as ___________.

high-pitched sounds s, z, t, f, and q

risk factors for caregiving

higher levels of stress and depression, lower levels of subjective well-being and physical health, female caregivers provide more direct care-report higher levels of burden and depression.

UAP - TASKS

housekeeping clerical transportation dietary support ADLs

developmental theories

human growth and development are orderly predictive processes that begin with conception and continue through death.

Nuclear family

husband wife and perhaps (one or more children)

seizure

hyperexcitation and disorderly discharge of neurons in the brain leading to a sudden, violent, involuntary series of muscle contractions that is paroxysmal and episodic, causing loss of consciousness, falling, tonicity, and clonicity

Roy's theory

identifies types of demands placed on patients. (ex. we help patient adapt to them)

SBAR situation

identify yourself, and the site you are calling from. Identify the patient by name, DOB, sex, age, reason for report. describe reason for phone call

PRESSURE ULCER

impairment of the skin as a result of prolonged ischemia (decreased blood supply) in tissues characterized initially by inflammation and usually forms over a bony prominence Ischemia develops when the pressure on the skin is greater than the pressure inside the small peripheral blood vessels supplying blood to the skin.

Preoperative assessment of vital signs and physical findings provides an

important baseline with which to compare postoperative assessment data.

Assessing ADL function during an assessment gives you what information?

important information of baseline functioning of patient and helps to guide discharge planning.

Orem's theory

in practice you assess and interpret data to determine patients self care needs, self care deficits, and self care abilities in management of their disease.

CENTER OF GRAVITY

in the midline the line of gravity is from the middle of the forehead to a midpoint between the feet Laterally the line of gravity runs vertically from the middle of the skull to the posterior third of the foot

circular transaction model

includes several elements: the referent, sender and receiver, message, channels, context or environment in which the communication process occurs, feedback, and interpersonal variables. In this model, each person in the communication interaction is both a speaker and a listener and can be simultaneously sending and receiving messages. Both parties view the perceptions, attitudes, and potential reactions to a sent message. Feedback from the receiver or environment enables the communicators to correct or validate the communication. This model also describes the role relationship of the communicators as complementary and symmetrical. Complementary role relationships function with one person holding an elevated position over the other person. Symmetrical relationships are more equal.

What are age related changes for the respiratory system?

increased time for respiratory rate to return to resting rate after activity shallow breathing diminished breath sounds in the lung bases decreased tidal volume increased rigidity of thorax and vertebrae

How does hypertension increase risk for a patient going into surgery?

increases risk for cardiovascular complication during anthesia (pt could have a stroke ,inadequate tissue oxygen

Most older adults remain functionally _______ despite the increasing prevalence of chronic disease.

independent

native americans dietary regulations

individual tribal beliefs influence food practices.

HYPOSTATIC PNEUMONIA

inflammation of the lung from stasis or pooling of secretions

feedback

informs the system of how it functions

modulation

inhibition of the pain impulse of the nociceptive process

Serotonin

inhibits pain transmission

Before the nurse assumes hearing loss what should she check for

inspect the external auditory canal for the presence of cerumen

five realms of family life-family health system assessment

interactive, developmental, coping, integrity, health

family durability

intrafamilial system of support and structure that may extend beyond the walls of the household

How do you interact with a vision impaired older patient?

introduce yourself when entering the room and inform patient when you are leaving angle lights away from patients face (prevents glaring) Make sure patient wears glasses (make sure lenses are clean) provide adaptive devices (magnifiers)

What are examples of altered presentation of illnesses in older adults in the home care setting:

investigate falls, focusing on balance, gait and neurological issues. monitor older adults with late stage heart disease for loss of appetite as an early symptom of impending failure. Drug-drug and drug-food interactions in the older patients who are seeing more than one provider and taking multiple medications are common. Watch for signs.

Nonverbal communication

involves the five senses and everything that does not involve spoken or written words as important as verbals: tone, eye contact, body positioning *unconsciously motivated and more accurately indicates a person's intended message sociocultural factors is a major influence on the meaning of nonverbals personal appearance, posture and gait, facial expression, eye contact, gestures, sounds, territoriality and personal space

Autonomy

is being self-directive and independent in accomplishing goals and advocating for others.

