Process FINAL
maturation phase
the third phase of wound healing, in which scar tissue forms (Collagen fibers remodeled, Tensile strength increase, Contraction (shrinkage) of wound)
Factors Affecting Skin Integrity
-Age -Mobility status -Nutrition/hydration -Sensation level -Impaired circulation -Medications -Moisture -Fever -Infection -Lifestyle
RIPS pain scale
(riley infant pain scale) used for under one year of age
Psychosocial Development: Erikson's 8 Stages
*Stage I: Trust vs. Mistrust (Birth-about 18 months) *Stage 2: Autonomy Vs. Shame & Doubt (18 months-3 yrs.) *Stage 3: Initiative Vs. Guilt (3-5yrs.) *Stage 4: Industry Vs. Inferiority (6-11yrs.) *Stage 5: Identity Vs. Role Confusion (11-21yrs.) *Stage 6: Intimacy Vs. Isolation (21-40yrs.) *Stage 7: Generatively Vs. Stagnation (40-65 yrs.) *Stage 8: Ego Integrity Vs. Despair (Over 65ys.)
Strategies to promote motivation for learning
Act interested in the patient and the learning process Create a warm, friendly environment Act enthusiastic Provide rewards and incentives Help the client see the importance of learning
Who do we care for?
All ages; the well, the ill, disabled and dying.
What are the initiatives of the institute of healthcare improvement?
Are to make sure that healthcare improves and has better safer practices. Set standards, such as approval of the abbreviations list, and accreditation of facilities to make sure that they are providing the care needed and safety.
Barriers to communication
Asking too many questions Fire-Hosing Information Asking Why Changing the subject inappropriately Failing to Probe Expressing approval or disapproval Offering Advice Providing False Reassurance Stereotyping Using Patronizing Language
Stage 3 Pressure ulcer
Full-thickness pressure ulcer extending into the subcutaneous tissue and resembling a crater. May see subcutaneous fat but not muscle, bone, or tendon.
stage 4 pressure ulcer
Full-thickness tissue loss with exposed bone, muscle, or tendon
A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet?
Broth, Coffee, Gelatin
What is the interdisciplinary team and who are some the members?
Doctors, Physical therapy, nurses, nurse aids, dietary, OT, Pharmacy, housekeeping, maintenance, mid-levels, spiritual care, Respiratory therapist, Radiology tech. Surgical team and clerical staff.
Bloom's Domains of Learning
Cognitive (knowledge), Social (attitude), and Psychomotor (skills).
group communication
Communication in which one person is communicating with an audience of two or more people. The roles of communicator and audience can be changing constantly.
How is this team valuable in caring for your patient?
Each bring expertise and provides an environment of holistic care for the client.
Stage 6: Intimacy Vs. Isolation (21-40yrs.)
Erickson defines intimacy as "the capacity to commit himself to concrete affiliations and partnerships and to develop the ethical strength to abide by such commitments" This stage develops commitments to relationships and work. Failures= impersonal relationships and difficulty with maintaining a job
What is the most common type of hypertension?
Essential hypertension
Stage 7: Generatively Vs. Stagnation (40-65 yrs.)
Goal is to be creative and productive; accomplished through work/relationships (raising healthy, functional children, contributing to society by developing a distinguished career) May show stagnation if they fail to achieve these things
Where do nurses work and care for their client (patient)?
Hospital, community, schools, industry, education, research, government. Clinics
What does IOM stand for?
Institution of medicine
Define nursing?
Nurses encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people, advocacy. Promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management and education are also key nursing role
What is the purpose of nursing?
Promotion of health, prevention of illness, and the care of ill.
What does QSEN state for?
Quality and Safety Education for Nurses.
