Super Super Foundations Set

Why is the carotid artery so important?

It supplies oxygenated blood to the head and neck The carotid artery reflects heart function better than peripheral arteries because its pressure correlates with the pressure of the aorta.

What will happen if the patient injects insulin into the thigh and then goes jogging?

Jogging could increase body heat and circulation, which could increase the rate of insulin absorption and speed the onset of action, thus resulting in hypoglycemia

What is footdrop?

Inability to dorsiflex and invert foot because of peroneal nerve damage

What position should a patient be in when examining the rectum?

Knee-chest or Sims

What are concave curves in the fingernail called?

Koilonychia (spoon nail)

What is droplet transmission?

Large particles that travel up to 3 feet and come in contact with susceptible host (e.g., from coughing, sneezing, talking)

When should you palpate tender areas?

Last

What position should a patient be in when examining the heart?

Lateral recumbent

What is criminal law?

Federal or state statutory laws that define as a crime certain actions that inflict or threaten substantial harm to individuals or the public interest without justification

What changes are expected in the reproductive system of an older adult?

Female: Decreased estrogen; decreased uterine size; decreased secretions; atrophy of epithelial lining of vagina; vaginal dryness Male: Decreased testosterone; decreased sperm count; erections less firm and slower to develop; decreased testicular size

Why are females at a greater risk for UTI than males?

Females have a shorter urethra

What is an aqueous suspension?

Finely dissolved drug particles dispersed in liquid medium; when suspension is left standing, particles settle to bottom of cont

What risk is associated with patients who are on supplemental oxygen?

Fire risk (oxygen is very flammable)

Macule

Flat, nonpalapable change in skin color

What is pigeon toes?

Internal rotation of forefoot or entire foot; common in infants

Why is potassium important?

It maintains the resting membrane potential of cardiac, skeletal, and smooth muscle contraction, allowing for normal muscle function

How do you assess the Oculomotor Nerve (CN 3)?

Measure pupil reaction to light reflex and accommodation Assess directions of gaze.

What position should a patient be in when examining the musculoskeletal system?

Prone

What does it mean to "cultivate a spirit of inquiry"?

Questioning and analyzing current clinical practices and believing in the value of EBP

What should be looked at when assessing an immobile patient's musculoskeletal system?

ROM, muscle strength, activity tolerance, and posture and alignment

What is the third heart sound (S3)?

Rapid ventricular filling

Why is this diagnostic statement wrong? Shortness of breath

Shortness of breath is a symptom and is *not enough info to identify a diagnosis*. Look at clusters of symptoms such as shortness of breath, pain on inspiration, and productive cough in a postoperative patient Correct diagnosis statement: Ineffective Breathing Pattern related to increased airway secretions

What is orthostatic hypotension?

a decrease in blood pressure of 40 mm Hg or more systolic or 20 mm Hg or more diastolic that occurs within 15 seconds of standing

How do you palpate the sinuses?

by exerting pressure with the thumb up and under the patient's eyebrow

Where/how is insulin produced?

by the β-cells in the islets of Langerhans of the pancreas

How are dysrhythmias classifed?

by their site of origin and cardiac response

What is menopause?

occurs when a woman stops ovulating and menstruating (12 months or more have passed since last menstrual flow)

What could pinpoint pupils mean?

opioid intoxication

What are vitamins?

organic substances present in small amounts in food and are essential for life They generally serve as coenzymes or catalysts in cellular enzyme reactions

What is friction?

surface damage caused by the skin rubbing against another surface that often results in an abrasion

What does patency of an IV catheter mean?

that fluid can flow easily through it.

What is the first heart sound (S1)?

the "lub" sound, caused by the mitral and tricuspid valves closing

What is postural drainage?

the use of positioning techniques to drain secretions from specific segments of the lungs and bronchi into the trachea for expectoration

What is palpation?

the use of the hands to touch body parts and make sensitive assessments

What happens during systole?

the ventricles contract and eject blood from the left ventricle into the aorta and from the right ventricle into the pulmonary artery

What happens during diastole?

the ventricles relax, and the atria contract to move blood into the ventricles and fill the coronary arteries

How much fluid does a normal, healthy person need to have adequate fluid intake?

up to 2300 mL of fluid in a 24-hour period

What does prn mean?

whenever there is a need

What is the sclera?

white of the eye

What are the 4 major sections of a problem-oriented medical record (POMR)?

1) Database 2) problem list 3) Care plan 4) Progress notes

What are 5 factors that influence communication?

1) Psychophysiological Context—Internal Factors Influencing Communication 2) Relational Context—Nature of Relationship Between Participants 3) Situational Context—Reason for Communication 4) Environmental Context—Physical Surroundings in Which Communication Occurs 5) Cultural Context—Sociocultural Elements That Affect Interaction

What are the 7 basic elements of the communication process?

1) sender 2) receiver 3) message 4) feedback 5) channel 6) interpersonal variables 7) environment

What are the five steps of the nursing process?

1. Assessment 2. Nursing Diagnosis 3. Planning 4. Implementation 5. Evaluation *(ADPIE)*

What are the 7 concepts (or traits) for a critical thinker?

1. Truth seeking 2. Open-mindedness 3. Analyticity 4. Systematicity 5. Self-Confidence 6. Inquisitiveness 7. Maturity

What are the 2 types of standards for critical thinking?

Intellectual standards and professional standards

What are variances?

Unexpected outcomes, unmet goals, and interventions not specified within the critical pathway

What does verbal communication involve?

Written and spoken word

What is compassion fatigue?

a combination of secondary traumatic stress and burnout experienced by professional and lay caregivers Secondary traumatic stress is the emotional trauma you experience when witnessing patients' traumatic experiences and stories of pain, fear, and suffering Burnout occurs when your perceived demands of caregiving outweigh the resources (e.g., staffing, supplies, time) you have available

What does nonverbal communication involve?

messages sent through body language without using words

What are reports?

oral, written, or audiotaped exchanges of information between members of the health care team

What is involved with clinical decision making?

problem solving and reasoning so you can choose the options that produce the best patient outcomes based on a patient's condition and priority of the problem

What is confidentiality?

safeguarding a patient's right to privacy by carefully protecting confidential information

In order to keep your nursing documentation succinct, what should you do?

• Stick to the facts • Write in short sentences • Use simple, short words • Avoid the use of jargon or abbreviations

What are strategies for communicating with children?

1) Avoid sudden movements 2) Be calm and gentle 3) Use a quiet, friendly, confident tone of voice 4) Use simple, direct language 5) Be honest 6) Prepare a child by explaining what to expect 7) Avoid overly lengthy or involved explanations 8) Meet at eye level 9) Use drawing or playing with toys to foster communication

What is the purpose of medical records?

1) Communication 2) Legal record of patient care 3) Healthcare reimbursement 4) Quality improvement 5) Research 6) Nursing education

What is the difference between a cue and an inference during assessment?

A cue is information you obtain through *your senses* An inference is your *judgment* or *interpretation* of these cues

What is SBAR?

A tool used in telephone and verbal reports: *S*ituation *B*ackground *A*ssessment *R*ecommendation

What are 11 attitudes for critical thinking?

A. Confidence B. Independence C. Fairness D. Responsibility E. Risk taking F. Discipline G. Perseverance H. Creativity I. Curiosity J. Integrity K. Humility

What does AIDET mean?

Each letter stands for part of a communication pattern that ensures that patients receive clear communication: • *A*cknowledge: Recognize and greet the patient • *I*ntroduce yourself: Provide your name, department, and job role on your initial visit. • *D*uration: The patient wants to understand how long an appointment, treatment, test, or procedure will take, including likely periods of waiting. • *E*xplanation: Discuss the reason for an appointment, test, intervention, or action with the patient. • *T*hanks: Demonstrate sincere appreciation to the patient and others.

What is complex critical thinking?

Learning to analyze data and examining choices more independently, looking beyond expert opinion, learning that you must consider alternative and perhaps even conflicting solutions.

The following is an example of which therapeutic communication technique? The patient asks whether the test for a blood clot will be painful, and the nurse responds, "The ultrasound test that your doctor has ordered is not painful. It involves moving a wand across parts of your body and uses sound waves to visualize your bloodstream for blockages."

Clarifying information

What does feedback mean (with respect to communication)?

Feedback is the message that the receiver returns to the sender (indicates whether the receiver understood the sender's message)

The following is an example of which therapeutic communication technique? The patient begins to ramble about the many painful medical tests and treatments that he had in the past following his injuries in the Vietnam War. The nurse asks "Are you concerned that your current problem may become very complicated and painful?"

Focusing

What is a clinical information system (CIS)?

It includes monitoring systems; order entry systems; and laboratory, radiology, and pharmacy systems.

What qualities should your nursing documentation have?

Nursing documentation should be: 1) Factual 2) Accurate 3) Current 4) Organized 5) Complete

The following is an example of which therapeutic communication technique? The patient states, "I've been walking more, and I don't need as much help as I did before." The nurse replies, "You feel you're getting stronger and more independent?"

Paraphrasing

What is the REFLECT model for nursing reflection?

R *R*ecall the events: Review the facts about a situation, and describe what happened. E *E*xamine your responses: Think about or discuss your thoughts and actions at the time of the situation. F Acknowledge *F*eelings: Identify any feelings you had during the situation. L *L*earn from the experience: Review and highlight what you learned from the situation, for example, your patient's responses and your actions. E *E*xplore options: Think about or discuss your options for similar situations in the future. C *C*reate a plan of action: Create a plan for action in future similar situations. T Set a *T*imescale: Set a time by which your plan of action will be completed.

The following is an example of which therapeutic communication technique? The patient voices reluctance to have help at home, even though he can see that he is not able to do everything he needs to for self-sufficiency. The nurse responds, "After I had surgery a few years ago it was hard for me to have someone help me with daily tasks I had always done myself. I have always been independent. Is that how it is for you?"

Self-disclosure

What is metacommunication?

The exploration of all factors that influence communication

What is a clinical decision support system (CDSS) ?

a computerized program used within the health care setting to aid and support clinical decision making

What is a clinical judgment?

a conclusion a nurse makes about a patient's needs, concerns, or health problems and/or the decisions to take or avoid action, use or modify standard approaches, or improvise new approaches based on the patient's response

What should you communicate with someone who is mute, unable to speak, or cannot speak clearly?

• Answer nurse call system in person. • Listen attentively, be patient, and do not interrupt or finish patient's sentences. • Ask simple questions that require "yes" or "no" answers. • Allow time for understanding and responses. • Use visual cues (e.g., words, pictures, objects) when possible. • Allow only one person to speak at a time. • Use normal volume and do not shout or speak too loudly. • Let patient know if you do not understand. • Use communication aids as needed: • Pad and felt-tipped pen or Magic Slate • Flash cards • Communication board with words, letters, or pictures denoting basic needs • Computer toy ("speak and spell" type) for children • Call bells or alarms • Sign language • Use of eye blinks or movement of fingers for simple responses ("yes" or "no") • Be attentive and responsive to restless physical movements.

The following is an example of which therapeutic communication technique? The nurse tells the patient that another ultrasound of his calf is scheduled to evaluate the effectiveness of his treatment. The nurse includes how long it will take and how long it will take to get the results of the test.

providing information

What is assertive communication?

the ability to be self-directive in acting to accomplish goals and advocate for others an assertive response promotes self-esteem and upholds personal and professional rights.

What is empathy?

the ability to understand and accept another person's perspective Empathic responses are neutral and nonjudgmental and foster shared respect.

What is narrative documentation?

the format traditionally used by nurses and health care providers to record patient assessment, clinical decisions, and care provided it simply uses a story-like format to document information

What does channel mean (with respect to communication)?

the means of conveying and receiving messages through visual, auditory, and tactile senses

What is nursing informatics?

the use of information and computer technology to support all aspects of nursing practice, including direct delivery of care, administration, education, and research

What should you communicate with someone who is unresponsive?

• Call patient by name during interactions. • Communicate both verbally and by touch. • Speak to patient as though he or she could hear. • Explain all procedures and sensations. • Provide orientation to person, place, and time as needed.

What does the research tell us about clinical judgments?

• Clinical judgments are influenced more by the nurse's experience and knowledge than by the objective data about the situation at hand. • Sound clinical judgment partly relies on knowing the patient and his or her typical pattern of responses as well as an engagement with the patient and his or her concerns. • Clinical judgments are influenced by the context of clinical situations and the culture of patient care units. • Nurses use a variety of reasoning patterns alone or in combination, including reflection.

What are school age children most at risk for (with respect to safety)?

Head injuries resulting from falls, motor vehicle injuries, and bicycle injuries Injuries from playground or sports

What can happen when a parent refuses medically necessary treatment for a child?

Health care providers sometimes petition the court to intervene on the child's behalf. Using the standard known as "the best interests of the child," courts may overrule parental decisions

When is the need for hospice indicated?

Hospice care is provided when curative care is forgone Requires physician certification that life expectancy is 6 months or less

What are borborygmi?

Hyperactive, loud, growling bowel sounds

What causes Xanthelasma (yellow lipid lesions in nasal portion of upper or lower eyelid)?

Hyperlipidemia; abnormal lipid metabolism

What produces a PaCO2 less than 35 mm Hg?

Hyperventilation

What are lipids?

fats (insoluble in water but soluble in organic solvents such as ethanol and acetone)

What are saturated fats?

fats that are saturated with as much hydrogen as they can hold Most animal fats have a high proportion of saturated fatty acids most vegetable fats have higher amounts of unsaturated fatty acids

What are symptoms of an upper urinary tract (pyelonephritis) infection?

fever (39° C [102.2° F]), chills, diaphoresis, flank pain, and lower back pain Older adults with a UTI often experience delirium, new or increased incontinence, agitation or absence of normal behavior, decreased appetite, and deteriorating mobility resulting in increased falls.

What are the primary areas to observe when physically assessing urinary function?

kidneys, bladder, external genitalia, urethral meatus, and perineal skin

Where is water absorbed during digestion?

large intestine

What is scoliosis?

lateral spinal curvature

How do you assess the Trochlear Nerve (CN 4)?

Assess directions of gaze.

How should you assess an immobilized patient's cardiovascular health?

Assess heart rate including the apical pulse Monitor peripheral pulses Check for capillary refill note the color of extremities Check for dependent edema Palpate legs to determine if there is tenderness or pain; observe legs' color. Carefully compare findings in both legs; unilateral redness, tenderness, and edema indicate possible DVT. Measure bilateral calf circumference and record it daily as an alternate way to assess for DVT

Tumor

Solid mass that extends deep through the subcutaneous tissue

What are conditions caused by angiopathy?

cardiovascular disease and strokes

What is post-mortem care?

care of the body after death

What is postmortem care?

care of the body after death (for immediate viewing by the family) -Close patient's eyes -Replace dentures -Wash and position body -Remove tubes and dressings if appropriate. -Straighten the body, leaving the pillow to support the head and prevent pooling of blood and discoloration of the face.

What is tissue ischemia?

decreased blood flow to tissues

What are alginate dressings?

highly absorptive dressings made of spun fibers of seaweed

What does the bladder do?

holds urine until the volume in the bladder triggers a sensation of urge, sending impulses to the sacral level of the spinal cord indicating the need to pass urine

What stage is a pressure injury if it is covered with eschar or slough?

It is unstagable

What is adduction?

Movement of extremity toward midline of body

How do you determine pack-years?

Multiply the number of years smoking by the number of packs smoked per day.

Why are patients with parenteral nutrition at risk for infection?

PN requires intravascular access and because of the high concentration of glucose in PN solutions

What is cardiopulmonary resuscitation (CPR)?

PR is a basic emergency procedure of artificial respiration and manual external cardiac massage.

What is chronic episodic pain?

Pain that occurs sporadically over an extended period of time is episodic pain. Examples are migraine headaches and pain related to sickle cell crisis.

What is dysuria?

Painful urination

Where should unopened insulin vials and insulin pens be stored?

in the refrigerator

What are signs/symptoms of hypermagnesemia?

lethargy, hypoactive deep tendon reflexes, bradycardia, hypotension

In order to accuse a nurse of malpractice, what must the patient prove?

(1) there was a provider-patient relationship between the nurse, or defendant, and the patient (2) the nurse breached the duty owed to the patient under that relationship (3) the patient's injury was due to the nurse's breach of duty (4) the patient has accrued damages (physical or monetary) because of the injury.

What would be an example of the "teach-back" method?

"We've gone over a lot of information today about how you might change your diet, and I want to make sure I explained everything clearly. In your own words, please review what we talked about. How will you make it work at home?"

What is a DNR?

"do not resuscitate" (CPR will not be administered)

What is the difference between colonization and infection?

*Colonization* is the presence and growth of microorganisms within a host but without tissue invasion or damage. *Infection* results only if the pathogens grow or multiply and alter normal tissue function.

What can decrease the fraction of inspired oxygen concentration (FiO2)?

*Decreased environmental oxygen* (the effect at high altitudes) or *decreased delivery of inspired oxygen* (e.g., incorrect oxygen concentration setting on respiratory therapy equipment) results in decreased FiO2.

What should you do if there is a minor discrepancy between the blood product label and the patient information?

*Do not give the blood.* Notify the blood bank immediately.

What are risk factors for primary hypertension?

-Age -Alcohol -Tobacco use -Diabetes mellitus -Elevated serum lipids -Excess dietary sodium -Gender -Family history -Obesity -Ethnicity -Sedentary lifestyle -Socioeconomic status -Stress

What are key characteristics of physical development of young adults?

-Completed physical growth -Peak of physical health -few severe illnesses

What are the interprofessional care goals when addressing hypertension?

-Control blood pressure -Reduce cardiovascular disease risk factors and target organ disease

Why is cultural and religious assessment of the patient important when considering end of life care?

-Attitudes and beliefs about death and dying differ dramatically -Satisfaction with care is linked to satisfaction with spiritual care -avoid assumptions, and ensure that patients and families are able to follow tenets of particular culture or religion as they wish

What factors should be considered when deciding upon a cancer treatment?

-Benefits of treatment must outweigh risks -Patient must be given some idea of the benefits of proposed therapy -One of these three should be possible: Cure, prolongation of life, palliation

What kind of objective data should a nurse collect when assessing a patient with hypertension?

-Blood pressure readings -Heart sounds -Pulses -Edema -Body measurements -Mental status changes

What is the purpose of radiation in cancer treatment?

-Can kill tumor & reduce size -Relieve pain, obstruction -Works by injuring DNA in rapidly dividing cells

What are examples of known carcinogens?

-Chemicals -Occupational hazards -Viruses -Drugs -Hormones -Radiation

What are other diseases or conditions that can cause diabetes?

-Cushing syndrome -hyperthyroidism -recurrent pancreatitis -cystic fibrosis -hemochromatosis -parenteral nutrition

How is cancer diagnosed?

-Cytology -Biopsy -Fluoroscopy -Open Techniques -Imaging: CT, Xray, MRI -Tumor Markers -Combination tests

What are the major drug classes of chemotherapy drugs?

-Cytotoxic agents -Hormones and hormone antagonists -Biologic response modifiers -Targeted drugs

What are key characteristics of psychosocial development of young adults?

-Develop greater sense of intimacy -Identify a preferred occupation -Increased stress

What are skin care recommendations for patients with external radiation?

-Do not wash off marks -Protect skin, plain soap only -No sun exposure for at least one year

What is secondary hypertension?

-Elevated BP with a specific cause -5% to 10% of adult cases -Clinical findings relate to underlying cause -Treatment aimed at removing or treating cause

What is primary hypertension?

-Elevated BP without an identified cause -90% to 95% of all cases -Exact cause unknown but several contributing factors (Also called essential or idiopathic hypertension)

What are chronic complications of diabetes?

1) angiopathy 2) diabetic retinopathy 3) nephropathy 4) neuropathy 5) lower limb amputation 6) skin problems 7) infections 8) psychological issues

What are symptoms of severe hypertension?

-Fatigue -Dizziness -Palpitations -Angina -Dyspnea

How much sleep do school-age children need?

A 6-year-old averages 11 to 12 hours of sleep nightly an 11-year-old sleeps about 9 to 10 hours

What are the benefits of palliative care?

-Improves quality of life -Decreases costs of health care -Alleviates the burden of care

What should be noted when considering older adults with hypertension?

-Increased incidence with age -Isolated systolic hypertension (ISH): Most common form of hypertension in individuals age >50 -Older adults are more likely to have "white coat" hypertension -Age-related physical changes contribute to hypertension

What are key characteristics of cognitive development of young adults?

-Increased rational thinking habits -Increased flexible thought -Increased conceptual, problem-solving and motor skills

What is the purpose of a wound dressing?

1) minimizes exposure to microorganisms 2) promotes hemostasis 3) fosters normal healing by eliminating dead space in underlying tissues 4) absorbs minimal oozing of wound drainage

What is brain death?

-Irreversible loss of all brain functions including the brainstem -Occurs when the cerebral cortex stops functioning or is destroyed (Exact definition of death can be controversial)

What is used to diagnose hypertension?

-Measurement of BP -Urinalysis -BUN and serum creatinine -Creatinine clearance -Serum electrolytes, glucose -Serum lipid profile -Uric acid levels -ECG -Echocardiogram

What is tumor lysis syndrome (TLS)?

-Potentially lethal complication of cancer treatment -Occurs when large numbers of neoplastic cells are killed resulting in release of potassium, phosphate, and uric acid into systemic circulation -Most commonly seen in patients with lymphoma, leukemia, or multiple metastatic conditions

What are common nursing diagnoses for patients susceptible to or affected by infection?

-Risk for infection -Social isolation • Disturbed Body Image • Delayed Surgical Recovery • Risk for Infection • Imbalanced Nutrition: Less Than Body Requirements • Acute Pain • Impaired Skin Integrity • Risk for Impaired Skin Integrity

What are modifiable risk factors for cancer?

-Stress -Diet -Occupation -Obesity -Infection -Tobacco -Alcohol -Sun exposure

What are factors that influence blood pressure?

-Sympathetic nervous system (SNS) -Baroreceptors -Vascular endothelium -Renal system -Endocrine system

What are the preferred antihypertensive drugs in older adults?

-Thiazide diuretic -Calcium channel blockers -ACE inhibitors or ARBs Caution use of NSAIDs

What precautions should be recommended for a patient with thrombocytopenia (low platelet count)?

-Use stool softeners -Avoid harsh nose blowing -Avoid alcohol containing rinses

What care/precautions should be taken for patients with radiation implants?

-Wastes considered dangerous -Limit contact/use lead shield -Use radiation monitoring badge -Client in private room, private bath -Bedrest to avoid dislodging implant

What is the role of family caregivers during end of life?

-Working and communicating with the patient, other family members, and friends -Supporting patient concerns -Helping patient resolve any unfinished business

What lab findings would indicated DKA?