The nursing process

is central to nursing but not a theory

chronic pain

is chronic in the absence of an identifiable physical or psychological cause or pain perceived as excessive for the extent of an organic pathological condition

Assertiveness

is expressing feelings without judging or hurting others - intermittent eye contact, nonverbal communication reflecting interest, honesty, active listening, spontaneous verbal responses with confident voice, culturally sensitive use of touch and space - communicate self-assurance, communicates feelings, takes responsibility for choices, respectful of others - increases self-esteem and self confidence, increased development of effective interpersonal relationships, increases goal attainment "I want" "I feel" AIDET: acknowledge, introduce, duration, explain, thank you

Partilineal

is kinship that is only limited to the fathers family

Relaxation for Pain

is mental and physical freedom from tension or stress that provides individuals with a sense of self-control

Fictive

is nonblood kin but considered family in some cultures

assertive communication in patient care

is not: yelling or bullying accusatory being disrespectful of authority is: focused on patient noting your perceptions persistently raising concerns, intended to move toward desired action

acute pain

is protective, has a cause, is of short duration, and has limited tissue damage and emotional response

Regional anesthesia

is the injection of a local anesthetic to block a group of sensory nerve fibers

Emic Worldview

is the insider or native perspective

Symbolic communication

is the verbal and nonverbal symbolism used by others to convey meaning such as art and music.

Bilineal

kinship that extends to both the fathers and mothers side of the family.

Matrilineal

kinship that is only limited to the mother's family

what food are cross contraindicated for patients with latex allergies ?

kiwi avacodos potaotes chestnuts bannans strawberries necterines tomatoes wheat

BODY ALIGNMENT - LYING DOWN

lateral position head supported by pillow while body is supported by mattress vertebrae should be aligned without causing discomfort

Pain tolerance

level of pain a person is willing to put up with

The assessment of an older adult takes long or shorter than a younger adult

longer because of the longer life and medical history and potential for complexity of the history

MUSCULOSKELETAL CHANGES

loss of endurance, strength, and muscle mass decreased stability/balance impaired calcium metabolism impaired joint mobility osteoporosis joint contractures footdrop

What are the more common losses?

loss of health, loss of significant other, sense of being useful, loss of socialization, loss of income, and loss of independent living

What are the age related changes for the nervous system?

loss of nerve cells in the brain and spinal cord diminished perceptions of deep pain and temperature decreased speed of fine motor movements diminished deep tendon reflexes decreased ability to respond to multiple stimuli decreased writing reflexes decreased pupil size decreased stage 4 sleep modest decline in ability to learn new things

How do you communicate effectively with the older patient?

lower the pitch of your voice speak more slowly pronounce words clearly. ****Do not shout it raises the pitch of your voice****** use visual cues such as hand gestures and facial expressions

metabolic alkalosis

lungs retain CO2 to lower pH loss of acid or excess base Hypokalemia elevation of HCO3- usually caused by an excessive loss of metabolic acids pH up, PaCO2 normal, HCO3 up

Explain the purpose of perineural local anesthetic infusion

manage pain from a variety of surgical procedures with a pump that is set as a demand or continuous mode and left in place for 48 hours

posture and gait

manner or pattern of walking are forms of self-expression reflects attitudes, emotions, self-concept, health status

restraint

manual method that immobilizes or reduces the ability of a patient to move a body part freely.

families and health

many factors relating the the family influence health. the family's class and ethnicity produce different access to the health care system. the family's beliefs, values, and practices influence health behaviors

the caregiver

may have conflicting responsibilities for aging parents, children, spouse, and job. may frequently try to "do it all". may not recognize need for help or request help. may not focus on own health care

Channels

means of sending and receiving messages through visual, auditory, and tactile senses facial expressions send visual messages spoken words travel through the auditory channel message may be better understood if multiple channels are used

3 malignancies related to sun exposure

melanoma, basal cell carcinoma and squamous cell carcinoma

jehovah's witnesses dietary regulations

members avoid food prepared with or containing blood.