What are the patient safety goals?
a. Identify patients correctly, b. improve staff communication, c. Use medicines safely, d. Use alarms safely, e. prevent infection, f. identify patient's safety risks, g. Prevent mistakes in surgery.
proliferation phase
The second phase of wound healing, in which new tissue forms, closing off the wound. (fibroblasts enter the wound, collagen synthesis, new blood & lymph vessels form, epithelial proliferation & migration)
Which form of communication is the nurse using when interviewing the patient during the admission health history and physical assessment? a. Small Group b. Intrapersonal c. Group d. Interpersonal
d. Interpersonal
Serosanguinous drainage
Thin watery drainage that is blood tinged (might be pink)
A female patient refuses to have a male nurse provide care. Which intervention by the charge nurse is best? a. Explore with the patient her beliefs and determine which might have caused her to make this statement. b. Assure the patient that each nurse is capable of providing professional nursing care, regardless of gender. c. Comply with the patient's request and assign a female nurse to care for the patient. d. A female patient refuses to have a male nurse provide care. Which intervention by the charge nurse is best?
a. Explore with the patient her beliefs and determine which might have caused her to make this statement.
Neuman's Continuum
Views health as an expression of living energy available to an individual
Purulent drainage
Yellow-pus
Illness-Wellness Continuum
a model that illustrates the full range of health between the extremes of illness and wellness
Which question is most effective for assessing the psychosocial impact of chronic pain? a. "How has chronic pain affected your professional life?" b. "Does your family offer you emotional support?" c. "Do your coping strategies seem to be effective?" d. "Has chronic pain caused you to feel depressed?"
a. "How has chronic pain affected your professional life?"
You are working at a telephone hotline center when Abby, a rape victim, calls. Abby states she is afraid to go to the hospital. What is your best response? a. "I am here to listen and we can talk about your feelings." b. "You don't need to go to the hospital if you don't want to go." c. "If you don't go to the hospital we can't collect evidence to help convict your rapist." d. "Why are you afraid to seek medical attention?"
a. "I am here to listen and we can talk about your feelings."
The nurse is educating a female patient about hygiene measures to reduce her risk for a urinary tract infection (UTI). What does the nurse instruct the patient to do? a. "wipe front to back" b. "only use white toilet paper" c. "douche-but only once a month" d. "wipe with soft toilet paper"
a. "wipe front to back"
Cleansing hands with an alcohol-based hand rub (hand sanitizer) is appropriate in which situation? a. After handing oral medications to a patient b. After working with a patient who has diarrhea due to Clostridium difficile c. After using the bathroom d. To cleanse visibly soiled or sticky hands
a. After handing oral medications to a patient
Which nursing action reflects correct use of the Wong-Baker FACES® Pain Rating Scale? a. Encouraging the patient to choose a cartoon face that best represents the pain b. Instructing the patient to choose a phrase that best describes the pain c. Matching a face shown on the scale to the patient's facial expression d. Asking the patient to rate the pain using a horizontal 0- to 10-point scale
a. Encouraging the patient to choose a cartoon face that best represents the pain
An 80-year-old patient is bedridden after having a cerebrovascular accident (CVA). Which nursing intervention does the nurse use to help prevent skin breakdown? a. Ensuring the patient's skin remains dry and clean b. Turning and repositioning at least every 4 hours c. Applying moist packs to the skin every shift d. Decreasing calories consumed; avoiding weight gain
a. Ensuring the patient's skin remains dry and clean
A client from a non-American culture says that to maintain health there needs to be a balance between the body and nature. Which health belief system does this client follow? a. Holistic b. Biomedical c. Scientific d. Magico-religious
a. Holistic
public speaking
the process of speaking with a purpose to a group of people in a relatively formal setting
Which of the following are goals of Healthy People 2020? a. Increase access to health services for all people. b. Attain high-quality life living longer free of preventable disease. c.Free universal health care for all people. d. Have community awareness to increase physical environments and good health for all. e. Improve healthy behaviors such as improved school lunch programs.
a. Increase access to health services for all people. b. Attain high-quality life living longer free of preventable disease. d. Have community awareness to increase physical environments and good health for all. e. Improve healthy behaviors such as improved school lunch programs.
Which statement reflects correct education for a patient with a blood pressure (BP) of 136/86 mm Hg? a. Lifestyle modification is needed to decrease the workload of the heart. b. The BP is low and the patient should be further assessed for orthostatic hypertension. c. It is a normal reading, so no action is needed. d. The patient has hypertension or high blood pressure.
a. Lifestyle modification is needed to decrease the workload of the heart.