-a blood glucose level greater than or equal to 250 mg/dL -arterial blood pH less than 7.30 -serum bicarbonate level less than 16 mEq/L -moderate to large ketones in the urine or serum

What are risk factors for developing type 2 diabetes?

-being overweight or obese -being older -having a family history of type 2 diabetes -ethnicity (African Americans, Asian Americans, Hispanics, Native Hawaiians or other Pacific Islanders, and Native Americans have a higher rate of type 2 diabetes than whites)

What are long-term complications associated with diabetes?

-blindness -renal disease -nontraumatic lower limb amputations -heart disease -stroke -hypertension -high cholesterol levels

What risks can gestational diabetes cause?

-cesarean delivery babies have increased risk for -perinatal death -birth injury -neonatal complications

What are the leading causes of death of middle age adults?

-heart disease -cancer -stroke -accidental injuries -COPD

What are non-modifiable risk factors for cancer?

-heredity -age -gender -social status -race and ethnicity

What are problems associated with insulin therapy?

-hypoglycemia -allergic reactions -lipodystrophy -Somogyi effect.

What are precipitating factors for DKA?

-illness and infection -inadequate insulin dosage -undiagnosed type 1 diabetes -poor self-management -neglect

What are key characteristics of cognitive development of middle-age adults?

-increased verbal abilities and tasks involving stored knowledge -Not as adept at solving new or unusual problems

What are risks associated with insulin pumps?

-infection at the insertion site -an increased risk for DKA if the insulin infusion is disrupted -the increased cost of the pump and supplies being attached to a device

What are symptoms of type 1 diabetes?

-polydipsia (excessive thirst) -polyuria (frequent urination) -polyphagia (excessive hunger) -a history of recent and sudden weight loss -weakness and fatigue -ketoacidosis

What are common side effects of radiation therapy?

-skin damage -ulcerations -nausea and vomiting -necrosis of adjacent tissues -pneumonitis

What are the 7 steps of evidence-based practice (EBP)?

0. Cultivate a spirit of inquiry. 1. Ask a clinical question in PICO(T) format. 2. Search for the most relevant and best evidence. 3. Critically appraise the evidence you gather. 4. Integrate the best evidence with your clinical expertise and patient preferences and values in making a practice decision or change. 5. Evaluate the outcomes of practice decision or change based on evidence. 6. Communicate the outcomes of the EBP decision or change.

What are possible adverse effects of a blood transfusion?

1) A transfusion reaction, ranging from a mild response to severe anaphylactic shock, acute intravascular hemolysis, or acute lung injury 2) Circulatory overload 3) infection from donor

What are examples of direct nursing care?

1) ADL (activities of daily living) 2) Instrumental activities of daily living 3) Physical care techniques 4) Lifesaving measures 5) Counseling 6) Teaching 7) Controlling adverse reactions 8) Preventative measures

What are the stages of full thickness wound repair?

1) Hemostasis phase (controls bleeding) 2) Inflammation phase (WBCs) 3) Proliferative phase (production of new tissue, epithelialization, and contraction) 4) Remodeling phase (scar tissue formed)

What are physiological factors which influence pain?

1) Age 2) Fatigue 3) Neurological function 4) Gender

What are factors that affect wound healing?

1) Age of person 2) Scar Tissue 3) Nutrition Status 4) Immunosuppression 5) Obesity (Adipose tissue has a poor blood supply) 6) Extent of Wound 7) Tissue Perfusion 8) Diabetes Mellitus and Peripheral Vascular Diseases 9) Radiation therapy . 10) Stress (Stress increases production of corticosteroids, which impedes wound healing)

How should patients be instructed to take care of fingernails and toenails ?

1) Cut nails only after soaking them about 10 minutes in warm water. (Exception: Not Patients with diabetes) 2) Avoid using over-the-counter preparations to treat corns, calluses, or ingrown toenails. 3) Cut nails straight across and even with tops of fingers or toes. (use file for patients with diabetes) 4) Shape nails with file or emery board (not scissors)

What factors should be assessed before administering medications?

1) History (allergies, diet, etc.) 2) Physical examination 3) Patient's health literacy level 4) Patient's ability to self-administer meds (older adults) 5) Patient's knowledge and understanding of med

What are factors the influence loss and grief?

1) Human development (i.e. children experience grief differently than adults) 2) pyschological perspectives of grief and loss 3) the nature of the personal relationship 4) Nature of the loss (e.g. is it public or private) 5) culture and ethnicity 6) spiritual beliefs

What physical hazards in homes lead to falls?

1) Inadequate lighting 2) barriers along normal walking paths and stairs 3) a lack of safety devices (e.g., walkers or handrails)

What should you look for when examining a patient's head?

1) Note the position, size, shape, and contour of the head 2) Note facial features looking at the eyelids, eyebrows, nasolabial folds, and mouth for shape and symmetry. 3) Palpate the skull for nodules or masses.

What are Bowlby's 4 phases of mourning?

1) Numbing 2) Yearning and searching 3) disorganization and despair 4) Reorganization

What are examples of common record-keeping forms?

1) Nursing admission history 2) Flow sheets and graphic sheets 3) Patient care summary 4) Standardized care plans 5) Discharge summary forms 6) Acuity ratings systems

What are the 2 types of artificial airways?

1) Oral airway 2) Tracheal airway

What are the 3 phases for conducting an interview with a patient about his/her health history?

1) Orientation (introduce self, gain trust, get demographic info) 2) Working (gather info about health history) 3) Termination (give clue that interview is ending, thank patient)

What are the 3 types of suctioning techniques?

1) Oropharyngeal and Nasopharyngeal Suctioning 2) Orotracheal and Nasotracheal Suctioning 3) Tracheal Suctioning

What are methods of data collection for a nurse?

1) Patient interview 2) Physical examination 3) Diagnostic and lab data 4) Observation

What are the 4 zones of personal space and touch?

1) Social Zone (Permission Not Needed) hands, shoulders, arms, back 2) Consent Zone (Permission Needed) Mouth, wrists, feet 3) Vulnerable Zone (Special Care Needed) Face, Neck, Front of body 4) Intimate Zone (Great Sensitivity Needed) Genitalia, Rectum

What are the 5 key qualities of goals and expected outcomes?

1) Specific 2) Measurable 3) Attainable 4) Realistic 5) Timed *SMART* acronym

What are the benefits of PCA?

1) better pain control 2) a need for less medication 3) pain relief that does not depend on nurses' availability

What are possible causes of absent bowel sounds?

1) bowel obstruction 2) paralytic ileus (decreased or absent peristalsis), 3) peritonitis (inflammation of the peritoneum

What are the 3 types of law that govern nursing practice?

1) common law 2) statutory law 3) administrative law

What are Kubler-Ross' five stages of grief?

1) denial 2) anger 3) bargaining 4) depression 5) acceptance.

What helps to mobilize pulmonary secretions out of lung airways?

1) hydration 2) humidification 3) nebulization

What are the stages of partial thickness wound repair?

1) inflammatory response (erythema and edema, WBCs) 2) epidermal repair 3) dermal repair

What are key factors of Swanson's Theory of Caring?

1) knowing 2) being with 3) doing for 4) enabling 5) maintaining belief

What are the 3 types of analgesics?

1) nonopioids including acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs) 2) opioids (traditionally called narcotics) 3) adjuvants or coanalgesics, medications that enhance analgesics or analgesic properties

What are the 2 sleep phases?

1) nonrapid eye movement (NREM) sleep 2) rapid eye movement (REM) sleep

What conditions cause decreased cardiac output?

1) primary coronary artery disease (CAD) 2) valvular disorders 3) cardiomyopathic conditions 4) congenital heart defects 5) conduction disorders 6) pulmonary disease

What are the 3 types of NANDA diagnoses?

1) problem-focused diagnoses 2) risk diagnoses 3) health promotion diagnoses

What are signs/symptoms of hypoxia?

1) tachycardia 2) tachypnea and dyspnea 3) peripheral vasoconstriction 4) dizziness 5) mental confusion

What should be considered when using touch?

1) the person's preferences 2) cultural considerations 3) past trauma or abuse 4) the pain or injury of the person 5) gender

How much urine do kidneys produce per day?

1-2 liters

What are acceptable patient identifiers?

1. A patient's name on an armband. 2. A patient stating his or her name or an identification number assigned by a health care agency. 3. A patient's date of birth on an armband. 4. A patient's social security number. 5. A patient's phone number (note phone numbers can change at any time).

What are the principles of sterile procedures?

1. A sterile object remains sterile only when touched by another sterile object. 2. Place only sterile objects on a sterile field. 3. A sterile object or field out of the range of vision or an object held below a person's waist is contaminated. 4. A sterile object or field becomes contaminated by prolonged exposure to the air. 5. A sterile object or field becomes contaminated by capillary action when a sterile surface comes in contact with a wet contaminated surface. 6. Because fluid flows in the direction of gravity, a sterile object becomes contaminated if gravity causes a contaminated liquid to flow over the surface of an object. 7. The edges of a sterile field or container are contaminated.

What are principles for administering eye medications?

1. Avoid instilling any form of eye medication directly onto the cornea. The cornea of the eye has many pain fibers and is very sensitive to anything applied to it. 2. Avoid touching the eyelids or other eye structures with eyedroppers or ointment tubes. The risk for transmitting infection from one eye to the other is high. 3. Use eye medication only for a patient's affected eye. 4. Never allow a patient to use another patient's eye medications.

What are tips for reducing violence in a potentially violent situation?

1. Be nonjudgmental and empathetic of patient's feelings. 2. Respect personal space. 3. Use nonthreatening nonverbal communication. 4. Do not overreact. 5. Focus on feelings. 6. Redirect or refocus any challenging questions, such as "Why does it always take so long for the doctor to see me?" or "Who's going to make me go to that test?" 7. Set limits.. 8. Choose wisely what you insist on. 9. Allow silence for reflection. 10. Allow time for the patient to make a decision.

What are the 3 types of normal breath sounds?

1. Bronchial 2. Bronchovesicular 3. Vesicular

What are the 6 nutrients?

1. Carbohydrates 2. Proteins 3. Fats 4. Vitamins 5. Minerals 6. Water

What are the 2 parts of nursing assessment?

1. Collection and verification of data 2. Analysis of data

What are some tips for collecting data about older adults?

1. Do not assume that aging is always accompanied by illness or disability. 2. Allow extra time; be patient. 3. Provide adequate space for an examination. 4. Plan the history and examination, taking into account an older adult's energy level, physical limitations, pace, and adaptability. 5. Measure performance under the most favorable conditions. 6. Sequence an examination to keep position changes to a minimum. 7. Be sure that an examination of an older adult includes review of mental status.

What principles should you follow when mixing medications from 2 vials?

1. Do not contaminate one medication with another. 2. Ensure that the final dose is accurate. 3. Maintain aseptic technique.

What are factors that influence heat and cold tolerance?

1. Duration of application (shorter periods are tolerated better) 2. Body part (some parts are more sensitive) 3. Damage to body surface 4. Prior skin temperature 5. Amount of Body surface area 6. Age and physical condition

What should be considered when preparing for an examination?

1. Environment 2. Equipment 3. Physical preparation of patient 4. Psychological preparation of patient 5. Tailoring assessment to different age groups

What are risk factors aside from developmental levels (with respect to safety)?

1. Lifestyle 2. Impaired mobility 3. Sensory impairment (for example, hearing or vision problems) 4. Cognitive impairment 5. Safety awareness (reading labels, etc.)

What principles should be followed during inspection?

1. Make sure that adequate lighting is available. 2. Position and expose body parts so that you can view all surfaces. 3. Inspect each area for size, shape, color, symmetry, position, and abnormalities. 4. When possible compare each area inspected with the same area on the opposite side of the body. 5. Use additional light (e.g., a penlight) to inspect skin surfaces or body cavities. 6. Do not hurry inspection. Pay attention to detail.

What are the recommended steps for the aerobic swab wound-culture technique?

1. Prepare to collect specimen using sterile technique (before administering antibiotics). 2. Clean wound surface 1 cm2 with an antiseptic solution. 3. Moisten swab with normal saline. 4. While applying pressure, rotate applicator within 1 to 2 cm2 of clean wound tissue (try to draw out tissue fluid). 5. When tip is saturated, insert into appropriate sterile container. 6. Complete laboratory slip providing clinical data, which includes wound site, time collected, and prior antibiotics. 7. Transport specimen within 1 hour to laboratory to keep the specimen stable.

What are the only reasons restraints may be applied?

1. Reduce the risk for patient injury from falls 2. Prevent interruption of therapy such as traction, IV infusions, nasogastric tube feeding, or Foley catheter 3. Prevent the confused or combative patient from removing life-support equipment 4. Reduce the risk for injury to self or others

What are the 6 rights of medication administration?

1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation

What are the steps of insulin administration?

1. Wash hands thoroughly. 2. Always inspect insulin bottle before using it. Make sure that it is the proper type and concentration, expiration date has not passed, and top of bottle is in perfect condition. 3. For intermediate-acting insulins (which are normally cloudy), gently roll the insulin bottle between the palms of hands to mix the insulin. (Clear insulins do not need to be agitated.) 4. Select proper injection site 5. Ensure that the site is clean and dry. 6. Push the needle straight into the skin (90-degree angle). If you are very thin, muscular, or using an 8- or 12-mm needle, you may need to pinch the skin and/or use a 45-degree angle. 7. Push the plunger all the way down, leave needle in place for 5 sec to ensure that all insulin has been injected, and then remove needle. 8. Destroy and dispose of single-use syringe safely.

What might be the cause of diaphoresis in a patient?

1. activity 2. warm environments 3. obesity 4. anxiety 5. excitement 6. certain conditions such as diabetes, fever, menopause, and hyperthyroidism

What is the normal plasma concentration of Mg2+ (magnesium)?

1.5 to 2.5 mEq/L

How much sleep do toddlers and pre-schoolers need?

11 to 14 hours a day

What is the normal respiratory rate in adults?

12 to 20 respirations/min

What is the pre-hypertension systolic blood pressure range ?

120 to 139 mm Hg

What does TID, tid mean?

3 times a day

What is the normal serum Na+ (sodium) concentration range?

135 to 145 mEq/L

What is the Stage 1 hypertension systolic blood pressure range?

140 to 159 mm Hg

What is the onset of action for rapid-acting insulin?

15 minutes (should be injected within 15 minutes of mealtime)

How much sleep do neonates and infants up to 3 months need?

16 to 18 hours of sleep a day

What is the healthy range for BMI?

18.5 to 24.9 kg/m2

How many patient identifiers should you use before administer meds to a patient?

2

What is deep vein thrombosis (DVT)?

A DVT is a clot that forms on the wall of a vein, most of the time in the deep veins of the calves and thighs. Immobile patients are at greater risk for DVT

What test is recommended if deep vein thrombosis (DVT) is suspected?

A Doppler study (a noninvasive test that examines venous blood flow)

What is the normal adult cardiac index range?

2.5-4 L/min/m3

What is the normal serum phosphate level?

2.7 to 4.5 mg/dL

How many times per minute does a normal person blink?

20 times

How is hypoglycemia treated in an acute care setting?

20 to 50 mL of 50% dextrose IV push

What age range is considered young adult?

20-30 years of age

What is the normal range of bicarbonate?

22 to 26 mEq/L

What is the average daily fluid intake for healthy adults?

2200 to 2700 mL

When a person is in hospice, when is care available?

24 hours/day, 7 days/week Care provided by medically supervised professional teams and volunteers

What BMI is considered overweight?

25-29.9

How does immobility affect the bones?

Disuse osteoporosis can develop It is a disorder characterized by increased bone resorption from immobilization)

What is the onset of action for short-acting insulin?

30 to 60 minutes (injected 30 to 45 minutes before a meal )

What is the normal range of PaCO2?

35 - 45 mmHg

How much energy do proteins provide?

4 kcal/g

How much energy do carbs provide?

4 kilocalories per gram

What are normal serum ionized Ca2+ levels?

4.5 to 5.3 mg/dL

What age range is considered middle adulthood?

40-65 years of age

What is the normal stroke volume range for an adult?

50-75 mL per contraction

What is a normal WBC level?

5000-10,000/mm3

How much sleep do young adults need?

6 to 8.5 hours

When taking a pulse that is irregular, how long should you take the pulse for?

60 seconds

At what age does older adulthood begin?

65 and/or retirement

Generally speaking, what temperature range is comfortable for most people?

65 to 75 degrees F (18.3° C and 23.8° C)

What pH value is neutral?

7.0

What is the normal pH range of arterial blood?

7.35 to 7.45

What is the normal arterial blood pH value?

7.35 to 7.45 (acidic is less than 7.35, and alkalotic is greater than 7.45)

What is the normal blood glucose range?

70 to 110 mg/dL

How much sleep do adolescents need?

8 to 10 hours of sleep each night

What are normal serum total Ca2+ levels (bound plus free)?

8.4 to 10.5 mg/dL

What is the normal range of PaO2?

80 to 100 mm Hg

What glucose level should be the goal for people with diabetes?

80 to 130 mg/dL before meals

What is the pre-hypertension diastolic blood pressure range?

80 to 89 mm Hg

How much energy do lipids provide?

9 kcal/g

How much sleep do infants older than 3 months need?

9 to 11 hours at night (and naps during day)

What is the Stage 1 hypertension diastolic blood pressure range?

90 to 99 mm Hg

What is normal serum Cl− (chloride) concentration?

95 to 105 mEq/L

What is the normal range of SaO2?

95% to 100%

What is clubfoot?

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

What are the ABCDEs of pain assessment and management?

A *Ask* about pain regularly. B *Believe* patients and family caregivers in their report of pain and what relieves it. C *Choose* pain control options appropriate for patient, family, and setting. D *Deliver* interventions in timely, logical, and coordinated fashion. E *Empower* patients and their families.

What is the difference between a systemic and localized infection?

A *systemic infection* affects the body as a whole (example: the flu) A *localized infection* affects just one part of the body (example: an infected wound)

What can help prevent the Somogyi effect?

A bedtime snack, a reduction in the dose of insulin, or both

What lab values would indicate HHS?

A blood glucose level greater than 600 mg/dL and a marked increase in serum osmolality Ketone bodies are absent or minimal in both blood and urine.

What is bacteremia?

A bloodstream infection

What is a positively charged ion called?

A cation

What is obstructive sleep apnea (OSA)?

A cessation or stopping of airflow despite the effort to breathe. It occurs when muscles or soft structures of the oral cavity or throat relax during sleep. The upper airway becomes partially or completely blocked, and nasal airflow diminishes (hypopnea) or stops (apnea).

What is aldosterone?

A hormone that regulates ECV (extracellular volume) by influencing how much sodium and water are excreted in urine The adrenal cortex releases aldosterone in response to increased plasma potassium concentration or as the end product of the renin-angiotensin-aldosterone system (RAAS).

What is a carrier?

A human who is carrying the pathogen, but show no signs of disease

What is a secondary lesion?

A lesion that results from later formation of trauma to a primary lesion such as a pressure injury

What is a situational loss?

A loss that occurs as a result of an unpredictable life event Example: a divorce

What is diabetic nephropathy?

A microvascular complication associated with damage to the small blood vessels that supply the glomeruli of the kidney. It is the leading cause of end-stage renal disease in the United States and is seen in 20% to 40% of people with diabetes.

What is the depression stage of grief?

A person realizes the full significance of the loss during the depression stage. When depressed, the person feels overwhelmingly lonely or sad and withdraws from interactions with others.

What is the holistic view of health?

A person's health depends on a balance of physical, psychological, sociological, cultural, emotional, developmental, and spiritual variables

What is the difference between a physical restraint and a chemical restraint?

A physical restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move arms, legs, body, or head freely. Chemical restraints are medications such as anxiolytics and sedatives used to manage a patient's behavior and are not a standard treatment for a patient's condition

What is breakthrough pain?

A transient flare of moderate-to-severe pain superimposed on continuous or persistent pain

What is the "Rule of 15"?

A treatment for hypoglycemia 1) Ingest 15 g of a simple (fast-acting) carbohydrate, such as 4 to 6 oz of fruit juice or a regular soft drink. 2) Recheck the blood glucose 15 minutes later. If the value is still less than 70 mg/dL, ingest 15 g more of carbohydrate and recheck the blood glucose in 15 minutes. 2) If no significant improvement occurs after two or three doses of 15 g of simple carbohydrate, contact the HCP.

What does horizontal jerking or bobbing of the head indicate?

A tremor

What is paraphimosis?

A urologic emergency in which the retracted foreskin of an uncircumcised male cannot be returned to its normal anatomic position Can cause dangerous swelling

What is a colonoscopy?

A visual exam of the lining of the entire large intestine with a lighted, flexible fiber optic video endoscope.

What is wound irrigation?

A way of cleansing wounds of exudate and debris You use an irrigating syringe to flush the area with a constant flow of solution Irrigations clean open, deep wounds and sensitive or inaccessible body parts.

What is cerumen?

A yellow, waxy substance

What are fat-soluble vitamins?

A, D, E, and K (They are stored in the body for longer periods)

What is CAUTI?

Catheter Associated Urinary Tract Infection A CAUTI is defined as the development of a UTI in a patient in whom an indwelling urinary catheter was in place for greater than 2 days or within 2 days of urinary catheter removal

What should be considered when matching blood for a transfusion?

ABO blood type and Rh factor

CN XI

Accessory Nerve - controls sternocleidomastroid, trapezius muscles

CN VIII

Acoustic Nerve - hearing, balance, and head position

Is potassium more abundant in the ICF or the ECF?

In the ICF K+ has a high intracellular concentration

What is a common cause of diarrhea in health care facilities?

Clostridium difficile ("C. diff")

What is it called when there is a change in angle between nail and nail base (eventually greater than 180 degrees) with nail bed softening with nail flattening?

Clubbing

What are instrumental activities of daily living (IADLs)?

Activities such as shopping, preparing meals, banking, taking medications, and ADLs

What increases output of K+ from the GI tract?

Acute and chronic diarrhea

CN VI

Abducens Nerve - eye movement

What are adventitious sounds?

Abnormal breath sounds

What is asystole?

Absence of electrical activity; no discernible rate or rhythm

What is venipuncture?

Accessing a vein by puncturing through the skin using a sharp rigid stylet (e.g., metal needle)

What is sleep deprivation?

Acute or chronic and results from insufficient or disrupted sleep. Causes include illness (e.g., fever, difficulty breathing, pain), emotional stress, medications, environmental disturbances (e.g., frequent interruptions in sleep during nursing care, noisy neighbors or pets), and variability in the timing of sleep as a result of shift work. Sleep disorders such as sleep apnea or insomnia can cause sleep deprivation.

What is acute pain?