Assimilation

members of an ethnocultural community are absorbed into another community and lose their unique characteristics such as language, customs, and ethnicity.

Feedback

message a sender receives from the receiver indicates whether receiver understood the message from the sender occurs simultaneously between sending and receiver sender seeks verbal and nonverbal feedback to evaluate the receiver's response and how effective the message was communicated

Relevence

messages more important to situation at hand are more effective discussing risks of smoking before emergency surgery is not relevant

Range of Motion (ROM)

mobility

middle-range theories

more limited in scope and less abstract, focuses on a specific field of nursing.

With aging comes a decrease in gastric________ and impaired sensation to __________.

motility, defecate

Islam (health care beliefs and response to illness)

must be able to practice five pillars of islam. sometimes has fatalistic view of health. muslims use faith healing. family members are comfort. group prayer is strengthening. they often permit withdrawal of life support. they do not practice euthaniasia. they believe that time of death is predetermined and cannot be changed. they maintain sense of hope and often avoid discussions of death.

PATIENT/FAMILY CENTERED CARE MODEL

mutual partnerships among the patient, family, and health care team are formed to plan, implement, and evaluate the nursing and health care delivered

comprehensive assessments, information regarding strengths, limitations, and resources, the nurse and the older adult identify what

needs and problems

CARTILAGE

non-vascular supporting connective tissue located in the: - joints - thorax - trachea - larynx - nose - ear

Cartilage

nonvascular, supporting connective tissue with the flexibility of a firm, plastic material; because of its gristle-like nature, cartilage sustains weight and serves as a shock absorber between articulating bones

Muscle Tone

normal state of balanced muscle tension

changes in reproductive structure and function do what?

not affect libido; sexual desires, thoughts and actions continue throughout all decades of life

Herbals for Pain

not sufficiently studied; however, many use herbals such as echinacea, ginseng, gingko biloba, and garlic supplements

Henderson

nurse works with other health care professionals to help patient gain independence. ex. Henderson's 14 basic needs

Orientation phase

occur when the nurse and patient meet and get to know one another - set the tone for the relationship with a warm, empathetic, caring manner - recognize initial relationship superficial, uncertain, tentative - expect patient to test competence and commitment - closely observe patient and expect to be closely observed back - assess patient's health status - prioritize their problems and identify their goals - clarify the patient's and your roles - form contracts that will specify who will do what - let the patient know when to expect the relationship to be terminated

Pre-interaction phase

occurs before meeting the patient: - review available data, medical and nursing history - talk to other caregivers who have information about the patient - anticipate health concerns or issues that arise - identify location and setting that fosters comfortable, private interaction - plan enough time for the initial interaction

Termination phase

occurs during the ending of the relationship - remind patient that termination is near - evaluate goal achievement with patient - reminice about relationship with patient - separate from patient by relinquished responsibility for his or her care - transition to other caregivers as needed

Working phase

occurs when the nurse and the patient work together to solve problems and accomplish goals - encourage and help the patient to express feelings about their health - encourage and help the patient with self-exploration - provide informtion needed to understand and change behavior - encourage and help set goals - take action to meet the goals - use appropriate self-disclosure and confrontation - use therapeutic communication skills to facilitate successful interactions

spirituality

often defined as an awareness of one's inner self and a sense of connection to a higher being, nature, or some purpose greater than oneself.

disengagement

oldest psychosocial theory, states aging individuals withdraw from customary roles and engage in more introspective, self focused activities

WHEN TO MEASURE VITAL SIGNS

on admission to a health care facility during home care visit physical condition changes reporting of non-specific symptoms *BEFORE/DURING/AFTER...* blood transfusions medication administration therapy that affects cardio/resp/temp nursing interventions

A fall risk assessment should be conducted when?

on admission, following a fall whenever the patients status changes

Nursing diagnoses for a surgical patient apply to nursing care during

one or all phases of surgery.