The nurse is assigned to the care of the following patients. In planning nursing care, the nurse knows to use touch cautiously when communicating with which patient? a. Older adult with a history of dementia admitted for dehydration b. Middle-aged woman just diagnosed with terminal lung cancer c. Middle-aged man experiencing the acute phase of myocardial infarction (MI) d. Young adult in the rehabilitative phase after arthroscopic surgery
a. Older adult with a history of dementia admitted for dehydration
Name six core competencies and nurse role in each?
a. Patient-centered care b. teamwork and collaboration c. evidence -based practice d. Quality improvement e. safety f. informatics
What are the most common serum laboratory tests to assess for generalized malnutrition? a. Prealbumin and albumin b. Iron and hemoglobin c. Glucose and insulin d. Vitamin D and calcium
a. Prealbumin and albumin
Deep tissue wounds, such as chronic pressure injuries, take longer to heal because they heal by which intention? a. Second b. First c. Third d. Mixed
a. Second
Which test does the primary health care provider recommend as the first step in assessment of incontinence in patients of any age? a. Urinalysis b. Digital Rectal Exam c. Voiding Cystourethrogram d. Electromygraphy of the pelvic muscles
a. Urinalysis
A nurse who is skilled in complementary and alternative medicine (CAM) therapies works on a cancer unit with patients who are terminally ill. For which patient symptom does the nurse use these therapies? a. Increased Pain b. cool extremities c. constipation d. memory loss
a. increased pain
Stage 8: Ego Integrity Vs. Despair (Over 65ys.)
acceptance of ones life, worth and eventual death; ego integrity reflects a satisfaction with life and an understanding of one's place in the life cycle Despair= sense of loss, discomfort with life and aging and fear of death
pain
an unpleasant sensory and emotional experience associated with actual or potential tissue damage
The registered nurse is teaching a student nurse about the risk factors associated with kidney problems. Which statement made by the student nurse indicates a need for further teaching? a. "Sudden onset of hypertension may lead to kidney disease." b. "A high dose of acetaminophen (Tylenol) will not affect kidney function." c."Iodinated contract medium interaction may lead to kidney dysfunction." d. "Pre-existing medical conditions such as Diabetes Mellitus increase the risk for kidney dysfunction."
b. "A high dose of acetaminophen (Tylenol) will not affect kidney function."
A nurse named Darryl has been hired to work in a psychiatric intensive care unit. He has undergone training on recognizing escalating anger. Which statement indicates that he understands danger signs in regard to aggression? a. "I need to be aware of patients who are withdrawn and sitting alone." b. "An obvious change in behavior is a risk factor for aggression." c. "Patients who seek constant attention are more likely to be violent." d. "Patients who talk to themselves are the most dangerous."
b. "An obvious change in behavior is a risk factor for aggression."
Considering the guilt that a patient feels after being sexually assaulted, which nursing assessment question has priority? a. "Do you want the police to be called?" b. "Do you have thoughts of harming yourself?" c. "Do you have someone you trust that can stay with you?" d. "Do you recognize the person who assaulted you?"
b. "Do you have thoughts of harming yourself?"
A patient who is using patient-controlled analgesia (PCA) is asleep. The nurse observes a family member pushing the PCA button for the sleeping patient. What does the nurse say to the visitor? a. "The patient is asleep and is not in pain." b. "Please allow the patient to push the button when needed." c. "Please don't touch any equipment in the patient's room." d. "Thank you. I am sure the patient appreciated that."
b. "Please allow the patient to push the button when needed."
What health care-acquired infection (HCAI) occurs most frequently? a. Pneumonia b. Catheter-associated urinary tract infection (CA-UTI) c. Surgical Site Infection (SSI) d. Catheter-related bloodstream infection (CR-BSI)
b. Catheter-associated urinary tract infection (CA-UTI)
A patient reports discomfort and pain when voiding. How does the nurse document this finding? a. Anuria b. Dysuria c. Oliguria d. Polyuria
b. Dysuria
The nurse notices a visitor walking into the room of a patient on airborne isolation with no protective gear. What does the nurse do? a. Tells the visitor that the patient cannot receive visitors at this time b. Provides a mask for the visitor c. Ensures that the patient is wearing a mask d. Provides a particulate air respirator to the visitor
b. Provides a mask for the visitor
Which of Bloom's domains of learning requires mental and physical activity? a. Cognitive b. Psychomotor c. Affective d. Application
b. Psychomotor
What must the nurse do in order to discuss a client's sexual health needs in a comfortable and competent manner? a. Perform an accurate and comprehensive physical assessment. b. Recognize and set aside personal biases or experiences related to sexuality. c. Collect an accurate and comprehensive sexual history. d. Acquire theoretical knowledge of sexual health concerns.
b. Recognize and set aside personal biases or experiences related to sexuality.