Acute pain is protective, usually has an identifiable cause, is of short duration, and has limited tissue damage and emotional response. It is common after acute injury, disease, or surgery.

What are ways to promote health/safety in adolescents?

Adolescents need: Adult to serve as good role models accurate instructions about abstinence and safe sexual practices. education about signs of school violence including bullying, fighting, weapon use, gang violence, and electronic aggression education about complying with rules and regulations regarding safe driving and the use of a car

What special care should diabetic patients take regarding their feet?

Advise patients to inspect their feet daily, avoid going barefoot, and wear shoes that are supportive and comfortable.

What does PC, pc mean?

After meals

What facilitates K+ renal excretion?

Aldosterone and polyuria

What are proteins?

Amino acids, which are vital for the synthesis of body tissue in growth, maintenance, and repair.

What are signs/symptoms of hypernatremia?

Decreased level of consciousness (confusion, lethargy, coma), perhaps thirst; seizures if develops rapidly or is very severe

What is valvular heart disease?

An acquired or congenital disorder of a cardiac valve characterized by stenosis, which obstructs blood flow, or valvular degeneration and regurgitation, which result in backflow of blood.

What is an endogenous infection?

An infection that occurs when part of a patient's flora becomes altered and overgrowth results (e.g., staphylococci, enterococci, yeasts, streptococci)

What is a standing order?

An order you carry out until the health care provider cancels it by another order or until a prescribed number of days elapses.

What causes pallor of the mouth and lips?

Anemia

What might cause pallor of the lips?

Anemia

What types of information should you ask about when getting a nursing history of the eyes?

Any history of partial or complete vision loss from eye disease (e.g., glaucoma, cataracts), eye trauma, diabetes, hypertension, or eye surgery Assess for common symptoms of eye disease such as eye pain, photophobia (sensitivity to light), burning, itching, excessive tearing, diplopia (double vision), blurred vision, or visual disturbances Review the patient's occupational history, use of glasses or contact lenses, use of safety glasses, and visits to an optometrist Determine the patient's current medication use including any eye medication.

What is a pathogen?

Any microbe that is capable of producing an illness

What are the 6 anatomical sites for assessment of cardiac function?

Aortic, pulmonic, second pulmonic area, tricuspid, mitral (apical) and epigastric

In a healthy nail, what is the angle between the nail and the nail bed?

Approximately 160 degrees

What is an aerosol?

Aqueous medication sprayed and absorbed in the mouth and upper airway; not meant for ingestion

How do you assess the Olfactory Nerve (CN 1)?

Ask patient to identify different aromas in each nostril such as coffee and vanilla

How do you assess the Glossopharyngeal Nerve (CN 9)?

Ask patient to identify sour or sweet taste on back of tongue. Use tongue blade to elicit gag reflex; have person swallow.

How do you assess the Vagus Nerve (CN 10)?

Ask patient to say "Ah." Observe movement of palate and pharynx. Assess speech for hoarseness.

What is paradoxical breathing?

Asynchronous breathing; chest contraction during inspiration and expansion during expiration

What is AMDS?

Automated medication dispensing systems

What common toxic inhalant decreases the oxygen-carrying capacity of blood?

Carbon monoxide

What is Leininger's transcultural view of caring?

Care as the domain sets nursing apart from other health care disciplines. Care is universal and vital to recovery from illness and the maintenance of healthy life practices in all cultures.

What is palliative care?

Care or treatment focusing on reducing the severity of symptoms

What changes are expected in the heart and vascular system of an older adult?

BP remains within normal limits, less than 120/80 mm Hg BP between 120/80 and 139/89 mm Hg is considered prehypertension; elevations in BP are not a normal aspect of aging, and older adults need minor elevations monitored peripheral pulses easily palpated; pedal pulses weaker, and lower extremities colder, especially at night; orthostatic hypertension common

What causes splinter hemorrhages in fingernails?

Bacterial endocarditis

What causes petechiae on conjunctivae?

Bacterial endocarditis or bleeding disorder

How can you assess pain in a patient unable to report it?

Be alert for subtle behaviors that indicate pain Note a patient's vocal response (e.g., moaning, crying, gasping), facial movements (e.g., grimacing, clenched teeth, tightly closed eyes), and body movements (e.g., restlessness, pacing) or inactivity. Also assess social interaction. Does the patient avoid conversation or social contacts? Does the patient have a short attention span?

What dental hygiene practices should be recommended for people with diabetes?

Because of the susceptibility to periodontal disease, encourage daily brushing and flossing in addition to regular visits to the dentist. When having dental work done, have the patient inform the dentist that he or she has diabetes.

What is plantar flexion?

Bending of toes and foot downward

Why is bicarbonate important?

Bicarbonate is a base and a key component of the bicarbonate buffering system essential to acid-base balance

Where is blood colloid osmotic pressure the greatest in a capillary?

Blood colloid osmotic pressure is greater at the *venous end* of a capillary.

Why does left-sided heart failure cause respiratory symptoms?

Blood eventually backs up into the pulmonary veins, causing patients to present with pulmonary symptoms such as crackles on auscultation and complaints of fatigue, dyspnea, and orthopnea (difficulty breathing while lying down)

What is eupnea?

Breathing 12-20 breaths/min Normal in adults

What is tachypnea?

Breathing greater than 20 breaths/min Results from anxiety, pain, fever, respiratory infection, or other causes that lead to respiratory distress; can lead to respiratory alkalosis, paresthesia, tetany, and confusion

What does exophthalmos mean?

Bulging eyes

Which are the water-soluble vitamins?

C and B complex vitamins (They are stored in limited amounts for short periods of time in the body, requiring daily consumption)

What is casuistry?

Case-based reasoning; focuses on an "intimate understanding of particular situations" This approach to ethical discourse depends on finding consensus

What is the sequence for CPR?

C-A-B: chest compression, early defibrillation, establishing an airway, and rescue breathing

Why is this diagnostic statement wrong? Fatigue related to cancer

Cancer is a medical diagnosis, not a nursing diagnosis Correct diagnosis statement: Fatigue related to chronic disease process

What causes barrel chest?

COPD; may be a normal finding in older adults

Which electrolyte is inversely proportional with phosphate?

Calcium if one rises, the other falls (except during end-stage renal disease)

What memory changes are seen in older adults?

Certain aspects of short-term memory (e.g., numbers) decrease with age; however, visual memory, which allows a person to remember how to read, remains strong. Long-term memory for newly learned information decreases significantly with age, but recall for distant experiences and procedural experiences (e.g., driving) do not seem to be affected in the later years of life.

How does immobility affect the integumentary system?

Changes in circulation and pressure on body can cause skin to breakdown, resulting in a pressure injury

What does assessing the skin reveal?

Changes in: 1) oxygenation 2) circulation 3) nutrition 4) local tissue damage 5) hydration

What increases output of Ca2+ in the feces?

Chronic diarrhea and undigested fat

What causes clubbing of fingertips?

Chronic hypoxemia

What effect does chronic hypoxemia have on the production of RBCs?

Chronic hypoxemia stimulates RBC production by the bone marrow, leading to secondary polycythemia (when marrow makes too many RBCs).

What are potential causes of clubbing?

Chronic lack of oxygen: heart or pulmonary disease

What causes pursed-lip breathing?

Chronic lung disease; increased respiratory effort

What is chronic pain?

Chronic pain is prolonged, varies in intensity, and usually lasts longer than 3 to 6 months and beyond the expected or predicted healing time. Chronic pain is not protective. Examples of chronic pain include arthritis, low back pain, myofascial pain, headache, and peripheral neuropathy.

What is often the cause of clear exudate that drains along the wall of the posterior pharynx?

Chronic sinus problems

Vesicle

Circumscribed elevation of the skin filled with serous fluid

Pustule

Circumscribed elevation of the skin similar to a vesicle, but filled with pus

What should you do if a healthcare provider gives you an order which you think could cause harm to the patient?

Clarify the order with healthcare provider; if there is still a dispute, notify your supervisor

What is an elixir?

Clear fluid containing water and/or alcohol; often sweetened

What does serous drainage look like?

Clear, watery plasma

What is an enteric-coated tablet?

Coated tablet that does not dissolve in stomach; coatings dissolve in intestine, where medication is absorbed

What is data validation?

Comparing data with another source to confirm data accuracy

What is an extract?

Concentrated medication form made by removing the active part of medication from its other components

What is hospice care?

Concept of care that provides compassion, concern, and support for persons in the last phases of a terminal disease It is a concept, not a place

What is feminist ethics?

Considering how ethical decisions will affect women as a way to repair a history of inequality

How do you assess skin integrity in an immobile patient?

Continually assess the skin for signs of pressure injury formation especially over bony prominences. Inspect for redness, tenderness, edema, and actual skin breakdown. If you find an area of redness, check for blanching. Nonblanchable redness (hyperemia) is an early indicator of impaired skin integrity

What is the difference between CPAP and BiPAP?

Continuous positive airway pressure (CPAP) maintains a steady stream of pressure throughout a patient's breathing cycle. It benefits patients with obstructive sleep apnea. Bi-level positive airway pressure (BiPAP) works by providing assistance during inspiration and preventing alveolar closure during expiration. It provides two levels of pressure: inspiratory positive airway pressure (IPAP) and lower expiratory positive airway pressure (EPAP).

What changes are expected in the musculoskeletal system of an older adult?

Decreased muscle mass and strength; bone demineralization (more pronounced in women); shortening of trunk from intervertebral space narrowing decreased joint mobility; decreased range of joint motion kyphosis (usually in women) slowed reaction time

What changes are expected in the neurological system of an older adult?

Decreased rate of voluntary or automatic reflexes; decreased ability to respond to multiple stimuli; insomnia; shorter sleeping periods

What does strabismus mean?

Crossed eyes

What changes are expected in the GI system of an older adult?

Decreased salivary secretions, which makes swallowing more difficult decreased peristalsis decreased production of digestive enzymes, hydrochloric acid, pepsin, and pancreatic enzymes, leading to indigestion and constipation

What qualities should you be aware of when assessing the texture of the skin?

Determine whether the patient's skin is smooth or rough, thin or thick, tight or supple, or indurated (hardened) or soft

Why is this diagnostic statement wrong? Impaired Skin Integrity related to poor hygiene habits

Do not make prejudicial statements about the patient Correct diagnosis statement: Impaired Skin Integrity related to lack of knowledge about perineal care

What causes cyanosis of nail beds?

Decreased cardiac output or hypoxia; sometimes the result of decreased circulation to affected limb or vasoconstriction secondary to cold

What does DNR mean in terms of CPR?

DNR should prevent initiation of CPR However DNR does not equate to "Do Not Care"

What causes decreased skin turgor?

Dehydration (normal finding in older adults as a result of decreased skin elasticity)

What is the main consequence of diarrhea?

Dehydration leading to fluid and electrolyte and acid-base imbalances can result

What is urinary hesitancy?

Delay in start of urinary stream when voiding

What nursing interventions can promote musculoskeletal health in an immobile patient?

Develop an exercise schedule (2 hours of exercise for every 24-hour period) For completely immobile patients, teach family caregivers how to perform passive ROM exercises for all immobilized joints at least 3 or 4 times a day unless contraindicated If one extremity is paralyzed, teach the patient to perform passive ROM on the paralyzed limb and encourage him or her to engage in active ROM with all other extremities Encourage patients to use mobile extremities during ADLs (e.g., dressing) as much as possible

What should you consider when setting priorities?

Diagnoses which left untreated could harm the patients or others have the highest priority Consider Maslow's hierarchy of needs when setting priorities

What is oliguria?

Diminished urinary output in relation to fluid intake

What should you do if your mask becomes moist?

Discard it and put on a new one

What is a binder?

Dressings made of large pieces of material to fit a specific body part. A binder reduces stress on a wound. An arm sling is an example of a binder.

What is airborne transmission?

Droplet nuclei, residue or evaporated droplets suspended in air (e.g., from coughing, sneezing, talking)

What is due process with respect to disciplinary proceedings by the State Board of Nursing?

Due process requires a State Board of Nursing to notify the nurse of the listed charges or violations and conduct a hearing at which the nurse may hear the evidence of the charges and offer a defense with or without the assistance of legal counsel

What is the function of sleep?

During NREM stage 3 sleep, the body releases human growth hormone for the repair and renewal of epithelial and specialized cells such as brain cells. Protein synthesis and cell division for the renewal of tissues also occur during rest and sleep. The basal metabolic rate lowers during sleep, which conserves the energy supply of the body. REM sleep appears to be important for early brain development, cognition, and memory.

What is the bargaining stage of grief?

During bargaining the individual postpones awareness of the loss and tries to prevent it from happening by making deals or promises.

What happens in the disorganization and despair phase of mourning?

During the phase of disorganization and despair an individual spends much time thinking about how and why the loss occurred. The person often expresses anger at anyone he or she believes to be responsible.

What is the acceptance stage of grief?

During the stage of acceptance the individual begins to accept the reality and inevitability of loss and looks to the future.

What is evidence-based practice (EBP)?

EBP addresses a clinical problem by seeking the very best scientific and clinical evidence available for treating or managing the problem and implementing changes in practice

What does excessive infusion of a sodium-containing isotonic solution cause?

ECV excess, with shortness of breath and crackles in the lungs

How can infection transmission be controlled?

Each patient should have own set of personal care items When using a stethoscope, always wipe off the bell, diaphragm, and ear tips with a disinfectant such as an alcohol wipe before proceeding to the next patient do not shake linens or bedclothes Dust surfaces within a patient's room with a treated or dampened cloth to prevent dust particles from entering the air do not allow soiled items and equipment to touch your clothing Never put clean or soiled linens on the floor.

What foods can cause urine to change color?

Eating beets, rhubarb, and blackberries sometimes causes red urine

What are indications on the skin that a person has a history of IV drug use?

Edematous, reddened, and warm areas along the arms and legs suggest recent, repeated IV injections Hyperpigmented and shiny or scarred areas suggest areas of old injection sites

Nodule

Elevated solid mass, deeper and firmer than a papule

What nursing interventions can promote psychosocial health in an immobile patient?

Encourage patients to participate in routine and informal socialization. Encourage visits to the home by friends. Help family caregivers learn the importance of keeping patients involved in decisions about their care and engaging them in conversation and self-help activities. Plan activities to give patients in health care settings the opportunity to interact with the staff. If possible, place these patients in a room with other mobile patients. If the patient remains in a private room, ask staff members to visit periodically throughout waking hours. Provide stimuli to maintain orientation and entertain the patient. Encourage patients to wear their glasses or dentures and to shave or apply makeup to enhance body image. Encourage patients to perform as much self-care as possible. Make sure that hygiene and grooming articles are within easy reach.

How often should you change tubing for intermittent infusion?

Every 24 hours

How often should an ostomy pouching system be changed?

Every 3 to 7 days

CN VII

Facial Nerve - controls expression, tear, saliva, sweet, sour, salty

What is a dysrhythmia?

Failure of the heart to beat at regular successive intervals

What is the leading cause of unintentional death for people 65 years of age and older?

Falls

What are older adults most at risk for (with respect to safety)?

Falls and accidents due to aging, effects of multiple medications, psychological factors, and acute or chronic disease

What safety risks associated with nutrition?

Food poisoning (also malnutrition)

What is the Stage 2 hypertension diastolic blood pressure range?

Greater than 100 mm Hg

How can you enhance a dying person's self-esteem by attending to their physical appearance?

Helping the patient with cleanliness, absence of body odors, wearing attractive clothing, and personal grooming

What is residual urine?

Leftover urine from when the bladder does not empty completely

What effect does mild hypoxia have on breathing and respiration rates?

Mild hypoxia stimulates peripheral chemoreceptors to *increase* heart and respiration rates

Can a medical diagnosis be given as a related factor?

No!

What is the recommended colon cancer screening protocol?

Occult blood test yearly. Colonoscopy at age 50, then q 10 yr

CN III

Oculomotor Nerve - eye movement

What are strategies to encourage fluid intake?

Offering small sips of fluid frequently, popsicles, and ice chips. If possible, provide each patient's preferred fluids at the preferred temperature

CN I

Olfactory Nerve - smell

What is proteinuria?

Protein in the urine (suggests glomerular injury)

What symptoms might indicate oxygenation problems?

Reduced mental alertness, nasal flaring, somnolence (sleepiness), and cyanosis

What nursing interventions can promote respiratory health in an immobile patient?

Regular exercise and activities such as changing the position of patients at least every 2 hours Make sure that the immobile patient has a fluid intake of at least 2000 mL per day Remove pulmonary secretions through chest physiotherapy (CPT), and/or deep breathing and coughing exercises

What is sinus tachycardia?

Regular rhythm, rate 100-180 beats/min (higher in infants), normal P wave, normal QRS complex

What is internal rotation?

Rotation of joint inward

What is necessary for organ/tissue donation?

Signed consent

What position should a patient be in when examining the rectum and vagina?

Sims

What is the best position the patient should be in to hear high-pitched heart murmurs?

Sitting up and leaning forward

What is wrong with this outcome statement? "Body temperature remains normal"

This is not measurable. Correct outcome statement: "Body temperature remains 98.6° F"

What are examples of appreciation of unique meanings in the Caring Assessment Tool (CAT)?

The nurses.... • Are concerned with how I view things. • Know what is important to me. • Acknowledge my inner feelings. • Show respect for things having meaning to me.

What are examples of human respect in the Caring Assessment Tool (CAT)?

The nurses.... • Listen to me. • Accept me. • Treat me kindly. • Respect me. • Pay attention to me.

What does it mean to heal by primary intention?

The skin edges approximate, or close together, and the risk for infection is minimal (the wound has little or no tissue loss) Example: a clean surgical incision

What is hemoptysis?

bloody sputum

What does it mean to heal by secondary intention?

The skin edges cannot come together because of the extensive tissue loss, and healing occurs gradually. A layer of granulation tissue covers the wound base; wound contraction brings the wound edges together; and the wound closes with scar formation.

What is the tragus?

The small, rounded, fleshy bulge that lies immediately anterior to the ear canal.

What is the purpose of the methods or design section?

This section explains how researchers organize and conduct studies to answer research questions or test hypotheses. (It also tells you how big the sample size is)

What is a myocardial infarction?

When decreased myocardial blood perfusion is extensive or perfusion is completely blocked, and the heart tissue becomes necrotic; A heart attack

Why is this diagnostic statement wrong? Potential for electrolyte complications related to severe gastroenteritis

The statement refers to a potential problem in nursing care rather than to the patient Correct diagnosis statement: Deficient Fluid Volume related to severe vomiting and diarrhea

What is a paste?

Thick ointment; absorbed through skin more slowly than ointment; often used for skin protection

What does purulent drainage look like?

Thick, yellow, green, or brown, indicating the presence of dead or living organisms and WBCs

What is senile keratosis?

Thickening of the skin

Atrophy

Thinning of skin with loss of normal skin furrow with skin appearing shiny and translucent

Why is this diagnostic statement wrong? Acute Pain related to alteration in comfort

This is a circular statement (i.e. acute pain is the same thing as alteration in comfort) Correct diagnosis statement: Acute Pain related to incisional trauma

What is a hemolytic transfusion reaction?

When incompatible RBCs agglutinate (clump together), causing a potentially life-threatening immune response

What are symptoms of acute hypoxemia?

Tachypnea, dyspnea, hypertension, hypotension, pallor, cyanosis, mental status changes (e.g., headache, anxiety, impaired judgment, confusion, euphoria, lethargy), and motor function changes (e.g., loss of coordination, weakness, tremors, restlessness, stupor, coma, death). Hypoxemia may also cause dysrhythmias, diaphoresis, blurred or tunnel vision, and nausea and vomiting.

What are complications of hypertension?

Target organ diseases occur most frequently in -Heart -Brain -Peripheral vascular disease -Kidney -Eyes

How is diaphragmatic breathing performed?

Teach the patient to place one hand on the chest and one hand on the belly. As the patient inhales the diaphragm descends (belly moves out), and as the patient exhales the diaphragm ascends (belly sinks in). Coach a patient to gently push on the abdomen with the lower hand to gently push on the diaphragm and help the patient exhale air.

What is glycogenesis?

When liver and muscle tissues store glucose in the form of glycogen via an anabolic process

What identification procedures must a nurse do before administering a blood transfusion?

Together two RNs or one RN and one LPN (check agency policy and procedures) must check the label on the blood product against the medical record and the patient's identification number, blood group, and complete name.

What is climacteric?

The decline of reproductive capacity and accompanying changes brought about by decrease in sexual hormones

What is the tympanic membrane?

The ear drum

How do the lungs regulate pH?

The lungs excrete carbonic acid in the form of CO2 and water. Respirations increase when more carbonic acid needs to be excreted, and they decrease (within limits) when the body needs to excrete less carbonic acid.

What are red or brown linear streaks in nail bed called?

Splinter hemorrhages

What is an aqueous solution?

Substance dissolved in water and syrups

For whom might tenting be a normal sign during a turgor assessment?

The elderly. (Skin elasticity and fat tissue decrease in the elderly)

Where does the process of digestion begin?

The mouth

What should you observe when the patient enters the room with respect to musculoskeletal assessment?

The patient's gait and posture

What is the xiphoid process?

The tip of the sternum (and the upper boundary of the anterior abdominal region)

What are feces?

The waste matter of digestion

Why is this diagnostic statement wrong? Chronic Pain related to insufficient pain medication

This statement applies blame to someone (i.e. the doctor did not prescribe the right pain medication or enough of it) and could get the doctor or the hospital in legal trouble Correct diagnosis statement: Chronic Pain related to incorrect adherence of analgesic schedule

What is a purpose statement?

This statement explains the focus or intent of a study. It identifies which concepts are researched including research questions or hypotheses

What is transduction (in reference to pain)?

Transduction converts energy produced by noxious thermal, mechanical, or chemical stimuli into electrical impulses

What clarity should normal urine be at the time of voiding?

Transparent

How can dyspnea be managed?

Treat the underlying cause of the dyspnea and: 1. Medications (e.g., bronchodilators, steroids, mucolytics, antianxiety drugs) to open the airways, decrease inflammation, thin secretions, or decrease anxiety 2. Oxygen therapy, as indicated and ordered, to treat hypoxia 3. Physical techniques (e.g., cardiopulmonary reconditioning, breathing techniques, cough control) to help mobilize secretions and strengthen the muscles used for breathing. 4. Psychosocial techniques (e.g., relaxation techniques, biofeedback, meditation) to lessen the sensation of dyspnea.

What is eversion?

Turning of body part away from midline

What is inversion?

Turning of body part toward midline

What does BID, bid mean?

Twice a day

What is wrong with this outcome statement? "Patient's lungs are clear to auscultation, and respiratory rate is 24 breaths/min by 8/22."

Two outcome statements are written. It should be split it into two parts. Correct outcome statement: "Lungs are clear to auscultation by 8/22" and "Respiratory rate is 24 breaths/min by 8/22."