HEMIPLEGIA

one-sided paralysis

depression

onset: happens with major life changes, often abrupt but can be gradual course: diurnal effects, typically worse in the morning; situational fluctuations but less than with delirium progression: variable, rapid or slow but even duration: lasts at least 6 weeks sometimes several months to years consciousness is clear alertness: normal attention is minimal impairment but easily distracted orientation selective disorientation memory is selective or patchy impairment, islands of intact memory, evaluation often difficult because of low motivation thinking is intact but with themes of hopelessness, helplessness or self deprecation perception is intact, delusions and hallucinations absent except in sever cases psychomotor behavior is variable; psychomotor retardation or agitation sleep/wake cycle is disturbed; usually early morning awakening associated features: affect depressed; dysphoric mood; exaggerated and detailed complaints; preoccupied with persona thoughts; insight present; verbal elaboration; somatic complaints, poor hygiene, neglect of self assessment:failings high lighted by individual, frequent don't knows, little, frequently gives up, indifferent toward test; does not care or attempt to find answer

Delirium

onset: sudden/abrupt; depends on cause course: short, daily fluctuations in symptoms; worse at night, in darkness, and on awakening abrupt progression duration: lasts hours to less than 1 month; longer if unrecognized and untreated consciousness is reduced/disturbed alertness fluctuates; lethargic or hypervigilant attention is impaired; fluctuates; inattention; distractible orientation generally impaired; severity varies memory is recent and immediate impaired; forgetful; many need instructions for simple tasks one step at a time thinking is disorganized; distorted, fragmented, illogical; incoherent speech, either slow or accelerated perception is distored, illusions, delusions, and hallucinations; difficulty distinguishing between reality and misperceptions psychomotor behavior is variable; hypokinetic, hyperkinetic, and mixed sleep/wake cycle is distrubed/wake cycle is reversed associated features: variable affective changes; symptoms of automomic hyperarousal; exaggeration of personality type; associated with acute physical illness assessment: distracted from task; makes numerous errors

Respiratory depression is an adverse effect of ?

opioids

Communication in small group should be:

organized, concise, complete

TOTAL PATIENT CARE

original care delivery model developed during Florence Nightingale's time. RN is responsible for all aspects of care for one or more patients during a shift of care works directly with patients, families, and health team members primarily found in critical care areas

Etic worldview

outsider's perspective

Hemiparesis

paralysis of one side of the body, hemiplegia; this condition causes decreased sensation which creates risk to the musculoskeletal system when lying down

Is malignant melanoma an age related change to skin or pathology changes?

pathology. In early stages it can be confused with seborrheic keratosis or be overlooked. Look for asymmetry, irregular boarders, variations in color and in diameter greater than 6mm.

goals of a therapeutic relationship

patient achieving optimal personal growth related to personal identity, ability to form relationships, ability to satisfy needs and achieve personal goals

SIDE-LYING POSITION

patient rests on the side with the major portion of body weight on the dependent hip and shoulder.

SUPINE POSITION

patient's in supine position rest on their backs the relationship of body parts is essentially the same as in good standing alignment, except that the body is in the horizontal plane.

NURSING INTERVENTIONS - MUSCULOSKELETAL SYSTEM

perform active/passive ROM exercises use continuous passive motion (CPM) machines

ACTIVE RANGE OF MOTION

performed by the patient unassisted performed to the point of patient's ability

PASSIVE RANGE OF MOTION

performed by the practitioner (nurse, therapist, etc) performed to the point of resistance should not cause pain

epidural anesthesia

permits control or reduction of severe pain and reduces the client's overall opioid requirement; can be short- or long-term

Domain

perspective of a profession, provides bot a practical and theoretical aspect of the discipline.

EXERCISE

physical activity for conditioning the body, improving health, and maintaining fitness

internal factors that exist within a patient system

physiological and behavioral responses to illnesses

NURSING INTERVENTIONS - INTEGUMENTARY SYSTEM

position/reposition patient every 1-2 hours provide skin care

Structured preoperative teaching positively influences a patient's

postoperative recovery.