In the powerpoint the scenario about the first graders which level of health care promotion did you need to develop a teaching plan for? a.Secondary importance of the epi-pen for a bee sting b. The primary importance of handwashing to stop the spread of germs c.Tertiary balancing exercise with rest d. Primary covering your mouth when you cough.
b. The primary importance of handwashing to stop the spread of germs
Sanguineous drainage
bloody drainage
The registered nurse is teaching a student nurse about the main functions of the skin. Which statement made by the student nurse indicates a need for further teaching? a. "Skin is an excretory organ." b. "Skin acts as a protective barrier." c. "Skin prevents the activation of vitamin D when exposed to the sun." d. "Skin is responsible for sensations such as pain, pressure, temperature, and touch."
c. "Skin prevents the activation of vitamin D when exposed to the sun."
Which patient has the highest risk for hypertension? a. 45-year old male b. 30-year old female c. 65-year old female d. 70-year old male
c. 65-year old female (menopause)
A patient is receiving immune-suppressive therapy after kidney transplantation. Which measure for infection control is most important for the nurse to implement? a. Adherence to therapy b. Strict clean technique c. Handwashing d. Monitoring for low-grade fever
c. Handwashing
Which of the following models of Health and Illness talks about energy output exceeding input resulting in illness and wellness occurs when more energy is generated than expended? a. Dunn's Health grid b. The Health illness continuum c. Neumann's continuum d. Erickson's
c. Neumann's continuum
A patient refuses a dose of medication. How should the nurse document the event? a. Patient is belligerent and argumentative and refuses the 0900 dose of digoxin. b. 0900 dose of digoxin not given. c. Patient refuses the 0900 dose of digoxin. d. Patient is uncooperative and refuses the prescribed dose of digoxin.
c. Patient refuses the 0900 dose of digoxin.
The department of nursing at a local hospital is considering changing to charting by exception (CBE). Which statement provides a rationale to support making this change? a. Establishes an ongoing care plan from admission b. Is most useful when constructing a timeline of events c. Reduces the time nurses spend charting d. Addresses the patients concerns holistically
c. Reduces the time nurses spend charting
A patient tells the nurse, "I feel that God has abandoned me. I am so angry that I can't even pray." The patient refuses to see his clergyman when he calls. Which is the most appropriate nursing diagnosis for this patient? a. Risk for Spiritual Distress b. Moral Distress c. Spiritual Distress d. Impaired Religiosity
c. Spiritual Distress
What is wound dehiscence? a. Sealing of the wound incision line b. Crusting of the wound incision line c. Splitting open of the wound d. Protruding of the internal organs from the wound
c. Splitting open of the wound
serous drainage
clear, watery plasma
intrapersonal communication
communication with oneself
The nurse is preparing a patient for a computed tomography (CT) scan of the abdomen. Which statement by the nurse is best (all contain correct information)? a. "You will need to be NPO and drink this contrast medium before your test." b. "You will need to remain NPO for the 4 hours prior to your CT scan." c. "You may need to void before you go down to the department for your CT scan." d. "You cannot have anything to eat or drink for 4 hours before your test."
d. "You cannot have anything to eat or drink for 4 hours before your test."
The nurse is caring for four patients, and understands that which is at greatest risk of infection? a. 19-year-old with stomach pain b. 64-year-old with history of prostate hyperplasia c. 36-year-old prescribed a 10-day steroid taper d. 24-year-old with chronic kidney disease
d. 24-year-old with chronic kidney disease
A patient from Italy has lived in the United States for years and practices elements from both cultures. What is this patient demonstrating? a. Socialization b. Assimilation c. Immigration d. Acculturation
d. Acculturation
A patient is receiving nutritional supplements to restore nutritional status. What does the nurse do to assess the effectiveness of the supplements for the patient? a. Keeps an accurate and precise food and fluid intake record daily b. Assesses the patient's skin for evidence of breakdown weekly c. Monitors vital signs every 4 hours and as needed d. Makes certain the patient is weighed daily at the same time
d. Makes certain the patient is weighed daily at the same time
What is the best way for the nurse to prevent a patient's stage I pressure injury from advancing to stage II? a. Pad the injury. b. Massage the reddened areas. c. Suggest an egg crate mattress. d. Promote mobility and/or frequent repositioning.
d. Promote mobility and/or frequent repositioning.