Why is this diagnostic statement wrong? Pain and Anxiety related to difficulty in ambulating

Two problems are identified (pain and anxiety). Each diagnostic statement should only have one problem. Correct diagnosis statement: Impaired Physical Mobility related to pain in right knee and Anxiety related to fear of falling

What might an abnormally foul urine odor indicate?

UTI

What is chest wall movement asymmetry?

Unequal expansion of lungs Caused by chest wall injury; collapsed lung

What does pallor mean?

Unusual paleness

What is a UTI?

Urinary tract infection

How do you assess the Optic Nerve (CN 2)?

Use Snellen chart or ask patient to read printed material while wearing glasses.

How do you assess the patient with an immobile patient?

Use a pain scale Compare a patient's baseline level of pain with the level of pain following interventions such as repositioning to determine your success in minimizing patient discomfort

What is a liniment ?

Usually contains alcohol, oil, or soapy emollient applied to skin

What vitamin is necessary to make proteins responsible for dietary Ca2+ absorption in the duodenum?

Vitamin D

What is polyuria?

Voiding excessive amounts of urine

What is urinary frequency?

Voiding more than 8 times during waking hours and/or at decreased intervals such as less than every 2 hours

How is a quad cough performed?

While the patient breathes out with a maximal expiratory effort, the patient or you push inward and upward on the abdominal muscles toward the diaphragm, causing the cough. The quad cough technique is for patients without abdominal muscle control such as patients with spinal cord injuries.

What is a sitz bath?

a bath in which only the pelvic area is immersed in warm fluid. The patient sits in a special tub or chair or in a basin that fits on the toilet so the legs and feet remain out of the water.

What is a venous thromboembolism (VTE)?

a blood clot in the vein and travels in the circulation, lodging in the lungs It is related to two life-threatening conditions: DVT is a clot in a deep vein, usually in the leg, and a pulmonary embolus is a deep vein clot that breaks free from a vein wall, travels to the lungs, and blocks some or all of the blood supply

What is hypocapnia?

a decrease in PaCO2

What does a click mean when auscultating the heart?

a device such as a prosthetic valve is present

What is an antigen?

a foreign material

What is pH?

a measure of fluid acidity or alkalinity

What is an electronic infusion device (EID)?

a medical device used to deliver fluids into a patient's body in a controlled manner

What effect does immobility have on the lungs?

a reduction in vital capacity, residual volume, functional residual capacity, and expiratory reserve There is also dependent stasis of secretions within the airways.

What are core measures?

a set of evidence-based, scientifically researched standards of care

What does stenosis mean?

abnormal narrowing of a blood vessel

What is hypercalcemia?

abnormally high Ca2+ concentration in the blood

What is flatulence?

accumulated gas

What is humidification?

adding moisture to the inspired air Humidification (adding moisture to the inspired air) is necessary for patients receiving oxygen therapy at a high flow, typically greater than 4 L/minute.

What is the intraocular medication delivery route?

administering medication into the eye by drops, ointment, or disk

What is the treatment of hypoxemia?

administration of oxygen and correction of the underlying cause

For whom it is abnormal to hear the S3 sound?

adults older than 30 years of age

What is a negatively charged ion called?

an anion

What is assault?

an intentional threat toward another person that places the person in reasonable fear of harmful, imminent, or unwelcome contact Example: to threaten to restrain a patient for an x-ray procedure when the patient has refused consent

What are bony prominences?

areas of the body where the bone lies close to the skin (pressure, friction, and shear cause the most wear and tear in these places) Protect these areas through the use of proper positioning and pressure-relief methods

What is hypercapnia?

arterial carbon dioxide [PaCO2] level greater than 45 mm Hg

What are transverse depressions in nails indicating temporary disturbance of nail growth?

beau lines

What are variables (in a study)?

characteristics or traits that vary among subjects

What is mastication?

chewing

What are transparent film dressings?

clear sheets coated on one side with an adhesive

What is atelectasis?

collapse of alveoli

What is Chvostek's sign?

contraction of facial muscles when facial nerve is tapped Indicative of hypocalcemia

What is evaluation?

determining whether a patient's condition or well-being improved after an intervention was delivered

What is a urinalysis used for?

diagnostic screening for fluid and electrolyte disturbances, UTI, presence of blood, and other metabolic problems

What is dysphagia?

difficulty with swallowing

How should you assess each peripheral artery?

elasticity of the vessel wall, strength, and equality You know the artery is elastic if you depress the artery, and it springs back to shape when pressure is released Compare pulses on each side of the body to determine equality

What are examples of disasters?

flood, hurricane, tornado, or wildfire strikes (natural disasters) Or could be something human-caused like a bombing

What are signs of delirium?

fluctuations in cognition that develop over a short time such as a reduced ability to focus, sustain, or shift attention acute changes in mood, arousal, and self-awareness. Other signs are hallucinations, transient incoherent speech, disturbed sleep pattern, and disorientation.

What are behaviors that establish your presence?

giving attention, answering questions, listening, and having a positive and encouraging (but realistic) attitude.

What is bereavement?

grief and mourning, the inner feelings and outward behaviors of a survivor

What are gingivae?

gums

What effect do Ginseng, garlic capsules, and Ginkgo biloba have on the circulatory system?

have properties similar to those of aspirin and decrease platelet aggregation, increasing the patient's risk for bleeding

How can you assess fine motor function?

have the patient extend the arms out to the sides and touch each forefinger alternately to the nose, first with eyes open, then with eyes closed

What is constipation?

having fewer than three bowel movements per week or (1) hard or dry stools, (2) decreased frequency of stooling, (3) sensation of incomplete evacuation following a bowel movement, and (4) pain or straining associated with stool elimination

What are signs/symptoms of respiratory acidosis?

headache, light-headedness, decreased level of consciousness (confusion, lethargy, coma), dysrhythmias

What is an HAI?

health care-acquired infection

Which biological functions slow during NREM sleep?

heart rate, respirations, temperature, blood pressure, and muscle tone

What is phimosis?

inability to retract foreskin

What is risk management?

identifying possible risks, analyzing them, acting to reduce them, and evaluating the measures taken to reduce them

Why might lipodystrophy occur?

if the same injection sites are used frequently

For which conditions is cold contraindicated?

if the site of injury is edematous or the patient has impaired circulation or is shivering (may intensify shivering and reduce blood flow)

What is the third section of the small intestine?

ileum

What is hypertonicity?

increased muscle tone

What is diuresis?

increased urine excretion

What effect does the herb ma huang have on the heart?

increases blood pressure and heart rate Patients with cardiopulmonary disease should not use this herb

What are developmental effects of immobilization?

infant, toddler, or preschooler - delays a child's motor skill and intellectual development adolescents - changes in growth patterns, less independence, behind peers in achieving certain milestones, social isolation

What might lesions on the lips indicate?

infection, irritation, or skin cancer

What is phlebitis?

inflammation of a vein

What is intertriginous dermatitis (ITD)?

inflammation of skin where two surfaces rub such as groin, beneath breasts, and underarm area

What is hypostatic pneumonia?

inflammation of the lung from stasis or pooling of secretions

What are minerals?

inorganic elements that catalyze biochemical reactions

How do you assess for phlebitis?

inspect for localized redness, tenderness, and swelling over vein sites Unilateral edema of the affected leg is one of the most reliable findings of phlebitis.

What is malpractice insurance?

insurance that provides you with an attorney, the payment of attorney's fees, and the payment of any judgment or settlement if a patient sues you for malpractice

What are characteristics of complicated grief?

intense yearning for the loss; intrusive thoughts of the death; and disturbing emotions of anger, avoidance, or disbelief

What is battery?

intentional offensive touching without consent or lawful justification Example: when a patient has consented to a right knee surgery and the surgeon performs surgery on the patient's left knee.

What is a single-lumen catheter used for?

intermittent/straight catheterization (i.e., insertion of a catheter for one-time bladder emptying)

What are the 2 main compartments where body fluids are distributed?

intracellular fluid (ICF) - inside cells (2/3 total body fluids) extracellular fluid (ECF) - outside cells (1/3 total body fluids)

What does vertigo mean?

loss of balance

What does untreated hypoglycemia result in?

loss of consciousness, seizures, coma, and death

What are signs/symptoms of metabolic alkalosis?

light-headedness; numbness and tingling of fingers, toes, and circumoral region; muscle cramps; possible excitement and confusion followed by decreased level of consciousness; dysrhythmias (may be caused by concurrent hypokalemia)

What are signs/symptoms of respiratory alkalosis?

light-headedness; numbness and tingling of fingers, toes, and circumoral region; tachypnea; excitement and confusion possibly followed by decreased level of consciousness; dysrhythmias

What are the two essential fatty acids (EFAs) in human nutrition?

linoleic acid (an omega-6 fatty acid) and linolenic acid (an omega-3 fatty acid)

What are examples of rapid-acting insulins?

lispro (Humalog) aspart (NovoLog) glulisine (Apidra)

What is auscultation?

listening for sounds produced by the body

What do lymph nodes that are large, fixed, inflamed, or tender indicate?

local infection, systemic disease, or neoplasm

What is a hematoma?

localized collection of blood under the tissue, often appearing as a bluish swelling or mass

What is stocking-glove neuropathy?

loss of sensation, abnormal sensations, pain, and paresthesias aka distal symmetric polyneuropathy

What is an abrasion?

loss of the dermis It is usually superficial with little bleeding but some weeping (plasma leakage from damaged capillaries)

What do bronchial sounds sound like?

loud, high pitched, and hollow sounding with expiration lasting longer than inspiration (3 : 2 ratio)

What is hypoglycemia?

low blood glucose (less than 70 mg/dL ) it occurs when there is too much insulin in proportion to available glucose in the blood.

What is hypotonicity?

low muscle tone

What are the two acid excretion mechanisms in the body?

lungs (excrete carbonic acid) and kidneys (excrete metabolic acids)

For which types of cancers does radiation therapy work best?

lymphoma, leukemia, neuroblastoma

What is the angle of Louis?

manubriosternal angle, the articulation of the manubrium and body of the sternum, continuous with the second rib

What are sublingual medications?

medications readily absorbed when placed under the tongue to dissolve Instruct patients not to swallow a sublingual medication or drink anything until the medication is completely dissolved to ensure that the medication will produce the desired effect.

What do bronchovesicular sounds sound like?

medium-pitched blowing sounds with equal inspiratory and expiratory phases

What are features of intellectual function?

memory, knowledge, abstract thinking, and judgment

What effect does immobility have on metabolic functioning?

metabolic rate decreases, altering the metabolism of carbohydrates, proteins, and fats. There is impaired glucose tolerance and hyperinsulinemia with the muscles developing insulin resistance.

What are 2 other terms for urination?

micturition and voiding

How is electrolyte concentration measured?

milliequivalents per liter (mEq/L) millimoles per liter (mmol/L) milligrams per deciliter (mg/dL)

What are electrolytes?

mineral salts within body fluid An electrolyte is a compound that separates into ions (charged particles) when dissolved in water

What are the 2 types of criminal laws?

misdemeanors and felonies

Why should lotion not be applied between the toes (especially for patients with diabetes)?

moisture between toes promotes growth of microorganisms, leading to infection

What is a NOW order?

more specific than a one-time order and is used when a patient needs a medication quickly but not right away

What is intensive or physiologic insulin therapy?

multiple daily insulin injections together with frequent self-monitoring of blood glucose

What is an example of a muscle disease which can impair breathing?

muscular dystrophy

What are signs and symptoms of carbon monoxide poisoning?

nausea, dizziness, headache, and fatigue often results in death

What are concomitant symptoms that occur with pain?

nausea, headache, dizziness, urge to urinate, constipation, depression, and restlessness

What is diabetic neuropathy?

nerve damage that occurs because of the metabolic derangements associated with diabetes mellitus The most common type of neuropathy affecting persons with diabetes is sensory neuropathy.

How often should you change continuous infusion tubing?

no more frequently than every 96 hours (unless the tubing has been compromised or contaminated)

What effect do diuretic medications have on sleep in administered late in the day?

nocturia, which leads to nighttime awakenings

What words are usually used to describe bowel sounds?

normal, audible, absent, hyperactive, or hypoactive

What is epistaxis?

nose bleed

What are nares?

nostrils

What are signs/symptoms of hypocalcemia?

numbness and tingling of fingers and circumoral (around mouth) region, positive Chvostek sign (contraction of facial muscles when facial nerve is tapped), hyperactive reflexes, muscle twitching and cramping, carpal and pedal spasms, tetany, seizures, laryngospasm, dysrhythmias

What is acid-base homeostasis?

pH balance maintained by controlling H+ ion concentration in body fluids Acid-base homeostasis balances acid production, acid buffering, and acid excretion

What are the 6 components of interpreting arterial blood gases (ABGs)?

pH, PaCO2, PaO2, SaO2, base excess, and HCO3-

What are buffers?

pairs of chemicals that work together to maintain normal pH of body fluids If there are too many free H+ ions, a buffer can take them up so that they no longer are free and cannot decrease the pH. If there are not enough free H+ ions, a buffer can release H+ to restore a normal pH. Buffers normally keep the blood from becoming too acidic when acids produced by cells are circulating to lungs and kidneys for excretion.

What is the normal color of urine?

pale yellow (like straw) to amber

What do spongy gums that bleed easily indicate?

periodontal disease or vitamin C deficiency

What is PAD?

peripheral artery disease (it causes a reduction in blood flow to the lower extremities, which can lead to longer wound healing)

What are complications of peripheral IV catheters?

phlebitis, infiltration, extravasation, catheter occlusion, nerve damage, and accidental removal

What are petechiae?

pinpoint-size red or purple spots on the skin caused by small hemorrhages in the skin layers

What is buccal administration?

placing the solid medication in the mouth against the mucous membranes of the cheek until it dissolves

How does immobility affect circulation?

pooling of blood in the legs Blood vessels may lose their ability to constrict in response to postural change, causing orthostatic hypotension

What are signs/symptoms of hypomagnesemia?

positive Chvostek sign, hyperactive deep tendon reflexes, muscle twitching and cramping, grimacing, dysphagia, tetany, seizures, insomnia, tachycardia, hypertension, dysrhythmias

What is surgical asepsis (sterile technique)?

procedures to eliminate all microorganisms from an area. Sterilization destroys all microorganisms and their spores Nurses in the operating room, in labor and delivery, and at the bedside practice sterile technique when using sterile instruments and supplies for patient care.

What is medical asepsis (clean technique)?

procedures used to reduce the number and prevent the spread of microorganisms. Examples: Hand hygiene, use of barrier techniques such as gloving and gowning, and routine environmental cleaning

What is a double-lumen catheter used for?

provide one lumen for urinary drainage and a second lumen that is used to inflate a balloon that keeps the catheter in place

What typically causes right-sided heart failure?

pulmonary disease or pulmonary hypertension; it may also result from untreated or end-stage left-sided heart failure

What does PERRLA mean?

pupils equal, round, reactive to light and accommodation

What is nonblanchable hyperemia?

redness that persists after palpation and indicates tissue damage When you press a finger against the red or purple area, it does not turn lighter in color. This indicates deep tissue damage and is commonly the first stage of pressure injury development.

What is blanchable hyperemia?

redness that turns white after palpation Blanchable hyperemia is more difficult to assess in patients with dark skin. The discoloration or redness is warm to touch and is often purple/blue or violet instead of red in darkly pigmented skin.

What is the basal-bolus regimen?

rapid- or short-acting (bolus) insulin before meals and intermediate- or long-acting (basal) background insulin once or twice a day

What are the 4 different categories of insulin?

rapid-acting short-acting intermediate-acting long-acting insulin

How are insulins classified?

rapid-acting, short-acting, intermediate-acting, and long-acting

What does erythema mean?

red discoloration of the skin

What is granulation tissue?

red, moist tissue consisting of blood vessels and connective tissue (young connective tissue)

What is diabetes-related dermopathy?

reddish brown, round or oval patches

What are symptoms of phlebitis?

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

What does atrophy mean?

reduced is size

What is racial identity?

refers to a sense of group or collective identity based on one's perception that he or she shares a common heritage with a particular racial group

Who *cannot* be a witness for living wills or advance directives?

relatives or the patient's health care providers

What is responsibility?

reliability and dependability in the performance of duties

What is a rare adverse effect of opioids in opioid-naïve (patients taking opioids for less than 1 week) patients?

respiratory depression Respiratory depression is clinically significant only if there is a decrease in the rate and depth of respirations from a patient's baseline assessment If a patient develops respiratory depression, administer naloxone

What might cause cyanosis of the lips?

respiratory or cardiovascular problems

What is metabolic alkalosis?

results from a gain of HCO3- or from excessive excretion of metabolic acid The most common causes are vomiting and gastric suction

What is tinnitus?

ringing in the ears

What is ethics?

standards of conduct, particularly right and wrong behavior

What is epibole?

rolled or curled-under closed wound edges that may be dry, callused, or hyperkeratotic

How can aspiration occur in someone with a feeding tube?

secretions or other material in the oral pharyngeal area or reflux of gastric contents including tube feeding formula

What is culture awareness?

self examination of biases, awareness of racism

What does photophobia mean?

sensitivity to light

What are examples of portals of exit?

skin and mucous membranes, respiratory tract, gastrointestinal (GI) tract, urinary tract, reproductive tract, and blood.

What is hospice care?

services for patients who are at the end of life Hospice teams provide *physical, emotional, and spiritual care for patients, family caregivers, and family members* in many settings (i.e., home, hospital, or extended care facilities). Hospice care focuses exclusively on *palliative care interventions* to relieve the symptoms and burdens of illness or treatment and help patients live as fully as possible until death.

What are causes of hyperventilation?

severe anxiety, infection, head injury, medications (e.g., stimulants), and acid-base imbalance

What are symptoms of hypoglycemia?

shakiness, palpitations, nervousness, diaphoresis, anxiety, hunger, and pallor difficulty speaking, visual disturbances, stupor, confusion, and coma

What are rescue medications?

short-acting; patients take them to relieve distress immediately

Where are nutrients absorbed during digestion?

small intestine

What are nephrostomy tubes?

small tubes tunneled through the skin into the renal pelvis to drain the renal pelvis when the ureter is obstructed Patients go home with these tubes and need careful teaching about site care and signs of infection.

Exposure to which substances is linked to respiratory disease?

smog, cotton dust, silicon, mold, cockroaches, secondhand smoke, and asbestos

What does a normal abdomen feel like?

smooth with consistent softness and nontender without masses (Older adults often lack abdominal tone)

What is maceration?

softening of the skin caused by moisture

What is the nail plate?

the transparent layer of epithelial cells covering the nail bed (aka fingernail)

What is the sinoatrial (SA) node?

the "pacemaker" of the heart. The conduction system of the heart originates here The SA node is in the right atrium next to the entrance of the superior vena cava

What is a circadian rhythm?

the 24-hour, day-night cycle also known as the diurnal cycle Circadian rhythms influence the 24-hour pattern of major biological and behavioral functions such as predictable changes in body temperature, heart rate, blood pressure, hormone secretion, sensory acuity, and mood

What does pH measure?

the H+ concentration in body fluids

What are the best injection sites for insulin?

the abdomen, followed by the arm, thigh, and buttock

What is compliance?

the ability of the lungs to distend or expand in response to increased intraalveolar pressure. It depends on the elasticity of the lungs and reflects how easily the lungs can expand.

What is accountability?

the ability to answer for your actions You are accountable to yourself, first and foremost, for your own actions and behaviors. As a professional nurse, you are then first and foremost accountable to the patients you serve. You are also accountable to your workplace and to the larger community.

What is chest percussion?

the manual external clapping of a patient's chest with cupped hands over the lung segments being drained.

What is autologous transfusion (autotransfusion)?

the collection and reinfusion of a patient's own blood

What is an ileoanal pouch anastomosis?

the colon is removed, a pouch is created from the end of the small intestine, and the pouch is attached to the anus

What is mourning?

the conscious and unconscious behaviors associated with loss.

What is Alzheimer disease?

the most common form of dementia. It is a progressive loss of memory (amnesia), loss of ability to recognize objects (agnosia), loss of the ability to perform familiar tasks (apraxia), and loss of language skills (aphasia). As the disease progresses some patients also experience changes in personality and behavior such as anxiety, suspiciousness, agitation, and delusions or hallucinations

What is fecal incontinence?

the temporary or permanent inability to control the passage of feces and gas from the anus

Who is at greater risk for hypoglycemia unawareness?

those who have had repeated episodes of hypoglycemia, older patients, and patients who use β-adrenergic blockers

How many lobes does the right lung have?

three lobes: the upper, middle, and lower lobes

What is the goal of oxygen therapy?

to prevent or relieve hypoxia Any patient with impaired tissue oxygenation benefits from controlled oxygen administration.

Why is it important to do post-mortem care as soon as possible?

to prevent tissue damage or disfigurement of body parts You want to make the body appear as natural and comfortable as possible

What is hand-off reporting?

transferring essential information from one nurse to another

What do ureters do?

transport urine from the kidneys to the bladder

How many lobes does the left lung have?

two lobes: the upper and lower lobes

If a patient is tilting his/her head to one side, what is this possibly a sign of?

unilateral hearing or visual loss (unilateral means on one side only)

How long can insulin vials and insulin pens currently in use be left at room temperature?

up to 4 weeks unless the room temperature is higher than 86° F or below freezing (less than 32° F)

What is pyelonephritis?

upper UTI

What is the manubrium?

upper portion of the sternum

What is a timed urine test?

urine collection and testing either at a specific time of day (such as 2 hours after eating) or urine collected over a specific time period (such as 24 hours)

How would you describe pericardial pain resulting from an inflammation of the pericardial sac?

usually nonradiating and often occurs with inspiration or when lying supine.

What should you look for when inspecting and palpating peripheral veins?

varicosities, peripheral edema, and phlebitis.

What is cultural desire?

wanting to engage with patients from diverse backgrounds

What does persistent cough (productive or nonproductive), blood-streaked sputum, voice change, chest pain, recurrent pneumonia or bronchitis indicate?

warning signs for lung cancer

What happens if peristalsis is too slow?

water continues to be absorbed, and a hard mass of stool forms, resulting in constipation

What is insensible water loss?

water loss that is not visible it is continuous and occurs through the skin and lungs

What is the technical definition of fluid?

water that contains dissolved or suspended substances such as glucose, mineral salts, and proteins

What is the recommended breast cancer screening protocol?

yearly mammogram after 40.

What is the recommended cervical cancer screening protocol?

yearly pelvic exam & q 2 yr PAP test after age 18

What is a STAT order?

you give a single dose of a medication immediately and only once

What are the signs and symptoms of hypoglycemia?