What are the age related changes for hearing in the older patient?

presbycusis (decreased ability to hear high frequency tones) cerumen buildup

Osmotic pressure

pressure that must be applied to prevent osmotic movement across a selectively permeable membrane

INTEGUMENTARY CHANGES

pressure ulcers INFLAMMATION ; ISCHEMIA break in skin integrity

FUNCTION OF SKELETAL SYSTEM

protects vital organs - skull (the brain) - ribs (heart & lungs) aids in calcium regulation.

NURSING INTERVENTIONS - ELIMINATION SYSTEM

provide adequate hydration serve diet rich in fluids, fruits, vegetables, and fiber

Leininger's theory

providing care with knowledge and caring as central force. (ex using emerging science)

When a patient with chronic pain seeks pain medication from multiple primary health care providers, the patient is called a drug seeker but not an illicit drug abuser.this called of addiction is called ?

pseudoaddiction.

The Joint Commision

recognized need to promote effective communication for patient and family-centered care, cultural competence, and improved patient safety created standards to promote this and became part of requirements

Immunizations

reduces, and in some cases prevents, the transmission of disease from person to person

Metacommunication

refers to all factors that influence communications. kid is tense but says "surgery is no big deal" need to further explore what the patient is feeling

AUTHORITY

refers to formal legitimate power to give commands and make final decisions specific to a given position

Ethnohistory

refers to significant historical experiences of a particular group

BODY ALIGNMENT

relationship of one body part to another while in different positions positioning of the joints, tendons, ligaments, and muscles while standing, sitting, and lying center of gravity is stable

serotonin

released from the brain stem and dorsal horn to inhibit pain transmission

What do you do if the patient does not understand a question?

rephrase the question (do not repeat the question)

What classification does a reconstruction/restorative surgery fall under ? and what is the description of one

restores function or appearance to traumatized or malfunction tissue . Ex:Internal fixation of fractures Purpose

Delirium or acute confusional state is potentially a ______.

reversible cognitive impairment

RIGHTS OF MEDICATION ADMINISTRATION

right medication right patient right dosage right route right time right documentation right reason

FIVE RIGHTS OF DELEGATION

right task right circumstances right person right direction/communication right supervision/evaluation

What is the psychosocial stresses of retirement?

role changes with the spouse or within the family and to loss of the work role; sometimes problems with social isolation and fiances are present

Transactional communication

role of sender and receiver switching back and forth between nurse and patient

Acculturation

second-culture learning that occurs when the culture of a minority is gradually displaced by the culture of the dominant group in the process of fully understanding.

Symmetrical Role Relationships

sender and receiver are equal; Nurses assume a symmetrical role in working with a client as partner on developing mutually defined goals

SCD

sequential compression device applying SCDs can be delegated to nursing assistive personnel (NAP)

Surgery is classified by level of

severity, urgency, and purpose.

effective care teaming

shared goals respectful-encourages participation open discussion of conflicts usually decision making by consensus frequent, constructive criticism shared governance assignments clear and acceptedly all feelings frequently expressed frequent and ongoing focus on solutions

Ethnicity

shared identity related to social and cultural heritage such as values, language, geographical space, and racial characteristics

circular transactional communication process

shows the situational contextual inputs, channels of communication, interpersonal contextual concepts, and factors affecting the sender and receiver

Cues that initiate the communication process

sights, sounds, sensations, perceptions, ideas

SCD/TED HOSE - CONSIDERATIONS

skill can be delegated to NAP assess for risk factors in VIRCHOW's TRIAD DO NOT MASSAGE patient's legs avoid wrinkles in elastic stockings

What are gastrointestinal function changes for older patients?

slowing of peristalsis and alterations in secretions

URINARY STASIS

slowing or stopping of urine flow In the upright position urine flows out of the renal pelvis and into the ureters and bladder because of gravitational forces. When a patient is recumbent or flat, the kidneys and ureters move toward a more level plane. Urine formed by the kidney needs to enter the bladder unaided by gravity. Because the peristaltic contractions of the ureters are insufficient to overcome gravity, the renal pelvis fills before urine enters the ureters

Enculturation

socialization into one's primary culture as a child

important initial component of interpersonal communication

socialization: easy, superficial, not deeply personal whereas therapeutic communication are often more intense, difficult, and uncomfortable

buddhism dietary regulations

some are vegetarians and do not use alcohol. many fast on Holy Days.

christianity dietary regulations

some baptists, evangelicals, and pentecostals discourage use of alcohol and caffeine. some roman catholics fast on Ash Wednesday and Good Friday. some do not eat meat on fridays during lent.

judaism dietary regulations

some observe the kosher dietary restrictions (e.g., avoid pork and shellfish, do not prepare and eat milk and meat at same time).

hinduism dietary regulation

some sects are vegetations. the belief is not to kill ANY living creature.