What safety-related responsibility does the nurse have in any situation of suspected abuse? a. Protect the patient from future abuse by the abuser. b. Inform the suspected abuser that the authorities have been notified. c. Arrange for counseling for all involved parties but especially the patient. d. Report suspected abuse to the proper authorities.
d. Report suspected abuse to the proper authorities.
When a client has had a stroke and you are working with them to improve their balance and strength. Which Health care level are they in? a. Primary b. Secondary c. Rehabilitation d. Tertiary
d. Tertiary
The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse provides dietary teaching and should focus on foods high in which vitamin that may be lacking in a vegan diet? a. Vitamin C b. Vitamin E c. Vitamin K d. Vitamin B12
d. Vitamin B12
Stage 3: Initiative Vs. Guilt (3-5yrs.)
develop initiative by gradually assuming responsibility and developing self-discipline; the superego (conscience) develops and they learn to manage impulses failure to this stage leads to guilt, limited creativity, lack of self-confidence, and pessimism
Stage I: Trust vs. Mistrust (Birth-about 18 months)
develops trust by having their needs consistently met, this is the beginning of self-confidence. Infants who don't have this met develop mistrust and suspiciousness that will affect them later on in life
Factors effect communication
environmental personal space developmental variations gender territoriality roles and relationships sociocultural factors
Phases of healing
inflammatory, proliferative, maturation
Stage 1 pressure ulcer
intact skin with nonblanchable redness
Factors affecting learning
motivation, readiness to learn, relevance of content, timing, environment, health status, cultural aspects
Wong-Baker FACES pain rating scale
pain scale using drawn faces
Stage 2 Pressure Ulcer
partial thickness skin loss involving epidermis, dermis, or both
Dunn's Health Grid
plots a person's status on the health-illness continuum against environmental conditions
Visual Analog Scale (VAS)
points to a specific location on the scale (no pain to the worst possible pain)
Which are risk factors for secondary hypertension? a. kidney disease b. pregnancy c. hyperlipidemia d. smoking
pregnancy and kidney disease
Stage 5: Identity Vs. Role Confusion (11-21yrs.)
puberty; adolescents develop a sense of self and begin to make decisions about the future; healthy role models, social groups impact these stages behaviors A person who fails to recognize their abilities and sense of self is unable to experience a solid place in the world; adults will have interpersonal relationships and occupational performances
Which are risk factors for primary hypertension? a. pregnancy b. smoking c. obesity d. kidney disease e. hyperlipidemia
smoking and hyperlipidemia
interpersonal communication
the exchange of thoughts, feelings, and beliefs between two or more people
Stage 2: Autonomy Vs. Shame & Doubt (18 months-3 yrs.)
the goal for the child is to develop self-control and independence, requires an ability to cooperate and express feelings and thoughts failure to successfully complete this stage leads to an adult who lacks self-confidence
inflammatory phase
the initial phase of wound healing in which bleeding is reduced as blood vessels in the affected area constrict (Release of histamine, serotonin, vasodilation & increased permeability of capillaries, Migraine of WBCs)
Stage 4: Industry Vs. Inferiority (6-11yrs.)
they learn recognition comes through completion of tasks; success occurs primarily in schools failure= adults will have a sense of inadequacy in all areas of life
subjective data
things a person tells you about that you cannot observe through your senses
FLACC Scale (Face, Legs, Activity, Cry, and Consolability)
used to assess pain in children 2 months to 7 years or individuals who are unable to communicate their pain
Numeric pain scale
uses 0-10 to describe severity of pain
Simple Descriptor Pain Scale
uses one of these words...mild, moderate, severe, to describe pain level
objective data
what the health professional observes by inspecting, palpating, percussing, and auscultating during the physical examination