• Blood glucose <70 mg/dL (3.9 mmol/L) • Cold, clammy skin • Numbness of fingers, toes, mouth • Rapid heartbeat • Emotional changes • Headache • Nervousness, tremors • Faintness, dizziness • Unsteady gait, slurred speech • Hunger • Changes in vision • Seizures, coma

What are the ways you can apply topical medications to mucous membranes?

• Direct application of a liquid or ointment (e.g., instilling eyedrops, gargling, or swabbing the throat). • Insertion of a medication into a body cavity (e.g., placing a suppository in the rectum or vagina or inserting medicated packing into the vagina). • Instillation of fluid into a body cavity (e.g., eardrops, nose drops, or bladder and rectal instillation). The fluid is retained. • Irrigation of a body cavity (e.g., flushing eye, ear, vagina, bladder, or rectum) with medicated fluid. The fluid is not retained. • Spraying a medication into a body cavity (e.g., instillation into nose and throat).

Which thought patterns/cognition are symptoms of normal grief?

• Disbelief • Confusion • Preoccupation about the deceased • Sense of the presence of the deceased • Guilty thoughts • Sense of despair

What are common nursing diagnoses related to bowel elimination?

• Disturbed Body Image • Bowel Incontinence • Constipation • Diarrhea • Nausea • Deficient Knowledge (Nutrition) • Acute Pain • Toileting Self-Care Deficit

What are signs/symptoms of hyperglycemia?

• Elevated blood glucose • Increase in urination • Increase in appetite followed by lack of appetite • Weakness, fatigue • Blurred vision • Headache • Glycosuria • Nausea and vomiting • Abdominal cramps • Progression to DKA or HHS

What are causes of hyperglycemia?

• Illness, infection • Corticosteroids • Too much food • Too little or no diabetes medication • Inactivity • Emotional, physical stress • Poor absorption of insulin

How can you control entry of pathogens through the skin?

• Keep skin clean and well lubricated. Use chlorhexidine gluconate for daily bathing of hospitalized patients • Avoid positioning patients on tubes or objects that might cause breaks in skin. • Use dry, wrinkle-free linen. • Offer frequent oral hygiene (see Chapter 31). • Provide frequent position changes for patients with impaired mobility. • Clean skin of patients who are incontinent with nonabrasive agent; avoid drying with abrasive towel or tissue.

What are the 4 ways topical medications are applied to the skin?

• Painting or spreading the medication over an area • Applying moist dressings • Soaking body parts in a solution • Giving medicated baths

What are the standards to decrease intravascular infection related to IV therapy?

• Palpate catheter insertion site for tenderness daily through the intact dressing. • Directly inspect a catheter site if patient develops tenderness at site, fever without obvious source, or symptoms of local or bloodstream infection. • Perform hand hygiene before and after palpating, inserting, replacing, or dressing any intravascular device. • Clean skin site vigorously before venipuncture with an appropriate single-use antiseptic solution. • Allow site to air-dry before proceeding with procedure: 2% chlorhexidine for 30 seconds, povidone-iodine for at least 2 minutes. • Do not palpate insertion site after skin has been cleaned with single-use antiseptic solution. • Use a catheter stabilization device that allows visual inspection of access site. • Change gauze dressings that cover a catheter site every 48 hours. • Leave transparent dressings in place until IV tubing is replaced. • IV tubing administration sets can remain sterile for 96 hours. • Replace dressing over peripheral venous catheters when replacing catheter or when dressing becomes damp, loosened, or soiled. • Clean injection ports with single-use antiseptic solution before accessing system. • Replace short-peripheral catheters and rotate sites based on clinical assessment indicating signs or symptoms of IV-related complications.

Which feelings are symptoms of normal grief?

• Sadness • Anger • Guilt or self-reproach • Anxiety • Loneliness • Fatigue • Helplessness • Shock/numbness (lack of feeling) • Yearning • Relief

What behaviors are symptoms of normal grief?

• Sleep disturbances • Appetite disturbances • Dreams of the deceased • Sighing • Crying • Carrying objects that belonged to the deceased

What effect does alcohol have on sleep?

• Speeds onset of sleep and disrupts REM sleep • Awakens person during night and causes difficulty returning to sleep

What is included in the documentation of informed consent?

• The patient's signature • The witnesses' signatures • The date and time of signing • Verification that the patient voluntarily signed the consent • Verification that the patient discussed the risks, benefits, alternatives, and the right to refuse the procedure with the health care provider • Verification that the patient understands the procedure and has had all questions answered satisfactorily

How are standards of care defined?

(1) State Nurse Practice Acts (2) state and federal hospital licensing laws and accreditation rules (3) professional and specialty organizations (American Nurses Association (4) formal policies and procedures of health care agencies

What are the 7 goals for patients on parenteral nutrition?

(1) preventing infection (2) maintaining the PN system (3) preventing metabolic, electrolyte, or fluid balance complications (4) ensuring that the patient's nutrient and fluid needs are being met (5) evaluating the continued need for PN or if oral intake or EN may be initiated (6) planning for home PN if this is indicated (7) supporting the patient and family during major lifestyle changes.

How can you promote the prevention of wounds in patients?

1) Proper position 2) Topical skin care 3) Using support surfaces 4) Good nutrition

What should the assessment of general appearance and behavior include?

1. Gender and race 2. Age 3. Signs of distress 4. Body type 5. Posture 6. Gait 7. Body movements 8. Hygiene and grooming 9. Dress 10. Body or breath odor 11. Affect, mood, and behavior 12. Speech 13. Patient abuse

What is the normal range for serum K+ (potassium) concentration?

3.5 to 5 mEq/L

What BMI is considered obese?

30 and greater

What does QID, qid mean?

4 times a day

What is the peak of intermediate-acting insulin?

4-12 hours

What is the glomerulus?

A cluster of capillaries in the nephron that filters water, glucose, amino acids, urea, uric acid, creatinine, and major electrolytes

What is loss of protective sensation (LOPS)?

A condition that prevents the patient from being aware that a foot injury has occurred.

What is the costovertebral angle?

An angle formed by the last rib and vertebral column (it is a landmark used during palpation of the kidney)

How do you assess the Spinal accessory Nerve (CN 11)?

Ask patient to shrug shoulders and turn head against passive resistance.

How do you assess the Hypoglossal Nerve (CN 12)?

Ask patient to stick out tongue to midline and move it from side to side.

Which should be done first when doing an abdominal examination - palpation or auscultation?

Auscultation - By using auscultation before palpation there is less chance of altering the frequency and character of bowel sounds. Palpation could falsely increase peristalsis.

Where is hydrostatic pressure the highest in a capillary?

Capillary hydrostatic pressure is greater at the *arterial end* of a capillary

What does Q4h mean?

Every 4 hours

What is the Somogyi effect?

Hyperglycemia in the morning A high dose of insulin produces a decline in blood glucose levels during the night. As a result, counterregulatory hormones are released, stimulating lipolysis, gluconeogenesis, and glycogenolysis, which in turn produce rebound hyperglycemia

What is ventricular fibrillation?

Irregular and chaotic rhythm with no discernible waves or rate

How should you "grade" muscle strength?

On a scale of 0 to 5

CN II

Optic Nerve - vision

What does PICOT stand for?

P: Patient population or area of interest I: Intervention of interest C: Comparison of interest O: Outcome T: Time

What is apnea?

Periods of no respiration lasting greater than 20 seconds Sometimes intermittent such as in sleep apnea or prolonged as in a respiratory arrest

What is sinus bradycardia?

Regular rhythm, rate less than 60 beats/min, normal P wave, normal P-R interval, normal QRS complex

For whom is it abnormal to hear the S4 sound?

S4 may be heard in healthy older adults, children, and athletes; but it is not normal in adults

What is the most common site for a pressure injury?

Sacrum

What is an intraocular disk?

Small, flexible oval (similar to contact lens) consisting of two soft, outer layers and a middle layer containing medication; slowly releases medication when moistened by ocular fluid

What does olfaction mean?

Smelling

What is the Patient Self-Determination Act?

Supports the patient's right to control future treatment in the event the individual cannot speak for himself or herself

What are examples of attentive reassurance in the Caring Assessment Tool (CAT)?

The nurses.... • Are available. • Seem interested. • Support a sense of hope. • Help me believe in myself. • Anticipate my needs.

What happens if peristalsis is too fast?

There is less time for water to be absorbed, and the stool is watery

CN IV

Trochlear Nerve - eye movement

CN X

Vagus Nerve - swallowing

What does jaundice mean?

Yellow-orange discoloration of the skin

What is peristalsis?

a contraction that propels food through the length of the GI tract

What is Afrezza?

a rapid-acting inhaled insulin

Is a solution with a greater concentration of H+ acidic or alkaline?

acidic The greater the concentration of H+, the more acidic the solution and the lower the pH

What is metabolism?

all bodily biochemical and physiological processes

What is insulin resistance?

condition in which body tissues do not respond to the action of insulin because insulin receptors are unresponsive, are insufficient in number, or both

What are four types of adventitious sounds?

crackles, rhonchi, wheezes, and pleural friction rub

What is eschar?

dead tissue (it is usually dry, thick, leathery, brown, or black)

What is the definition of safety?

freedom from psychological and physical injury

What is the most common dressing type?

gauze

What is counseling?

helping patients use a problem-solving process to recognize and manage stress and facilitate interpersonal relationships Counseling includes emotional, intellectual, spiritual, and psychological support

What is the suprasternal notch?

hollow U-shaped depression just above the sternum, in between the clavicles

What nursing interventions can promote metabolic health in an immobile patient?

incorporate enough carbohydrates, proteins, and fats in the patient's diet to combat the effects of immobility Collaborate with the registered dietitian for any dietary restrictions related to other medical conditions or for patients not consuming the necessary nutrients

What is the second section of the small intestine?

jejunum

What partial pressure of oxygen (PaO2) level is considered hypoxemia?

less than 60 mm Hg

What is anorexia?

loss of appetite

What does a nursing care plan include?

nursing diagnoses, goals and/or expected outcomes, and individualized nursing interventions

What is a transdermal disk?

patch medication (e.g., nitroglycerin, scopolamine, and estrogens)

What does dyspnea mean?

shortness of breath

What are the 2 phases of the cardiac cycle?

systole and diastole

What regulates bicarbonate levels?

the kidneys

What is bicarbonate?

the principal buffer in the ECF

What is basic critical thinking?

trusting that experts have the right answers for every problem (relying on manuals or guidelines)

What is nocturnal enuresis?

wetting the bed at night

What is a telephone order (TO)?

when a health care provider gives therapeutic orders over the phone to an RN.

What is disenfranchised grief?

when a person cannot openly acknowledge a loss or receive full social support from others For example: the loss of an ex-husband or an early miscarriage

What is complicated grief?

when a person has difficulty progressing through the loss experience

What is a stoma?

when a temporary or permanent opening is surgically created between the abdominal wall and the outside

What is active transport?

when electrolytes or other substances move across cell membranes against a concentration gradient (from an area of low concentration to one of higher concentration)

When should patients report to their health care provider?

when glucose levels are over 300 mg/dL twice in a row or urine ketone levels are moderate to high

How can side rails increase the risk of falls?

when patients attempt to get out of bed and crawl over a rail

When should needle receptacles be emptied?

when they are two-thirds full

Why are irrigations used?

• Cleanse an area. • Instill a medication. • Apply heat or cold to injured tissue

What are nursing interventions during the working phase?

• Encourage and help the patient express feelings about his or her health. • Encourage and help the patient with self-exploration. • Provide information needed to understand and change behavior. • Encourage and help the patient to set goals. • Take actions to meet the goals set with the patient. • Use therapeutic communication skills to facilitate successful interactions. • Use appropriate self-disclosure and confrontation.

What characteristics of sound should you listen for when you auscultate?

• Frequency: (high or low pitch) • Intensity: (loud or soft) • Quality: (example: blowing or gurgling) • Duration: (Length of time that sound last)

What safety precautions should be followed for oxygen therapy?

• Place an "Oxygen in Use" sign on the patient's room door or door of house. • No smoking should be allowed on the premises. • Keep oxygen delivery systems 10 feet from any open flames. • Be sure electrical equipment in the room is functioning correctly and is grounded. • Secure oxygen cylinders so that they do not fall over.

What does RACE mean with respect to fire safety?

• R—Rescue and remove all patients in immediate danger. • A—Activate the alarm. Always do this before trying to extinguish even a minor fire. • C—Confine a fire by closing doors and windows and turning off oxygen and electrical equipment. • E—Extinguish a fire with an appropriate extinguisher.

What effect does caffeine have on sleep?

• Stimulant; prevents person from falling asleep • Causes person to awaken during night

What effect do opiates have on sleep?

• Suppress REM sleep • Cause increased daytime drowsiness

How can hypoglycemia be prevented?

• Take prescribed dose of medication at proper time • Accurately administer insulin, noninsulin injectables, OA • Coordinate eating with medications • Eat adequate food intake needed for calories for exercise • Be able to recognize and know symptoms and treat them immediately • Carry simple carbohydrates • Teach family and caregiver about symptoms and treatment • Check blood glucose routinely • Wear or carry diabetes identification

What are some examples of databases where you can search for the best evidence?

1) CINAHL(Cumulative Index of Nursing and Allied Health Literature) 2) MEDLINE 3) PsycINFO 4) Cochrane Database of Systematic Reviews 5) National Guidelines Clearinghouse 6) PubMed 7) Worldviews on Evidence-Based Nursin

What are examples of low-flow oxygen delivery devices?

1) Nasal cannula 2) Oxygen-conserving cannula (Oxymizer) 3) Simple face mask 4) Partial nonrebreather mask

How should you weigh an infant?

1) Weigh infants in baskets or on platform scales. 2) Remove the infant's clothing, keeping the room warm to reduce heat loss. 3) Put a light cloth or paper on the scale to prevent surface contamination from urine or feces. 4) Hold a hand lightly above the infant to prevent falls. 5) Measure the weight of an infant in ounces, grams, and kilograms.

What are 2 pain assessment scales developed for children?

1) Wong-Baker 2) The Oucher scale

Which parts of the body should you check for cyanosis?

1) lips 2) nail beds 3) palpebral conjunctivae 4) palms

What are examples of nonverbal communication?

1) personal appearances 2) posture and gait (gait is the way someone walks) 3) facial expression 4) eye contact 5) gestures 6) territoriality and space

What are the four physiological processes of normal pain?

1) transduction 2) transmission 3) perception 4) modulation

What are the 6 core critical thinking skills?

1. Interpretation 2. Analysis 3. Evaluation 4. Inference 5. Explanation 6. Self-regulation

What are the 4 types of wound drainage?

1. Serous 2. Sanguineous 3. Serosanguineous 4. Purulent

What 5 things should you look out for when doing an abdominal inspection?

1. Skin 2. Umbilicus 3. Contour and symmetry 4. Enlarged organs or masses 5. Movements or pulsations

Why is this diagnostic statement wrong? Fatigue related to low red blood cell counts

A low red blood cell count is *not treatable by a nursing intervention* Correct diagnosis statement: Fatigue related to chronic disease process

What is melatonin?

A neurohormone produced in the brain that helps control circadian rhythms. It is a popular nutritional supplement in the United States used to aid sleep.

What is autonomic neuropathy?

A neuropathy that can affect nearly all body systems and lead to hypoglycemia unawareness, bowel incontinence and diarrhea, and urinary retention

What does a normal ECG waveform consist of?

A normal ECG waveform consists of a *P wave* (atrial depolarization), *QRS complex* (ventricular depolarization), and *T wave* (ventricular repolarization)

What is angiontensin II?

A peptide hormone that causes vasoconstriction, which helps regulate blood pressure, and it stimulates the release of aldosterone, which assists fluid homeostasis.

What is angiotensin I?

An enzyme in the kidney breaks down protein to form angiotensin I. Angiotensin I is a precursor to angiotensin II.

What infections require droplet precautions?

Bordetella pertussis, influenza virus, adenovirus, rhinovirus, Neisseria meningitidis, group A streptococcus

What is an example of protective touch?

Bracing a patient to avoid a fall

How do you test for rebound tenderness?

By pressing a hand slowly and deeply into the involved area and then letting go quickly. The test is positive if the patient feels pain when the hand is released.

How does exposure to carbon monoxide affect oxygenation?

Carbon monoxide binds strongly with hemoglobin, preventing the formation of oxyhemoglobin, and reducing the supply of oxygen delivered to the tissues

What are critical pathways?

Critical pathways (also known as clinical pathways, practice guidelines, or CareMap tools) are interprofessional care plans that identify patient problems, key interventions, and expected outcomes within an established time frame

What should you do if you suspect DVT in a patient?

Do not massage the area Report assessment findings to the health care provider immediately Elevate the leg, with no pressure on the area of the leg with the suspected thrombus

What are ways to promote health/safety in infants, toddlers and preschoolers?

Educate parents or guardians about preventing access to poisonous substances; creating a safe sleeping environment; using car seats correctly; using safe, age-appropriate toys; and teaching young children safety rules (e.g., proper use of scissors, how to walk in parking lots with parents)

What is lordosis?

Exaggeration of anterior convex curve of lumbar spine

What nursing interventions can promote skin health in an immobile patient?

Frequent positioning, skin care, and use of pressure-relief devices Family caregivers and patients must know the importance of changing position routinely if a patient is confined to a bed or wheelchair. Teach chair-bound patients who are able to move to shift their weight every 15 to 20 minutes, and provide a pressure-reducing device for the chair

What does sanguineous drainage look like?

Fresh bleeding

What is the DASH eating plan?

Fruits, vegetables, fat-free or low-fat milk, whole grains, fish, poultry, beans, seeds, and nuts

What is hospital-associated deconditioning (HAD)?

HAD is the loss of muscle mass, functional reserve, and decreased activity tolerance and the functional decline in activities of daily living (ADLs) and mobility regardless of a specific neurological or orthopedic insult (caused by inactivity during hospitalization)

What is the anger stage of grief?

In the anger stage a person resists the loss, is angry about the situation, and sometimes becomes angry with God.

What is kyphosis?

Increased convexity in curvature of thoracic spine

What might thick and cloudy urine indicate?

Infection or renal disease

What is an exogenous infection?

Infection that comes from microorganisms found outside the individual such as Salmonella, Clostridium tetani, and Aspergillus

What is a deep tissue pressure injury?

Intact or nonintact skin with localized area of persistent nonblanchable deep red, maroon, or purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss.

What is the description of a Stage 1 pressure injury?

Intact skin with a localized area of nonblanchable erythema, which may appear differently in darkly pigmented skin. The presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury

What is reflex urinary incontinence?

Involuntary loss of urine occurring at predictable intervals when patient reaches specific bladder volume related to spinal cord damage from C1 to S2.

What is urge urinary incontinence?

Involuntary passage of urine often associated with strong sense of urgency related to overactive bladder (involuntary bladder contractions) caused by neurological problems, bladder inflammation, or bladder outlet obstruction

What are potential causes of spoon nail?

Iron deficiency anemia, syphilis, use of strong detergents

What is atrial fibrillation (A-FIB)?

Irregular atrial activity resulting in irregular ventricular response with resultant irregular cardiac rate and rhythm. No identifiable P wave. Rate determined by conduction of multiple atrial impulses across AV node

How would you describe pain originating in the heart?

It is most often substernal and typically radiates to the left arm and jaw in men. Some women as well as some men have epigastric pain, complaints of indigestion, nausea or vomiting, or a choking feeling and dyspnea.

What is the purpose of chloride?

It is the major anion in ECF and an important part of gastric hydrochloric acid

What is the fecal occult blood test (FOBT)?

It measures microscopic amounts of blood in the feces (also called guaiac test)

What does end of life mean?

It refers to the final phase of a patient's illness, when death is imminent

What is scoliosis?

Lateral S- or C-shaped spinal column with vertebral rotation; unequal heights of hips and shoulders

What is common law?

Laws based on judicial decisions, or case law precedent, and includes both federal and state court decisions (e.g. Roe v. Wade)

How do you assess the Trigeminal Nerve (CN 5)?

Lightly touch cornea with wisp of cotton. Assess corneal reflex. Measure sensation of light pain and touch across skin of face. Palpate temples as patient clenches teeth; observe chewing.

What is usually the first clinical sign of osteoporosis?

Loss of height

What causes lateral displacement of the trachea?

Masses in the neck or mediastinum and pulmonary abnormalities

What is metabolic syndrome?

Metabolic syndrome has five components: 1) elevated glucose levels 2) abdominal obesity 3) elevated BP 4) high levels of triglycerides 5) decreased levels of high-density lipoproteins (HDLs) Individuals with metabolic syndrome are at an increased risk for the development of type 2 diabetes.

When is more ADH released?

More ADH is released when plasma osmolality increases increased ADH causes more water resorption and dilutes the plasma back to normal

What is flexion?

Movement decreasing angle between two adjoining bones; bending of limb

What are the 3 stages of NREM sleep?

N1 - lighter sleep N2 - sounder sleep N3 - slow wave sleep - deepest stage of sleep

Which organization has developed a model for organizing nursing diagnoses for documentation, auditing, and communication purposes?

NANDA International (NANDA-I)

Which insulins may be cloudy?

NPH lispro protamine aspart protamine

What is nebulization?

Nebulization uses the aerosol principle to suspend a maximum number of water drops or particles of the desired size in inspired air.

Can insulin be taken orally?

No! Insulin is *not* taken orally because it is inactivated by gastric fluids

Should you ever massage reddened areas of the skin?

No! Never! Do not massage reddened areas because reddened areas indicate tissue injury. Massage to these areas further injures the tissue by causing damage to the tissue capillaries.

Does DKA always require hospitalization?

No, not always. If fluid and electrolyte imbalances are not severe and blood glucose levels can be safely monitored at home, DKA may be managed on an outpatient basis.

If a patient does not understand English well, should you use a family member as an interpreter?

No. Call for an interpreter or a phone service interpreter.

What special preparation is needed for a routine urinanalysis?

None.

What substance should normally be used to cleanse a wound?

Normal saline

What should you do if you are assigned to care for more patients than is reasonable for safe care?

Notify your nursing supervisor. If you are required to accept the assignment, document this information in writing and provide the document to nursing administrators. Although documentation does not relieve you of responsibility if patients suffer harm because of inattention, it shows that you attempted to act appropriately. Keep a copy of this document.

What does a normal sleep cycle consist of?

Once asleep, a person usually passes through four to six complete sleep cycles, each cycle consisting of three (or four) stages of NREM sleep and a period of REM sleep, for a total of 90 to 110 minutes

What is bowlegs (genu varum)?

One or both legs bent outward at knee, which is normal until 2-3 years of age

What is a productive cough?

One that produces sputum that is swallowed or expectorated

What is the difference between open-ended and closed-ended questions?