Chvostek's sign

spasm of the facial muscles produced by sharply tapping over the facial nerve in front of the parotid gland and anterior to the ear; suggestive of latent tetany in patients with hypocalcemia

Antigravity muscles

stabilize joints; these muscles continuously oppose the effect of gravity on the body and permit a person to maintain an upright or sitting posture

GAIT BELT - CONTROLLED FALL TECHNIQUE

stand with feet apart to provide a base of support extend one leg and let patient slide against it to the floor bend knees to lower body as patient slides to the floor

communication with other healthcare workers

step 1: gather and clarify all of the information you need to provide to the physician -nature of the problem -supporting information or data -clarify in your mind what you would like for the patient to do step 2: state concisely to the physician the problems that the patient is experiencing -nature of the problem -supporting information or data -question or issue on which you need his/her input -SBAR step 3: actively listen to information communicated by the physician/healthcare worker -listen to the plan of care -clarify areas which are unclear by asking appropriate questions step 4: know how to tactfully use assertive communication when necessary -state your concern -state information that supports your concerns -suggest a course of action -recap why you feel this action is best option

What theories describe the biopsychosical processes of aging?

stochastic nonstochastic disengagement activity continuity developmental gerotranscendence

name factors associated with family violence

stress,poverty and social isolation

psychosocial theories

strive to meet the physiological, psychological, sociocultural, developmental and spiritual needs of patients.

myocaridal infarction in an older patient may present with what symptoms

sudden onset of dyspnea accompanied by anxiety and confusion

Continuity Theory

suggests that personality remains stable and behavior becomes more predictable as people age.

Primary responsibility for informed consent rests with the patient's

surgeon.

grand theories

systematic and broad in scope, complex, and therefore require further specification through research.

In the older adult delirium sometimes accompanies

systemic infection-often the presenting symptom for pneumonia or UTI

pneumonia in an older patient may present with what symptoms

tachycardia, tachypnea, and confusion with decreased appetite and functioning w/o fever and productive cough

Ability to relate to others

take initiative in establishing and maintaining communication, the be authentic, and to respond appropriately to the other person

RIGHT TASK

tasks to delegate are ones that: are repetitive require little supervision are relatively noninvasive are predictable potential minimal risk for example: simple specimen collection ambulating a stable patient preparing a room for patient admission

NURSING CARE DELIVERY MODELS

team nursing primary nursing patient/family centered care total patient care case management

Gender influences communication, (men)

tend to use less verbal communication but are more likely to initiate communication and address issues directly.

Ethnocentrism

tendency to hold one's own way of life superior to others.

territoriality and personal space

territoriality: need to gain, maintain, defnd one's right to space territory provides people with sense of privacy, identity, security, and control communication zones

TEAM NURSING MODEL

the RN is the leader who leads a team of other RNs, practical nurses, and nursing assistive personnel who provide direct patient care

Proprioception

the awareness of the position of the body and its parts; proprioceptors located on nerve endings in muscles, tendons, and joints monitor proprioception

What is functional status in older adults?

the capacity and safe performance of ADL's and instrumental activities of daily living

Mobility

the degree of the ability to move; has three parts, range of motion (ROM), gait, and exercise

nursing

the diagnoses and treatment of the human responses to actual or potential health problems

Output

the end product, ex. whether the patient's health status improves, declines, or remains stable

Palliative care

the goal is to live life fully with an incurable condition

Theory-based nursing practice

the integration of theory into nursing practice

Gait

the manner or style of walking, including rhythm, cadence, and speed

Perception

the point at which a person is aware of pain

Cultural competence

the process of acquiring specific knowledge skills and attitudes to ensure-delivery of culturally congruent care

Retirement affects who

the spouse, adult children, and even grandchildren along with person who retired

DISUSE ATROPHY

the tendency of cells and tissue to reduce in size and function in response to prolonged inactivity results from bed rest, trauma, casting of a body part, or local nerve damage

judaism (implications for health and nursing)

they believe that it is important to stay healthy. jews expect a nurse to provide competent health care. allow patients to express their feelings. allow family to stay with dying patient.