Open ended questions require more than a one or two word answer. (How does your pain interfere with your daily life?) Closed ended questions require a yes/no, number or one-word answer. (Did you have a bowel movement today??

What is a thrill?

Palpable bruit

How should you assess the temperature of a patient's skin?

Palpate skin with the dorsum (back of the hand)

What is required for a protective environment (for neutropenic patients)?

Patient: Private room; positive-pressure airflow with 12 or more air exchanges per hour; HEPA filtration for incoming air; Mask to be worn by patient when out of room during times of construction in area

For whom is 30 degree lateral position recommended?

Patients at risk for developing pressure injuries

What medications can cause urine to change color?

Patients taking phenazopyridine, a urinary analgesic, void urine that is bright orange. The kidneys excrete special dyes used in IV diagnostic studies, which discolor the urine.

What is direct transmission?

Person-to-person or physical contact between source and susceptible host (e.g., touching patient feces and then touching own face or mouth or consuming contaminated food)

What is indirect transmission?

Personal contact of susceptible host with contaminated inanimate object (e.g., needles or sharps, dressings)

What is a tablet?

Powdered medication compressed into hard disk or cylinder; in addition to primary medication, contains binders (adhesive to allow powder to stick together), disintegrators (to promote tablet dissolution), lubricants (for ease of manufacturing), and fillers (for convenient tablet size)

What should you do to prevent hemolysis when administering blood?

Prime the tubing with 0.9% sodium chloride

What is the largest route of phosphate output?

Renal excretion

What is a lotion?

Semiliquid suspension that usually protects, cools, or cleanses skin

What is the integument?

Skin, hair, scalp and nails

What is a caplet?

Solid dosage form for oral use; shaped like capsule and coated for ease of swallowing

What is the treatment method of choice for solid cancers?

Surgery

What are the major treatment options for cancer?

Surgery Radiation Drug therapy

What are the 7 types of events on the National Quality Forum List of Serious Reportable Events?

Surgical or Invasive Procedure Events Product or Device Events Patient Protection Events Care Management Events Environmental Events Radiologic Events Potential Criminal Events

How can you assess visual acuity (the ability to see small details) in a patient?

The Snellen chart

Which governing body has the power to suspend or revoke a nurse's license if the nurse's conduct violates provisions of the licensing statute?

The State Board of Nursing

What is virtue ethics?

The focus is on the character of an individual A virtue is a character trait that is socially valued Virtue ethics values the motivation of the individual over simple obedience to principles such as beneficence or respect for autonomy.

What is the introduction of a scientific article?

The introduction describes its purpose and the importance of the topic for the audience who reads it

What is the symphysis pubis?

The joint between the 2 pubic bones (the lower boundary of the anterior abdominal region)

How do the kidneys regulate pH?

The kidneys excrete all acids except carbonic acid by adjusting the amount of H+ excreted in the urine to maintain acid-base homeostasis

What is extravasation?

The leakage of intravenously (IV) infused potentially damaging medications into the extravascular tissue around the site of infusion

What is a normal sinus rhythm (NSR)?

The normal sequence of electrical impulses on the ECG

Who signs consent forms for a child?

The parent or legal guardian

What is the lunula?

The semilunar, whitish area at the base of the nail bed

Why is this diagnostic statement wrong? Offer bedpan frequently because of altered elimination patterns

This statement is an intervention, not a diagnosis Correct diagnosis statement: Diarrhea related to food intolerance

What is Virchow's triad?

Three factors that contribute to venous thrombus formation: (1) blood stasis resulting from decreased blood flow and increased viscosity, (2) hypercoagulability resulting from a change in clotting factors or increased platelet activity, and (3) vessel trauma

Why is auscultation of the carotid artery especially important for middle-aged or older adults or patients suspected to have cerebrovascular disease?

To assess if the lumen of a carotid is narrowed

For which types of cancers does chemotherapy work best?

Treatment of choice for disseminated cancers (leukemia, disseminated lymphomas, widespread metastases)

What is hope?

When a person has the attitude of living for and looking forward to something

What is modulation (in reference to pain)?

When a person perceives a harmful impulse, the brain releases inhibitory neurotransmitters such as endogenous opioids, serotonin, norepinephrine, and gamma-aminobutyric acid (GABA). The neurotransmitters hinder the transmission of pain to help produce an analgesic effect. A protective reflex response also occurs with pain that causes the person to withdraw from the source of the pain.

What is transmission (in reference to pain)?

When neurotransmitters transmit messages to the spinal cord then to the thalamus in the brain. The thalamus is the first structure in the brain to process the impulse.

What is pitting edema?

When pressure from your finger leaves an indentation in the edematous area

What is gluconeogenesis?

When the body breaks down fat and amino acids for conversion to glucose

In what position do the jugular veins usually protrude?

When the patient lies in supine position

What is an ethical dilemma?

When the right thing to do is not clear, when members of the health care team cannot agree on the right thing to do, or when the health care team and the patient and/or family disagree on a course of action.

Can you mix short- or rapid-acting insulin with intermediate-acting insulin in the same syringe?

Yes

What is a dysrhythmia?

a disturbance in the formation or conduction of the heart's electrical impulse; Any rhythm not generated at the SA node is classified as a dysrhythmia

What is sensory (or receptive) aphasia?

a person cannot understand written or verbal speech

What is lung volume determined by?

a person's age, gender, and height

What does it mean to heal by tertiary intention?

a surgical wound is initially closed in the deep tissue layers; however, the subcutaneous fat and skin layers are left open. The wound heals with a layer of granulation tissue at the edges and base, and several days after the initial wounding the health care provider brings the wound edges together with sutures or adhesive closures. Also called delayed primary closure

What is a problem-oriented medical record (POMR)?

a system of organizing documentation that places primary focus on patients' individual problems.

What is a computerized provider order entry (CPOE) system?

a system that allows health care providers to directly enter orders for patient care into a medical record from any computer in the hospital information system

What is anthropometry?

a systematic measurement of the size and makeup of the body using height and weight as the principal measures

What is charting by exception (CBE)?

a type of charting in which it is assumed that all standards are met unless otherwise documented

What is hyperkalemia?

abnormally high blood K+ concentration

What is hemolysis?

breakdown of RBCs

What are macronutrients?

carbohydrate, protein, and fat

What is the recommended prostate cancer screening protocol?

digital rectal exam q yr. PSA test yearly for high risk

What is typically the cause of left-sided heart failure?

hypertension or CAD

If you are administering time-critical meds, within how much time must you give them?

within 30 minutes before or after their scheduled time

What effect do antihistamines have on sleep?

• Cause drowsiness • Cause insomnia when used in excess

What are common nursing diagnoses related to nutrition?

• Deficient Knowledge (Nutrition) • Diarrhea • Feeding Self-Care Deficit • Imbalanced Nutrition: Less Than Body Requirements • Impaired Swallowing • Obesity • Overweight • Risk for Aspiration

Which patients are unable to report pain?

• Infants and children • Patients who are critically ill, unconscious, or on life-support equipment • Patients with dementia • Patients who are aphasic • Patients with an intellectual disability • Patients at the end of life

How is hyperglycemia prevented?

• Take prescribed dose of medication at proper time • Accurately administer insulin, noninsulin injectables, OA • Make healthy food choices • Follow sick-day rules when ill • Check blood glucose routinely • Wear or carry diabetes identification

What are the 5 steps of the evaluation process?

(1) comparing achieved effect with goals and outcomes (2) collecting data to determine if your patient met the criteria or standards (3) interpreting and summarizing findings (4) recognizing errors or unmet outcomes (5) revising the care plan as needed.

What 6 factors should be considered when choosing a nursing intervention?

(1) desired patient outcomes (2) characteristics of the nursing diagnosis (3) evidence base (research or clinical practice guidelines) for the intervention (4) feasibility of implementing the intervention (5) acceptability to the patient (6) your own competency

What are the 3 ways blood carries CO2?

(1) dissolved in plasma (2) as carbamino compounds (3) as bicarbonate

What are common goals for patients with diabetes?

(1) engage in self-care behaviors to actively manage his or her diabetes (2) experience few or no hyperglycemia or hypoglycemia emergencies (3) maintain blood glucose levels at normal or near-normal levels (4) prevent or minimize chronic complications related to diabetes (5) adjust lifestyle to accommodate the diabetes plan with a minimum of stress.

What does blood transfusion do?

(1) increase circulating blood volume after surgery, trauma, or hemorrhage (2) increase the number of RBCs to maintain hemoglobin levels in patients with severe anemia (3) provide selected cellular components as replacement therapy (e.g., clotting factors, platelets, albumin).

What does IV line maintenance include?

(1) keeping the system sterile and intact (2) changing IV fluid containers, tubing, and contaminated site dressings (3) assisting a patient with self-care activities (e.g., bathing) so that the IV system is not disrupted (4) monitoring for complications of IV therapy

What are changes in the urinary system that affect older adults?

*Men* An enlarged prostate obstructs urine flow from the bladder, resulting in incomplete bladder emptying, urgency, frequency, UTIs, and damage to the upper urinary tract from urinary retention *Women* A decrease in estrogen results in urethral changes and decreased closing pressure *Both* Aging and long-term neurological conditions such as multiple sclerosis, stroke, and dementia can also affect the urinary system and create elimination changes. These changes usually include decreased bladder capacity, decreased ability to delay voiding, loss of bladder contractility, and increased incidence of overactive bladder.

What is the difference between morals and ethics?

*Morals* refer to judgment about behavior, based on specific beliefs *Ethics* refers to the study of the ideals of right and wrong behavior

What are the PQRSTU characteristics of pain?

*Palliative or Provocative* factors - What makes your pain worse or better? *Quality*—How do you describe your pain? *Relief measures*—What do you do at home to gain pain relief? *Region* (location)—Show me where you hurt. *Severity*—On a scale of 0 to 10, with 0 being no pain and 10 being the worst, how bad is your pain now? . *Timing* (onset, duration, and pattern)—Is your pain constant, intermittent, or both? *U* (effect of pain on patient)—What are you unable to do because of your pain?

What important consideration should you note about a potassium chloride IV?

*Under no circumstances should you give KCl by IV push* (directly through a port in IV tubing). A direct IV infusion of KCl is *fatal*. IV administration of KCl requires dilution in solution and infusion with an IV pump over a period of time.

What is the difference between *self-transcendence* and *transcendence*?

*self-transcendence* is connecting to your inner self, which allows one to go beyond oneself to understand the meanings of experiences *transcendence* is the belief that there is a positive force outside of and greater than oneself that allows one to develop new perspectives that are beyond physical boundaries

What are nursing diagnoses related to hypertension?

-Ineffective health management -Anxiety -Sexual dysfunction -Risk for decreased cardiac perfusion -Risk for ineffective cerebral and renal perfusion -Potential complications: stroke, MI -

What kind of physicality is recommended for hypertension?

-Moderate-intensity aerobic activity, at least 30 minutes, most days of the week -Vigorous-intensity aerobic activity at least 20 minutes, 3 days a week -Muscle-strengthening activities at least 2 times a week -Flexibility and balance exercises 2 times a week

What other conditions does hypertension increase the risk of?

-Myocardial infarction (heart attack) -Heart failure -Stroke -Renal disease

What are effects of chemo toxicity on bone marrow?

-Neutropenia -Thrombocytopenia (low platelet count) -Anemia

What kind of subjective data should a nurse collect when assessing a patient with hypertension?

-Past health history (Hypertension, Cardiovascular, cerebrovascular, renal, thyroid disease, Diabetes mellitus, pituitary disorders, obesity, dyslipidemia, menopause or hormone replacement ) -Drugs -Family history -Salt and fat intake -Weight gain or loss -Nocturia -Fatigue, dyspnea on exertion, palpitations, pain -Dizziness, blurred vision -Erectile dysfunction -Stressful events

What are the goals of end of life care?

-Provide comfort and supportive care during dying process -Improve quality of remaining life -Help ensure a dignified death -Provide emotional support to family

What are key characteristics of physical development of middle-age adults?

-accepting and adjusting to physiological changes -decline in reproductive capacity

What are characteristics of spiritual distress?

-anger toward God or a higher being -change in behavior and mood -desire for spiritual assistance -displaced anger toward clergy

What are effects of chemotherapy toxicity?

-bone marrow supression -digestive tract issues -Alopecia -Hyperuricemia (uric acid build up) -Reproductive toxicity -Local injury from extravasation of vesicants -Carcinogenesis (cell mutilation) -Unique toxicities to the drug

What are common medications that can induce diabetes?

-corticosteroids (prednisone) -thiazides -phenytoin (Dilantin) -atypical antipsychotics (e.g., clozapine [Clozaril])

What are effects of chemo toxicity on digestive system?

-digestive tract injury -stomatitis -nausea, vomiting, diarrhea

What psychosocial changes must older adults adapt to?

-retirement -loss of spousal roles -death of spouses, friends, and sometimes children -loneliness -change in living arrangements

What are key characteristics of psychosocial development of middle age adults?

-sandwich generation (caring for children and parents at same time) -Life events (children moving away, divorce/death of spouse) -Career changes

What are symptoms of HHS in later stages?

-somnolence -coma -seizures -hemiparesis -aphasia

What do hospice programs focus on?

-symptom management -advance care planning -spiritual care -family support -palliative rather than curative care -quality rather than quantity of life.

What are the components of the chain of infection?

-the infectious agent or pathogen -reservoir or place for pathogen growth -portal of exit from the reservoir -mode of transmission or vehicle -portal of entry into the reservoir, - a susceptible host

What are common causes of HHS?

-urinary tract infections -pneumonia -sepsis -any acute illness -newly diagnosed type 2 diabetes

What are lifestyle modifications for hypertension?

-weight reduction -DASH eating plan -Reduce dietary sodium -Moderate alcohol intake -Increase physical activity -Avoid tobacco products -Decrease stress

What should be considered when using bed rails?

1) Always know agency policy about the use of side rails. 2) Be sure that a bed is in the lowest position possible when side rails are raised. 3) Always assess the risk of using side rails compared with not using them. 4) Check the condition of the side rails

What should you consider to ensure accuracy when weighing a patient many times over a period of time ?

1) Always use the same scale 2) Weigh the person at the same time each day

What are the categories of pharmacological pain therapy?

1) Analgesics 2) Patient-controlled analgesia 3) Perineural local anesthetic infusion 4) Local anesthetics 5) Epidural analgesia

What are psychological factors that influence pain?

1) Anxiety 2) Depression 3) Coping Style

What are conditions that benefit from heat therapy?

1) Arthritis or degenerative joint disease 2) Localized joint pain or muscle strains 3) Low back pain 4) Menstrual cramping 5) Hemorrhoid, perianal, and vaginal inflammation 6) Local abscesses

What should you ask about when getting a nursing history of the lungs?

1) Ask the patient about persistent cough (productive or nonproductive), blood-streaked sputum, voice change, chest pain, shortness of breath, orthopnea, dyspnea during exertion or at rest, poor activity tolerance, or recurrent pneumonia or bronchitis. 3) Assess for a history of tobacco or marijuana use 4) Determine if your patient works in an environment containing pollutants 5) Review risk factors for tuberculosis (TB) and/or HIV infection 6) Assess history of allergies to airborne irritants, foods, drugs, or chemical substances. 7) Ask if the patient has had pneumonia or influenza vaccine and a TB test. 8) Review the patient's family history for cancer, TB, allergies, or chronic obstructive pulmonary disease.

What are social factors that influence pain?

1) Attention (vs. distraction to pain) 2) Previous experiences 3) Family and social support

What are some guidelines about a female breast self-examination (BSE)?

1) BSE should be done once a month 2) For women who menstruate the best time to do an exam is between the 4th and 7th day of menstrual cycle

What are examples of drugs that promote sleep?

1) Benzodiazepines (temazepam, flurazepam, and triazolam, etc) 2) Trazodone, a SARI antidepressant 3) Non-benzodiazepine receptor agonists ( zolpidem, zaleplon, and eszopiclone)

What are 8 basic components of a nursing health history?

1) Biographical information 2) Reasons for seeking health care 3) Present illness or health concern 4) Health history 5) Family history 6) Environmental history (Hazards, pollutants, and physical safety) 7) Psychosocial and cultural history 8) Review of systems (Head-to-toe review of all major body systems and patient's knowledge of and compliance with health care)

what are excitory neurotransmitters related to pain?

1) Bradykinin 2) Substance P 3) Seratonin 4) Prostaglandins

Which skills are needed for implementation?

1) Cognitive 2) Interpersonal 3) Psychomotor

What are examples of indirect care?

1) Communicating nursing interventions 2) Delegating, supervising, and evaluating work of other staff members

What are therapeutic communication techniques?

1) Conveying empathy 2) active listening 3) sharing observations 4) using silence 5) providing information 6) clarifying 7) focusing 8) paraphrasing 9) summarizing 10) instilling hope 11) self-disclosure

What are signs of dysphagia?

1) Coughing during or after a swallow 2) difficulty or painful chewing or swallowing 3) change in voice 4) unintentional weight loss 5) frequent clearing of throat 6) recurrent chest infections 7) abnormal gag, delayed swallowing 8) incomplete oral clearance or pocketing, regurgitation 9) pharyngeal pooling 10) drooling 11) delayed or absent trigger of swallow 12) inability to speak consistently.

What are the 5 constructs of practicing care in a culturally competent manner?

1) Cultural awareness 2) Cultural knowledge 3) Cultural skill 4) Cultural encounter 5) Cultural desire

What are 4 factors that affect oxygenation?

1) Decreased Oxygen-Carrying Capacity. 2) Decreased Inspired Oxygen Concentration. 3) Increased Metabolic Rate. 4) Conditions Affecting Chest Wall Movement.

What are causes of hypoxemia?

1) Decreased diffusion of oxygen from the lung (alveoli) into the blood, as in pneumonia, asthma exacerbation, or atelectasis 2) High altitudes 3) Shunting of blood from the right side of the heart to the left side without exchange of gases in the lungs, as seen in some congenital heart defects

What should you ask about when taking a nursing history of the neck?

1) Determine if the patient has a history of a recent cold or infection, enlarged lymph nodes, or exposure to radiation or toxic chemicals. 2) If there is a history of enlarged lymph nodes, inquire about any past history of IV drug use, hemophilia, and risk factors for human immunodeficiency virus (HIV) infection. 3) Learn if the patient takes thyroid medication for a history of hypothyroidism or hyperthyroidism; ask about a family history of thyroid disease. 4) Ask the patient to describe any head or neck injury or pain of head and neck structures.

What kind of things should be asked about during a nursing assessment of the patient's nose or sinuses?

1) Determine if the patient has a history of exposure to dust or pollutants, allergies, nasal obstruction, recent nasal trauma or discharge, frequent infections, headaches, or postnasal drip. 2) Assess for a history of nosebleeds or use of nasal sprays, including frequency and duration 3) Ask about breathing difficulties or snoring.

What kind of things should you ask about when getting a nursing history on the mouth and pharynx?

1) Determine if the patient wears dentures or retainers and how they fit. 2) Assess for any recent changes in appetite or weight, which indicate problems with chewing and swallowing. 3) Assess the patient's dental hygiene practices. 4) determine if the patient smokes, chews tobacco, or consumes alcohol. (To identify cancer risks) 5) Identify if he or she still has his or her tonsils and adenoids.

What does it mean to provide presence in nursing care?

1) Developing a person-to-person relationship that conveys a closeness and sense of caring 2) A nurse and a patient are mutually open to one another 3) "being there" and "being with" (both in a physical sense and in understanding)

What are 2 common causes of edema?

1) Direct trauma 2) Impairment of venous return

How can you protect patient confidentiality when using the EHR at a clinical site?

1) Do not share information with classmates unless it is necessary for care or part of the learning process 2) Do not access medical records of other patients on the unit (who are not your patients) 3) any electronic or written materials you use in your student clinical practice must not include patient identifiers (e.g., name, room number, date of birth, demographic information) 4) Do not print records from the EHR for your own private use

How does a nurse promote infection control and prevention?

1) Education patients about nutritional requirements 2) Instruct patients on good hygiene practices 3) Educate patients about immunization programs 4) Teach patients about importance of sleep and rest

How can electrical accidents be prevented?

1) Electrical equipment should be regularly inspected and maintained (equipment should have safety inspection sticker with an expiration date) 2) use properly grounded and functional equipment 3) Remove equipment that is not in proper working order or that sparks when plugged in or is out of service

What are inhibitory neurotransmitters related to pain?

1) Endorphins 2) Enkephalins 3) Dynorphins

What are sources of diagnostic errors?

1) Errors in data collection ( when you conduct patient interview of physical assessment unskillfully) 2) Errors in Interpretation and Analysis of Data (When you do not validate data or do not consider cultural factors, etc.) 3) Errors in Data Clustering (when you cluster data prematurely, incorrectly, or not at all) 4) Errors in the Diagnostic Statement (you choose the wrong nursing diagnosis)

What interventions should be implemented in acute care settings to ensure patient safety?

1) Explain to patients how to use a nurse call or intercom system 2) place the call device close to a patient 3) respond quickly to nurse call systems and bed/chair alarms 4) Keep the environment around the bedside free from clutter 5) conduct hourly rounds 6) During rounding, address toileting, turning, pain control, and hydration

How do you assess a person's faith?

1) First determine his or her beliefs, especially beliefs that influence hope 2) Determine which of your patient's beliefs serve as a guide and help the patient find meaning in life events 3) Finally assess to what extent your patient interrelates with self, others, and a source of authority.

What are important safety needs with respect to nutrition?

1) Food is properly refrigerated, stored and prepared 2) There is an adequate supply of fresh, clean water 3) There is regular garbage collection and sanitary conditions

What are Watson's 10 carative factors?

1) Forming a human-altruistic value system 2) Instilling faith-hope 3) Developing a helping-trusting, human, caring relationship 4) Developing a helping-trusting, human, caring relationship 5) Promoting and accepting the expression of positive and negative feelings 6)Using creative problem-solving, caring processes 7) Promoting transpersonal teaching-learning 8) Providing for a supportive, protective, and/or corrective mental, physical, societal, and spiritual environment 9) Meeting human need 10) Allowing for existential-phenomenological-spiritual forces

What are causes of hypoxia?

1) Hypoxemia, or low arterial concentrations of oxygen in the blood 2) Inability of the tissues to extract oxygen from the blood, as in septic shock and cyanide poisoning 3) Impaired delivery of oxygen to the tissues, which can be seen in cases of low cardiac output, sepsis, thyroid storm, or exercise 4) Obstructive or restrictive pulmonary diseases 5) Impaired ventilation from multiple rib fractures, spinal cord injury, neuromuscular diseases, or CNS depression resulting from medications or overdose

What are conditions that benefit from cold therapy?

1) Immediately after direct trauma (e.g., sprains, strains, fractures, muscle spasms) 2) Superficial laceration or puncture wound 3) Minor burn 4) After injections 5) Chronic pain from arthritis, joint trauma, or delayed-onset muscle soreness; inflammation

What are causes of hypoventilation?

1) Impaired ventilation related to trauma, pain, infection, obstructive diseases (emphysema or sleep apnea), or fluid volume overload 2) Alterations in neurological regulation of breathing, such as occurs with head or spinal cord injuries 3) Alterations in chemical regulation of breathing

What are the therapeutic benefits of heat therapy?

1) Improve blood flow to injured body part 2) Promote delivery of nutrients and removal of wastes 3) Improve delivery of leukocytes and antibiotics to wound site 4) Promote muscle relaxation 5) Reduce pain from spasm or stiffness 6) Increase blood flow 7) Provide local warmth 8) Promote movement of waste products and nutrients

What motor vehicle safety hazards should be considered for different age groups?

1) Infants and children - parents not following laws related to safety seats, boosters and seat belts 2) Teenage drivers - poor judgment, dangerous driving, driving while intoxicated, not using seat belts 3) Elderly drivers - poor vision, impaired cognitive and physical function

What are reasons a patient might have increased GI motility?

1) Inflammation of the bowel 2) anxiety 3) bleeding 4) excess ingestion of laxatives 5) reaction of the intestines to certain foods

What should be asked about when completing a nursing history for the musculoskeletal system?

1) Injury or trauma resulting from sports, employment, exercise, or chronic illnesses 2) Assess for osteoporosis risk factors including use of alcohol and/or caffeine; cigarette smoking; constant dieting; poor calcium or vitamin D intake; thin and light body frame; nulliparous status; menopause before 45 years of age; estrogen deficiency; postmenopause status; family history of osteoporosis; Caucasian, Asian, Native American, or Northern European ancestry; advanced age; history of fractures and/or falls; sedentary lifestyle; chronic diseases; long-term use of corticosteroids, methotrexate, phenytoin, and aluminum-containing antacids; and lack of exposure to sunlight. 3) a patient's description of problems with bone, muscle, or joint function including history of recent falls, trauma, lifting heavy objects, fractures, and bone or joint disease. I 4) assess a patient's normal activity pattern including the type of exercise routinely performed 5) determine if alterations affect the patient's ability to perform ADLs, sleep, and participate in social activities.

What are the 4 injections sites for parenteral administration?

1) Intradermal (ID): Injection into the dermis just under the epidermis. 2) Subcutaneous: Injection into tissues just below the dermis of the skin. 3) Intramuscular (IM): Injection into a muscle. 4) Intravenous (IV): Injection into a vein.

What are the 3 levels of communication (and what do they mean)?

1) Intrapersonal communication (person talks to himself/herself) 2) Interpersonal communication (between 2 people or a small group) 3) Public communication (between one person and a large group of people)

How can radiation exposure be prevented?

1) Know your agency-established protocols 2) limit the time spent near sources of radiation 3) make the distance from the source as great as possible between you and source 4) use shielding devices such as lead aprons 5) wear devices that track the cumulative exposure to radiation (for staff who work near radiation)

What are treatment options for sleep apnea?

1) Lifestyle changes (including a weight-reduction program in people who are obese and improved sleep hygiene) 2) Bilevel positive airway pressure (BPAP or BiPAP), continuous positive airway pressure (CPAP), surgery 3) oral repositioning devices for the jaw and tongue are treatment options

What are examples of physical hazards that can threaten a person's safety?

1) Motor vehicle accidents 2) Poison 3) Fire 4) Falls 5) Disasters 6) Pathogen transmission 7) Pollution

What are the factors in the Caring Assessment Tool (CAT)?

1) Mutual problem solving 2) Attentive reassurance 3) Human respect 4) Encouraging manner 5) Appreciation of unique meanings 6) Healing environment 7) Affiliation needs 8) Basic human needs

What tips should you follow when communicating with patients whom you suspect have health literacy problems?

1) Organize what you want to say so that the most important points come first. 2) Break complex information into understandable chunks. 3) Plan multiple short teaching sessions instead of one long session. 4) Use simple language, avoiding jargon and defining technical terms 5) Use the teach-back method 6) Use the active voice.

What are the components of a medication order?

1) Patient's full name 2) Date and time that order is written 3) Medication name 4) Dosage 5) Route of administration 6) Time and frequency of administration 7) Signature of health care provider:

How should assessing visual acuity using the Snellen chart be performed?

1) Patients wears prescription glasses or contact lenses during the assessment. 2) Identify the language the patient speaks and confirm reading ability. 3) Position the patient 6 m (20 feet) away from the chart. 4) Test each eye separately

How should patients be instructed regarding getting eye examinations?

1) People younger than 40 years of age need to have a complete eye examination every 3 to 5 years (or more often if family histories reveal risks such as diabetes or hypertension). 2) People older than 40 years of age need to have a complete eye examination every 2 years 3) People older than 65 years of age need to have a complete eye examination every year

What factors should you consider when using communication during assessment?

1) Physical and emotional factors 2) developmental factors 3) sociocultural factors 4) language 5) gender

What are general factors that affect sleep?

1) Physical illness 2) Drugs and substances 3) Lifestyle 4) Usual sleep patterns and excessive daytime sleepiness 5) Emotional stress 6) Environment 7) Exercise and fatigue 8) Food and caloric intake

What are the 4 phases of a therapeutic relationship?

1) Preinteraction Phase—Before Meeting the Patient 2) Orientation Phase—When You and the Patient Meet and Get to Know One Another 3) Working Phase—When You and the Patient Work Together to Solve Problems and Accomplish Goals 4) Termination Phase—During the Ending of the Relationship

What can a nurse do to promote good sleep hygiene practices?

1) Provide a sleeping environment with a comfortable room temperature and proper ventilation, minimal noise, a comfortable bed, and proper lighting. 2) Promote bedtime routines 3) Promote comfort 4) Promote activity 5) Stress reduction 6) Bedtime snacks 7) Sleep meds

What are 7 caring behaviors in nursing practice?

1) Providing presence 2) Using touch 3) Listening 4) Knowing the patient 5) Spiritual caring 6) Relieving symptoms and suffering 7) Family care

What are the 5 preparatory activities you should do before implementation?

1) Reassess the patient 2) Review and revise the care plan 3) Organize resources and care delivery 4) Anticipate and prevent complications 5) Implement nursing interventions

What are the therapeutic benefits of cold therapy?

1) Reduce blood flow to injured site, preventing edema formation 2) Reduce inflammation 3) Reduce localized pain 4) Reduce oxygen needs of tissues 5) Promote blood coagulation at injury site 6) Relieve pain

What health education topics should you teach patients about regarding cardiovascular health?

1) Regular blood pressure checkups and taking blood pressure medication as prescribed 2) Following the DASH diet and a proper caloric diet 3) getting an annual influenza vaccine and a pneumococcal vaccine 4) smoking cessation, and avoiding secondhand smoke exposure.

How can you help patients feel more hopeful?

1) Remind them of their strengths and reinforce their expressions of courage, positive thinking, and realistic goal setting. 2) Help patient feel a sense of control 3) Encourage family involvement in care 4) Offer information to patients about their illness, correct misinformation, and clarify patient's perceptions. 5) Help them practice healthy behaviors (e.g., enjoying meals, talking with friends, and getting rest) and suggest that they develop a workable schedule for each day. 6) Encourage patients to nurture important relationships

What are examples of nonpharmacological pain-relief measures?

1) Remove or prevent painful stimuli 2) Anticipatory guidance (Giving patients detailed descriptions of all medical procedures and expected postprocedural discomfort) 3) Distraction (directing a patient's attention to something else) 4) Cutaneous simulation (massage, warm bath, ice pack, and transcutaneous electrical nerve stimulation) 5) Relaxation and guided imagery

How do you assess visual fields in a patient (peripheral vision)?

1) Remove the patient's eyeglasses. 2) Have the patient stand or sit 60 cm (2 feet) away facing you at eye level. 3) He or she gently closes or covers one eye (e.g., the left) and looks at your eye directly opposite. 4) Close the opposite eye as the field of vision is superimposed on that of the patient. 5) Move a finger equidistant at arm's length from you and the patient outside the field of vision and then slowly bring it back into the visual field. 6) Ask the patient to tell you when the finger is visible. If you see the finger before the patient does, this reveals that a portion of the patient's visual field is reduced.

What are examples of illnesses and conditions that can alter sleep?

1) Respiratory disease 2) Coronary heart disease with episodes of chest pain and irregular heart rates 3) Hypertension 4) Hypothyroidism 5) Hyperthyroidism 6) Nocturia (reduced bladder tone, heart failure, diabetes, urethritis, prostate disease) 7) Gastric reflux 8) Depression 9) Perimenopause 10) Pain

What information should ask about when taking a nursing history on the ears?

1) Review risk factors for hearing problems with the patient 2) history of ear trauma or surgery. 3) Determine if the patient has ear pain, itching, discharge, tinnitus, vertigo, or change in hearing. 4) Assess if the patient wears a hearing aid 5) How he or she normally cleans it and the ears.

What should you ask about when taking a nursing history for neurological assessment?

1) Review the patient's use of analgesics, alcohol, sedative-hypnotics, antipsychotics, antidepressants, nervous system stimulants, or recreational drugs. 2) review the patient's use of over-the-counter sleeping aids. 3) Determine if the patient has a recent history of seizures and/or convulsions and screen for symptoms of headache, tremors, dizziness, vertigo, numbness or tingling of body parts, visual changes, weakness, pain, or changes in speech. 4) Discuss with the patient's family any recent changes in the patient's behavior (e.g., increased irritability, mood swings, memory loss, change in energy level). 5) Ask the patient for a history of changes in vision, hearing, smell, taste, and touch. A history of head or spinal cord trauma, meningitis, congenital anomalies, neurological disease, or psychiatric counseling focuses your assessment of select findings. 6) If an older adult patient displays sudden acute confusion (delirium), review history for drug toxicity, serious infections, metabolic disturbances, heart failure, and severe anemia.

What should you ask questions about when assessing oxygenation?

1) Risk factors (familial, occupational, and environmental) 2) Fatigue 3) Pain (chest, jaw, left arm) 4) Breathing patterns (dyspnea, orthopnea, wheezing) 5) Coughing 6) Respiratory infections 7) Medication use

What should you ask about if you notice a patient has little hair on their or parts of their legs?

1) See if they shaved their legs 2) Ask if they wear tight-fitting jeans or socks If either is the case, then the lack of hair is probably not from a circulatory system issue

What are some techniques for interviewing the patient?

1) Select a comfortable environment (good temp, lighting) 2) Provide for the patient's comfort 3) Listen to the patient and consider the information shared 3) establish a positive nurse-patient relationship, the patient will feel comfortable asking you questions 4) make interview free of distractions, unnecessary noise, and interruptions 5) interview is private 6) Set aside enough time so that the person does not feel rushed 7) Sit facing the person and maintain eye contact 8) Ask open ended questions to get the whole story 9) Ask close-ended questions to focus on a specific problem 10) Use back-channeling 11) Clarify or validate info that is unclear

What are lesions that are commonly seen on the elderly?

1) Senile karatosis 2) cherry angiomas 3) atrophic warts

How should patients with diabetes be instructed to take care of their feet?

1) Set a time to inspect feet each day 2) Wash feet daily in warm water and carefully dry them, especially between toes. 3) Soften dry feet with lotion 4) Do not put lotion between toe 5) Don't use sharp objects to poke or dig under toenail or around cuticle. 6) Wear shoes and socks and don't go barefoot. 7) Protect feet from extreme heat and cold. 8) Keep blood flowing to feet. Elevate feet when sitting, and wiggle toes and move ankles periodically. Don't cross legs for long periods of time. 9) See a podiatrist for treatment of ingrown toenails and nails that are thick or tend to split.

What are factors that contribute to a pressure injury?

1) Sheer 2) Friction 3) Moisture 4) Nutrition 5) Age

What areas of ADLs should be assessed with respect to the influence of pain?

1) Sleep 2) Hygiene 3) Eating 4) Sexual Functioning 5) Home Management and Work Activities 5) Social Activities

What factors should a nurse assess when taking a patient's sleep history?

1) Sleep pattern and quality 2) Description of sleeping patterns 3) Sleep diary 4) Physical illness 5) Medications 6) Current Life Events 7) Emotional and Mental Status 8) Bedtime Routines 9) Bedtime environment 10) Behaviors of sleep deprivation

What should nurses do in their practice to perform patient-centered care which respects the person's cultural and personal values and beliefs?

1) Take time to know and clarify patients' values and beliefs regarding health care and caring practices 2) Determine if a member of a patient's family or cultural group is the best resource to guide caring practices 3) Allow patients to share their own perspective of the impact of their illness/trauma 4) Know patients' cultural practices regarding end-of-life care. 5) Understand how patients choose to communicate their feelings.

How do you test pupillary reflexes?

1) Test in a dimly lit room. 2) Instruct the patient to look straight ahead, bring a penlight from the side of the patient's face, and direct the light onto the pupil 3) Observe the quickness and equality of the reflex of the pupil constirction 4) Repeat the examination for the opposite eye.

What are sources of data about the patient?

1) The patient himself or herself 2) Family/significant others 3) Health care team 4) Medical records 5) Other records and medical literature 6) the nurse's experience

What is a double voided urine specimen?

1) The patient voids into the toilet 2) The patient drinks water 3) The patient voids into a collection container (the purpose of a double voided specimen is to get a specimen that has not been sitting in the bladder a long time)

What factors should you consider when organizing resources and care delivery?

1) Time management (provide timely, safe, competent and efficient care) 2) Equipment (decide what supplies are necessary and see if they are available) 3) Personnel (perform intervention or decide who to delegate it to) 4) Environment (it is safe and conducive to therapy) 5) Patient (patient is physically and psychologically comfortable)

What are examples of high-flow oxygen delivery devices?

1) Venturi mask 2) High-flow nasal cannula

What are 6 important aspects of verbal communication?

1) Vocabulary 2) Denotative and Connotative meaning 3) pacing (how fast or slow) 4) Intonation and volume 5) Clarity and brevity 6) Timing and relevance

What are requirements of informed consent?

1) a patient has all relevant information required to decide about undergoing treatment 2) the patient is capable of understanding the relevant information 3) the patient gives consent

What are the 2 approaches for comprehensive assessment?

1) a structured database format, based on an accepted theoretical framework or practice standard (such as Gordon's 11 functional health patterns) 2) the problem-focused approach

What are risk factors for phlebitis?

1) acidic or hypertonic IV solutions 2) rapid IV rate 3) irritating IV drugs such as potassium chloride (KCl) and vancomycin 4) VAD in area of flexion 5) poorly secured catheter 6) poor hand hygiene 7) lack of aseptic technique

What medical aseptic techniques should be employed by nurses?

1) adequate cleaning, disinfection and sterilization 2) control or elimination of reservoirs 3) control of portals of exit 4) hand hygiene 5) isolation and barrier protection 6) protective environment 7) PPE

When should you discontinue a VAD?

1) after the prescribed amount of fluid is infused 2) when infiltration occurs 3) if phlebitis is present 4) if a clot develops in the catheter

What factors affect a person's susceptibility to infection?

1) age 2) heredity 3) cultural practice 4) nutritional status 5) stress 6) rest and exercise 7) inadequate defenses (broken skin, compromised immune system) 8) personal habits (alcohol, smoking, multiple sex partners, etc.) 9) environmental factors 10) immunization/disease history 11) medical therapies 12) clinical appearance and data (fever, increased WBCs)

What might be the cause of dry, brittle hair?

1) aging 2) excessive use of chemical agents

What interventions are used to maintain or promote lung expansion?

1) ambulation 2) positioning 3) incentive spirometry 4) chest tube 5) noninvasive ventilation.

What are symptoms of a lower UTI?

1) burning or pain with urination (dysuria) 2) irritation of the bladder (cystitis) characterized by urgency, frequency, incontinence, suprapubic tenderness, and foul-smelling, cloudy urine 3) Sometimes blood in the urine (hematuria).

What are recommendations for preventing sheer?

1) by maintaining the elevation of the head of the bed at 30 degrees or less for the supine position 2) using assistive devices when turning or transferring patients 3) using the 30-degree lateral position

What are 3 coughing techniques that help a patient to remove secretions from the upper and lower airway?

1) cascade cough 2) huff cough 3) quad cough

What should you observe about a lesion?

1) color 2) location 3) texture 4) size 5) shape type 6) grouping (e.g., clustered or linear), 7) distribution (localized or generalized) 8) if it has changed (over time)

What are the 3 types of hearing loss?

1) conduction 2) sensorineural 3) mixed

What are the 5 most common predictors of patient violence?

1) confusion/cognitive impairment 2) anxiety 3) agitation 4) shouting/demanding 5) history of physical aggression

How should you *not* refer to a patient as?

1) cute names like honey, sweetie, grandpa, etc. 2) by the patient's diagnosis 3) by the patient's room number

What should you assess when you observe a patient that has abnormal weight changes?

1) diet habits 2) appetite 3) use of prescription or over-the-counter drugs 4) physical symptoms

What are the 3 levels of the Nursing Interventions Classification (NIC) model?

1) domains 2) classes 3) interventions

What are the 3 levels of solid foods for dysphagia?

1) dysphagia pureed 2) dysphagia mechanically altered 3) dysphagia advanced

Which parts of the body should you check for pallor?

1) face 2) buccal mucosa (mouth) 3) conjunctivae 4) nail beds

What are examples of marginalized groups?

1) gay, lesbian, bisexual, or transgender 2) people of color 3) people who are physically and/or mentally challenged 4) people who are not college educated

What might cause alopecia?

1) genetic tendencies 2) endocrine disorders such as diabetes and menopause

What should be done in acute care settings to limit fall risk?

1) have the patient dangle the legs for 5 minutes on the side of the bed before trying to ambulate 2) Give patient a bedside commode 3) use color coded wristbands to indicate patients with fall risk 4) use a gait belt for patients needing assistance to transfer or ambulate 5) Remove excess furniture and equipment 6) make sure that patients wear rubber-soled shoes/slippers to walk or during transfer 7) Make sure bed/commode/wheelchair can handle weight of patient 8) provide a clear path to the bathroom 9) keep rooms well lit 10) Use additional safety equipment and safe patient-handling techniques when moving and positioning patients 11) Inspect canes, walkers, and crutches to make sure they are safe and adjusted properly

How do you conduct a hearing assessment?

1) have the patient remove any hearing aid, if worn. 2) Note the patient's response to questions. 3) If you suspect a hearing loss, check the patient's response to the whispered voice. 4) Test one ear at a time while the patient occludes the other ear with a finger. Ask the patient to gently move the finger up and down during the test. 5) While standing 30 to 60 cm (1 to 2 feet) from the testing ear, cover your mouth so the patient is unable to read lips. After exhaling fully, whisper softly toward the nonoccluded ear, reciting random numbers with equally accented syllables such as nine-four-ten. 6) Ask the patient to repeat what was heard. 6) If necessary gradually increase voice intensity until the patient repeats the numbers correctly. 7) Then test the other ear for comparison.

What are examples of non-therapeutic communication techniques?

1) inattentive listening 2) overusing medical vocabulary 3) prying or asking personal questions 4) giving approval or disapproval 5) changing the subject 6) automatic responses 7) false reassurance 8) asking for explanations 9) arguing 10) being defensive 11) sympathy

What are the 4 factors of type 2 diabetes

1) insulin resistance 2) a marked decrease in the ability of the pancreas to produce insulin 3) inappropriate glucose production by the liver 4) altered production of hormones and cytokines by adipose tissue (adipokines)

What are the components of extracellular fluid (ECF)?

1) intravascular (within blood vessels) 2) interstitial (within tissues) 3) transcellular (minor)

How can accidental poisoning be prevented?

1) keep hazardous substances out of children's reach 2) Educate patients or family caregivers about keeping medications in original containers that are labeled in large print (for older adults) 3) Recommend the use of medication organizers that are filled once a week. 4) Have patients keep poisonous substances out of the bathroom and properly discard old and unused medications.

What factors (other than a specific skin condition) could cause dry skin?

1) lack of humidity 2) exposure to sun 3) smoking 4) stress 5) excessive perspiration 6) dehydration

What patient behavior might indicate he/she has hearing loss?

1) leaning forward to hear 2) inattentiveness to speech 3) requests to repeat comments.

How can hospital-associated deconditioning (HAD) negatively affect a patient's recovery?

1) longer length of stay (LOS) 2) development of medical complications such as pressure injuries, deep vein thrombosis (DVT), and falls 3) create the need for postdischarge rehabilitation.

What are some restraint alternatives for patients who continue to try to ambulate without assistance?

1) low beds with an adjacent mat on the floor 2) electronic bed/chair alarm devices

What are uncontrollable risk factors for heart disease?

1) male gender 2) family history of heart disease 3) ethnicity (Blacks, Caucasians, and Hispanics)

What could continuous dilation of pupils indicate?

1) neurological disorders 2) glaucoma 3) trauma 4) eye medication 5) withdrawal from opioids

What are the 3 types of sleep apnea?

1) obstructive 2) central 3) mixed, which has both an obstructive component and a central component.

When palpating the lymph nodes, what order should you palpate them?

1) occipital nodes at the base of the skull, 2) postauricular nodes over the mastoid 3) preauricular nodes just in front of the ear 4) retropharyngeal nodes at the angle of the mandible 5) submandibular nodes 6) submental nodes in the midline behind the mandibular tip

When should a nurse use agency-approved skin assessment tools and perform assessment of a patient for risk of development of pressure injuries?

1) on admission to the agency 2) 24 to 48 hours after admission 3) at regular intervals 4) when there is a significant change in a patient's condition

What are routes of fluid intake?

1) orally through drinking and eating 2) IV 3) GI (tube feedings) 4) rectal (e.g., enemas) 5) irrigation of body cavities that results in fluid absorption

What are types of parenteral replacement?

1) parenteral nutrition (PN) 2) IV fluid and electrolyte therapy (crystalloids) 3) blood product (colloids) administration

What are the 4 categories of related factors?

1) pathophysiological (biological or psychological), 2) treatment-related 3) situational (environmental or personal) 4) maturational (the process of growing)

What are examples for which an incident report would need to be completed?

1) patient falls 2) needlestick injuries 3) medication administration errors 4) accidental omission of ordered therapies 5) a visitor losing consciousness, 5) any circumstances that lead to injury or pose a risk for patient injury such as a "near miss."

Who are examples of patients likely to become immobilized?

1) patients with chronic illness 2) elderly patients 3) disabled patients 4) patients paralyzed by stroke or spinal cord injury 5) surgical patients who have postoperative complications 6) patients with multiple trauma 7) patients with coronary artery disease 8) patients with obstetrical complications (preeclampsia).