ACHILLES TENDON

thickest and strongest tendon in the body

Culture

thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups.

what is the goal of family centered nursing care

to address the comprehensive health care needs of a family to advocate,promote,support and provide for the well being and health of the patient and individual family members

transmucosal fentanyl

to treat breakthrough pain in opioid-tolerant clients, the unit is placed in the mouth and dissolved, not chewed

DELEGATION

transferring responsibility for the performance of an activity or task while retaining accountability for the outcome.

Retirement is a stage of life characterized by

transitions and role changes-letting go of certain habits and structure and developing new ones

family centered care

vales the family's role and contribution. identifies strengths and needs. collaborates with the family to solve problems. recommend resources to address concerns. educates by respectfully sharing information. provides support to the family, recalls family strengths. is culturally congruent

adjuvants/coanalgesics

variety of medications that enhance analgesics or have analgesic properties that were originally unknown

Subcultures

various ethnic, religious, and other groups with distinct characteristics from the dominant culture

Nonstochastic theories

view aging as the result of genetically programmed physiological mechanism within the body that control the aging process

stochastic theories

view aging as the result of random cellular damage that occurs over time. -The accumulated damage leads to the physical changes that are recognized as characteristics of aging process

DEVELOPMENTAL CHANGES - OLDER ADULTS

weaker bones increased fall risk increased physical dependence on others accelerated functional losses

S&S of Pneumonia

wet breath Rapid shallow respiration fever productive cough hypoxia tachycardia leukocytes Asymmetrical chest moments

Nature of communication process

what, when, where, why how to convey a message

single-Parent family

when one person leaves the nuclear family because of death,divorce,desertion or when a single person decides to adopt a child

blended family

when parents bring unrelated children from prior adoptive or foster parenting relationships into a new, joint living situation

Timing

when the patient expresses interest in communicating. ex: do not assess when patient is in distress

TENDONS

white, glistening, fibrous bands of tissue occur in various lengths/thickness strong, flexible, INELASTIC connect muscle to bone

LIGAMENTS

white, shiny, FLEXIBLE bands of fibrous tissue bind joints connect bones and cartilage ELASTIC aid joint flexibility/support

Ligaments

white, shiny, flexible bands of fibrous tissue that bind joints and connect bones and cartilage; they are elastic and aid joint flexibility and support

Islam (implications for health and nursing)

women prefer female health care providers. during month of ramadan muslims do not eat until after sun goes down. health and spirituality are connected. family and friends visit during time of illness. they usually do not consider organ transplantation or donation and postmortem examinations.

Older adults that retire from employment outside the home have to cope with loss of what.

work role

Lateral Violence

workplace bullying between colleagues sometimes occurs and includes behaviors such as withholding information, backbiting, making snide remarks or put downs, and nonverbal expressions of disapproval such as raising eyebrows or making faces. leads to job dissatisfaction, poor teamwork and retention of qualified nurses, nurses leaving the profession symptom of compassion fatigue, perceive threat and act emotionally instead of talking through it

Commonly used preoperative medications include:

• Sedatives: Used for relaxation and decrease in nausea • Tranquilizers: Used to decrease anxiety and relax skeletal muscles • Narcotic analgesics: Used to sedate, decrease pain and anxiety, and reduce the amount of anesthesia needed • Anticholinergics: Used to decrease mucous secretions in the oral and respiratory passages and prevent laryngospasm

Benefits of patient-controlled analgesia (PCA):

• allows clients to self-administer opioids with minimal risk of overdose • the goal is to maintain a constant plasma level of analgesic to avoid the problems of prn dosing