What are examples of symptoms a patient may experience at the end of life?

1) physical symptoms (e.g., dyspnea, fatigue, urinary incontinence, or nausea) 2) psychological symptoms (e.g., anxiety, fear, or depression) 3) social symptoms (e.g., loneliness, isolation, or loss of community) 4) spiritual symptoms (e.g., hopelessness, despair, or loss of meaning).

What are Maslow's hierarchy of needs?

1) physiological (food, water, shelter, etc.) 2) safety 3) love/belonging 4) esteem 5) self-actualization

What qualities in a nurse help to establish therapeutic relationships?

1) professionalism 2) courtesy 3) confidentiality 4) trust 5) acceptance and respect 6) presence

What are the steps for basic first-aid intervention for when a patient sustains a traumatic wound?

1) promote hemostasis 2) cleanse the wound 3) protect the wound from further injury

What are safety risks related to pollution?

1) pulmonary disease (from air pollution) 2) contaminated water (from water pollution) 3) health effects of excessive noise

What are 4 steps to the critical thinking process?

1) recognizing an issue (e.g., patient problem), 2) analyzing information related to the issue (e.g., clinical and historical data about the patient) 3) evaluating information (including assumptions and evidence) 4) drawing conclusions

How can you provide a comfortable a peaceful environment for a patient near death?

1) repositioning, keeping bed linens dry, and controlling environmental temperature and noise. 2) Keep the patient's immediate surroundings pleasant and clean. 3) Open curtains so that patients can experience the natural changes from day to night. 4) Remove sources of unpleasant odors (e.g., stale food and used bedpans or emesis basins) promptly. 5) Pictures, cherished objects, cards from friends and family, or plants create a comforting and familiar environment for patients and family members. 6) Offer the patient frequent body massage if desired 7) provide opportunities for patients to hear their favorite music

What are the four primary acid-base imbalances?

1) respiratory acidosis 2) respiratory alkalosis 3) metabolic acidosis 4) metabolic alkalosis It is possible to have two primary (mixed) acid-base imbalances.

What are controllable risk factors for heart disease?

1) smoking 2) hypertension 3) physical inactivity 4) obesity, diabetes 5) alcohol intake 6) high-fat/high-sodium diets 7) high low-density lipoprotein (LDL or "bad cholesterol") levels 8) low high-density lipoprotein (HDL or "good cholesterol") levels

What are common causes of house fires?

1) smoking materials or people falling asleep while smoking 2) improper use of stoves and other appliances 3) not having a smoke detector/batteries in smoke detector

What are patient behaviors that may indicate that a patient may become violent?

1) staring 2) eye contact 3) threatening tone and volume of voice 4) anxiety 5) mumbling 6) pacing

How is narcolepsy treated?

1) stimulants or wakefulness-promoting drugs (e.g., sodium oxybate, modafinil) that only partially increase wakefulness and reduce sleep attacks. 2) antidepressants to suppress cataplexy and other REM-related symptoms 3) Short daytime naps (no longer than 20 minutes) 4) Exercising regularly, maintaining a regular nighttime sleep schedule, eating light meals high in protein, deep breathing, chewing gum, and taking vitamins are other management methods 5) avoiding situations and activities that increase drowsiness (e.g., alcohol, heavy meals, exhausting activities, long-distance driving).

How pathogen transmission be controlled?

1) teach patients how and when to wash hands 2) Nurses use Standard Precautions when caring for all patients 3) Patients need to know how to dispose of infected material such as wound dressings and used needles in the home

What are signs/symptomsof a fecal impaction?

1) the inability to pass a stool for several days, despite a repeated urge to defecate 2) Continuous oozing of liquid stool after several days with no fecal output 3) Loss of appetite, abdominal distention and cramping, nausea and/or vomiting, and rectal pain

What is a a clean-catch midstream specimen?

1) the patient cleans the urinary meatus 2 to 3 times with a separate clean wipe each time 2) The patient starts voiding into the toilet 3) the patients stops voiding into the toilet, and then starts voiding into the collection container midstream

What should you document regarding a death that has occurred?

1) the time and date of death 2) the name of the health care provider who pronounces the death 3) organ or tissue donation status, preparation of the body 4) medical devices left in or on the body 5) valuables or belongings left with the patient (e.g., dentures, glasses, or wedding ring) or given to the family (e.g., clothing, mail, or photographs), time of discharge 6) destination of the body (e.g., morgue at the agency or funeral home)

What are the 4 levels of liquid for dysphagia?

1) thin liquids (low viscosity) 2) nectarlike liquids (medium viscosity) 3) honeylike liquids (viscosity of honey) 4) spoon-thick liquids (viscosity of pudding)

What are the 2 goals for cultural encounters?

1) to communicate in a way that generates a wide variety of responses and to send and receive both verbal and nonverbal communication accurately and appropriately in each culturally different context. 2) to continuously interact with patients from culturally diverse backgrounds to validate, refine, or modify existing values, beliefs, and practices about a cultural group

What is treatment for hyperventilation?

1) treating the underlying cause 2) improving tissue oxygenation 3) restoring ventilation 4) reducing respiratory rate 5) achieving acid-base balance

What is the treatment of hypoventilation?

1) treating the underlying cause 2) improving tissue oxygenation 3) restoring ventilation, and achieving acid-base balance

How can females avoid UTI?

1) wipe from front to back after voiding and defecation 2) avoid perfumed perineal washes and sprays, bubble baths, and tight clothing 3) void before and after sexual intercourse 4) wear cotton underwear

What is a nurse's responsibility with informed consent?

1) witnessing a patient's signature on a consent form 2) ask the patient if he/she understands the procedures for which they are giving consent. 3) If patients deny any understanding or if you suspect that they do not understand, notify the health care provider and your nursing supervisor immediately.

How is diabetes diagnosed?

1. A1C of 6.5% or higher. 2. Fasting plasma glucose (FPG) level greater than or equal to 126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 hours. 3. Two-hour plasma glucose level greater than or equal to 200 mg/dL (11.1 mmol/L) during an OGTT, using a glucose load of 75 g. 4. In a patient with classic symptoms of hyperglycemia (polyuria, polydipsia, unexplained weight loss) or hyperglycemic crisis, a random plasma glucose greater than or equal to 200 mg/dL (11.1 mmol/L).

What are interventions to help a patient relax during an abdominal examination?

1. Ask the patient to void before beginning. 2. Be sure that the room is warm and cover the patient's upper chest and legs. 3. The patient lies supine or in a dorsal recumbent position with the arms at the sides and knees slightly bent. Place small pillows beneath the knees. 4. Proceed calmly and slowly, being sure that there is adequate lighting. 5. Warm hands and stethoscope promote relaxation. 6. Ask the patient to report pain and point out areas of tenderness. Assess tender areas last.

When should you compare the label of the medication container with the MAR (medical administration record)?

1. Before removing the container from the drawer, compartment, or shelf 2. As the amount of medication ordered is removed from the container 3. At the patient's bedside before administering the medication to the patient

If your hands are not visibly soiled, when may you use an alcohol-based hand rub (at minimum) to decontaminate your hands?

1. Before touching a patient 2. Before clean/aseptic procedures (e.g., insertion of invasive devices, hygiene care) 3. After body fluid exposure/risk (e.g., contact during bathing, dressing changes, specimen collection) 4. After touching a patient 5. After touching patient surroundings (e.g., overbed table, bed linen, IV pump) (You may also wash hands with an antimicrobial soap and water in these situations.)

What are safety risks in a health-care agency?

1. Chemical exposure 2. Falls 3. Patient-Inherent Accidents (ex: self-inflicted wounds, having a seizure disorder) 4. Procedure-related accidents 5. Equipment-related accidents 6. Workplace safety (i.e. workplace violence)

What principles should you follow when cleansing wounds?

1. Cleanse in a direction from the least contaminated area to the most contaminated such as from the wound or incision to the surrounding skin or from an isolated drain site to the surrounding skin 2. Use light friction when applying antiseptics locally to the skin. 3. When irrigating, allow the solution to flow from the least contaminated to the most contaminated area.

What are the 5 components of critical thinking in nursing?

1. Competence 2. Specific knowledge base 3. Experience 4. Attitudes for critical thinking 5. Standards for critical thinking (intellectual and professional)

What are tips for collecting data about children?

1. Gain a child's trust before doing any type of an examination. 2. Initiate from the periphery and then moves to the center. 3. Gather all or part of the information from parents or guardians. 4. Offer support during examination and do not pass judgment about parents. 5. Call children by their preferred name and address parents formally rather than by first names. 6. Ask Open-ended questions 7. Treat older children and adolescents as adults 8. Remember an adolescent has a right to confidentiality.

What is the purpose of a health assessment and physical examination?

1. Gather baseline information about a patient's health status. 2. Supplement, confirm, or refute information learned during the health history. 3. Identify or confirm actual or at-risk nursing diagnoses. 4. Make clinical judgments about a patient's current or changing health status and ability to manage it. 5. Evaluate the outcomes of care.

What are complications of wound healing?

1. Hemorrhage 2. Infection 3. Dehiscence 4. Evisceration

What are the 5 steps of the scientific method?

1. Identifying the problem 2. Collecting data 3. Forming a question or hypothesis 4. Testing the question or hypothesis 5. Evaluating results of the test or study

What are the 3 methods of IV administration?

1. Infusion of large volume IV fluid containers that contain medications mixed by the pharmacy. 2. Injection of a bolus or small volume of medication through an existing IV infusion line or intermittent venous access (heparin or saline lock). 3. "Piggyback" infusion of a solution containing the prescribed medication and a small volume of IV fluid through an existing IV line.

What are principles for applying bandages and binders?

1. Inspect the surrounding skin for abrasions, edema, discoloration, or exposed wound edges. 2. Inspect the condition of underlying dressings and change if soiled. 3. Cover exposed wounds or open abrasions with a sterile dressing. 4. Assess the skin of underlying body parts that are distal to the dressing for signs of circulatory impairment (coolness, pallor or cyanosis, diminished or absent pulses, swelling, numbness, and tingling) to provide a means for comparing changes in circulation after dressing application.

What are 3 steps to establishing a healing relationship with your patient?

1. Mobilizing hope for you and for your patients 2. Finding an interpretation or understanding of the illness, pain, anxiety, or other stressful emotion that is acceptable to patients 3. Helping patients use social, emotional, or spiritual resources

What are the guidelines for breast cancer detection and screening?

1. Monthly BSE is an option for women starting in their 20s. 2. Women 20 years of age and older need to report any breast changes to a health care provider immediately. 3. Health care providers may perform a clinical breast examination every 3 years in women 20 to 40 years of age and annually in women older than 40 years of age. 4. Women 40 to 49 years of age may begin screening mammograms. Women should discuss options with their health care provider. 5. Screening mammograms should take place every 2 years for women 50 to 74 years of age. 6. For women of any age with an increased risk the ACS recommends discussion of screening options and additional testing with a health care provider.

What type of information is included on a transfer report?

1. Patient's name, age, date of birth, health care provider(s), and medical diagnosis 2. Summary of medical progress up to the time of transfer 3. Current health status (physical and psychosocial) 4. Allergies 5. Emergency code status 6. Family support 7. Current nursing diagnoses or problems and care plan 8. Any critical assessments or interventions to be completed shortly after transfer (helps receiving nurse establish priorities of care) 9. Up-to-date reconciled medication list 10. Need for any special equipment such as isolation equipment, suction equipment, or traction

What are the steps to change a patient's gown without disrupting the IV system?

1. Remove the sleeve of the gown from the arm without the IV line, maintaining the patient's privacy. 2. Remove the sleeve of the gown from the arm with the IV line. 3. Remove the IV solution container from its stand and pass it and the tubing through the sleeve. If this involves removing the tubing from an EID, use the roller clamp to slow the infusion to prevent accidental infusion of a large volume of fluid. 4. To apply a gown, place the IV solution container and tubing through the sleeve of the clean gown and hang it back on the stand. If the IV infusion is controlled by an EID, reassemble, turn on the pump, and open the roller clamp. 5. Place the arm with the IV line through the new gown sleeve. 6. Place the arm without the IV line through the new gown sleeve.

What are the 3 levels of critical thinking in nursing?

1. basic 2. complex 3. commitment

What is normal cardiac output range for an adult?

4-8 L/min

What is the most effective position for promoting lung expansion in patients with cardiopulmonary disease?

45-degree semi-Fowler's position

How long should you auscultate the abdomen before concluding the bowel sounds are absent?

5 minutes

What size catheters are usually used?

5 to 6 Fr for infants 8 to 10 Fr for children 10 to 12 Fr for adolescent girls 10 to 12 Fr for women 12 to 14 Fr for men

What is the normal amount of bowel sounds heard in one minute?

5-35 bowel sounds per minute

How much daily sodium is recommended to reduce hypertension?

< 2300 mg/day for healthy adults < 1500 mg/day for -African Americans -Middle-aged and older -Those with hypertension, diabetes, or chronic kidney disease

What is type 2 diabetes mellitus?

A combination of inadequate insulin secretion and insulin resistance. The pancreas usually produces some endogenous (self-made) insulin. However, the body either does not produce enough insulin or does not use it effectively, or both.

What is a multidisciplinary ethics committee?

A committee established by institutions to process ethical dilemmas that has representatives from nursing, medicine, professional disciplines, and the community at large

What is diabetic ketoacidosis (DKA)?

A condition caused by a profound deficiency of insulin and is characterized by hyperglycemia, ketosis, acidosis, and dehydration. It is most likely to occur in people with type 1 diabetes but may be seen in people with type 2 diabetes in conditions of severe illness or stress when the pancreas cannot meet the extra demand for insulin.

What is right-sided heart failure?

A condition that results from impaired functioning of the right ventricle

What is conduction hearing loss?

A conduction loss interrupts sound waves as they travel from the outer ear to the cochlea of the inner ear because they are not transmitted through the outer and middle ear structures.

What is a urine hat?

A container that collects urine in the toilet, allowing for patient privacy

What is a graduated measuring container?

A container that has volume measurement markings.

Ulcer

A deep loss of skin surface that may extend into the dermis; may cause periodic bleeding and the formation of scars.

What is gestational diabetes?

A diabetes that develops during pregnancy

What is a communicable disease?

A disease that is contagious

What is the ANA Code of Ethics for Nurses (2015)?

A document that lays out principles and obligations that shape professional nursing practice including responsibility, accountability, respect for confidentiality, competency, judgment, and advocacy

What is epidural anesthesia?

A form of regional anesthesia which blocks transmission of pain stimuli in the spinal cord.

What is the lacrimal glad?

A gland responsible for tear production

What is a pathogen?

A harmful microorganism

What is left sided heart failure?

A heart condition characterized by impaired functioning of the left ventricle

What is flail chest?

A life-threatening condition in which fractures cause instability in part of the chest wall. This causes paradoxical breathing in which the lung underlying the injured area contracts on inspiration and expands on expiration, making ventilation ineffective. Cause by fracture of two or more adjacent ribs

What would be an example of data validation?

A patient is crying. The nurse infers that the patient is crying about his diagnosis. The nurse says, "I notice you've been crying. Can you tell me about it?" to validate that the inference is correct. A patient complains of not feeling well. The nurse looks at the patient's lab results and notices an elevated white blood count, which is indicative of an infection.

What does a scratchy or raspy sound mean when auscultating the heart?

A pericardial friction rub

What does orthopnea mean?

A person must be in upright position to breathe

What is a reservoir?

A place where microorganisms survive, multiply, and wait to transfer to a susceptible host

What is a hypothesis?

A prediction made about the relationship among study variables

What is narcolepsy?

A rare CNS dysfunction of mechanisms that regulate sleep and wake states, causing excessive daytime sleepiness. During the day a person suddenly feels an overwhelming wave of sleepiness and falls asleep, often at inappropriate times.

What is intersectionality?

A research and policy model used to study the complexities of people's lives and experiences The model looks at how being marginalized affects people's health and access to care.

What is it important to have good lighting and comfortable temperatures when assessing the skin?

A room that is too warm causes superficial vasodilation, resulting in increased skin redness. Patients who are sensitive to cold develop cyanosis (bluish color) around the lips and nail beds. A room with poor lighting makes it hard to see.

What is sensorineural hearing loss?

A sensorineural loss involves the inner ear, auditory nerve, or hearing center of the brain. In this instance sound is conducted through the outer and middle ear structures, but the continued transmission of sound becomes interrupted at some point beyond the bony ossicles.

What is a world view?

A set of assumptions that begin to develop during childhood and guide how one sees, thinks about, experiences, and interprets the world It determines how people perceive others, how they interact and relate to reality, and how they process information

What support devices should be used when a patient is in supine position?

A small, flat pillow supports the head, neck, and upper shoulders. When a patient is immobile, use pillows, trochanter rolls, heel boots, hand rolls, or arm splints to increase comfort and reduce injury to the skin or musculoskeletal system.

What is cataplexy?

A sudden muscle weakness during intense emotions such as anger or laughter that can occur at any time during the day. Narcolepsy can occur with or without cataplexy.

What is a colostomy?

A surgically created opening of the colon out onto the abdomen wall.

What is deontology?

A system of ethics that defines actions as right or wrong based on principles such as truth and justice

What is a clinical practice guidelines

A systematically developed set of statements that helps nurses and other health care providers choose appropriate interventions for specific clinical circumstances

What is the Mini-Mental State Examination (MMSE)?

A test that measures a patient's orientation and cognitive function. It asks questions such as "What is the date?" and "Tell me where you are now."

What is the fecal immunochemical test (FIT) test?

A test to detect fecal blood which uses antibodies to detect human hemoglobin protein specifically

What is arcus senilis?

A thin white ring along the margin of the iris (common with aging but abnormal in anyone younger than 40 years of age)

What is the difference between active errors and latent errors?

Active errors are mistakes personnel perform Latent errors are mistakes in the organization or the process

What is the difference between activities of daily living and *instrumental* activities of daily living?

Activities of daily living (ADLs) are activities usually performed during a normal day and include ambulation, eating, dressing, bathing, and grooming. Instrumental activities of daily living (IADLs) are related to the patient's ability to be independent in society and include skills such as shopping, preparing meals, handling finances (e.g., writing checks), and taking medications.

What is the anion gap?

An anion gap reflects unmeasurable anions present in plasma Na - (Cl + HCO3) Calculation of the anion gap is useful for identifying the cause of metabolic acidosis

What is Type 1 Diabetes Mellitus.?

An autoimmune disorder, in which the body develops antibodies against insulin and/or the pancreatic β-cells that produce insulin. Formerly known as juvenile-onset diabetes or insulin-dependent diabetes, accounts for about 5% to 10% of all people with diabetes. Type 1 diabetes generally affects people under 40 years of age, although it can occur at any age.

What is an orthotopic neobladder?

An ileal pouch is used to replace the bladder Anatomically the pouch is in the same position as the bladder was before removal, allowing a patient to void through the urethra using the Valsalva technique.

How can you assess a patient's supportive community?

Ask questions such as: 1) "With whom do you bond or connect with?" 2) "Who do you find to be the greatest source of support in times of difficulty?" 3) "When you've faced difficult times in the past, who has been your greatest resource?"

How do you assess an immobile patient's elimination?

Assess a patient's elimination status each shift and the total intake and output every 24 hours auscultate for bowel sounds Note the frequency and consistency of bowel movements, and the patient's typical urine and bowel elimination patterns

How do you assess the Auditory Nerve (CN 8)?

Assess ability to hear spoken word.

What should you do if you commit a medication error

Assess and examine a patient's condition and notify the health care provider of an incident as soon as possible Report the incident to the appropriate person in the institution (e.g., manager or supervisor) once the patient is stable

How do you assess the Abducens Nerve (CN 6)?

Assess directions of gaze.

What inventions promote cardiovascular health in an *acute care* setting?

Attempt to have patients move as soon as their physical condition allows, even if this involves only sitting up in bed, dangling feet at the bedside, or moving to a chair Isometric exercises can improve activity tolerance Move patient gradually during transfers Teach the patient to breathe out while moving or being lifted up in bed to avoid straining (avoid Valsalva maneuver) leg exercises, encouraging fluids, wearing compression devices, and position changes to reduce risk of DVT Have patient wear elastic stockings. Remove and reapply elastic stockings at least every 8 hours or according to agency policy If patient is on heparin, monitor the patient for signs of bleeding

What is nocturia?

Awakened from sleep by urge to void

What does AC, ac mean?

Before meals

What is hematuria?

Blood in the urine (suggests glomerular injury)

What types of tissues is chemotherapy most toxic to?

Bone marrow Skin Hair follicles Sperm Gastrointestinal tract (tissue with high growth fraction)

What risk is associated with an improperly functioning heating system at home?

Carbon monoxide poisoning

What is palliative care?

Care that focuses on the prevention, reduction, or relief of physical, emotional, social, and spiritual symptoms of disease or treatment at the end of life when cure is no longer possible.

What is Swanson's Theory of Caring?

Caring is a nurturing way of relating to a valued other, toward whom one feels a personal sense of commitment and responsibility.

What does it mean if a patient is asymptomatic?

Clinical signs and symptoms of the illness are not present in the patient

What is required for an autopsy?

Consent by a patient before his or her death or by a close family member at the time of the patient's death The priority for giving consent for autopsies is (1) the patient, in writing before death; (2) durable power of attorney for health care (if named); (3) surviving spouse; and (4) surviving child, parent, brother, or sister in the order named

What is culture?

Culture reflects the whole of human behavior including: 1) ideas, beliefs, and values 2) ways of relating to one another 3) language and manners of speaking 4) work and lifestyle practices

What are signs/symptoms of hyponatremia?

Decreased level of consciousness (confusion, lethargy, coma); seizures if develops rapidly or is very severe

What changes are expected in the urinary system of an older adult?

Decreased renal filtration and renal efficiency; subsequent loss of protein from kidney; nocturia Female: Urgency and stress incontinence from decrease in perineal muscle tone Male: Frequent urination resulting from prostatic enlargement

What are signs/symptoms of DKA?

Dehydration (poor skin turgor, dry mucous membranes, tachycardia, and orthostatic hypotension) -lethargy and weakness (early symptoms) -skin becomes dry and loose, and the eyes become soft and sunken. -Abdominal pain may be present and accompanied by anorexia, nausea, and vomiting. -Kussmaul respirations (rapid, deep breathing associated with dyspnea) -Acetone is noted on the breath as a sweet, fruity odor

What is defibrillation?

Delivering an electrical current to the myocardium that stops all electrical activity and allows the heart's normal pacemaker to resume its normal electrical activity

What is cultural competence?

Delivering health care services is "a culturally conscious model of care in which a healthcare professional continually strives to achieve the ability and availability to effectively work within the cultural context of a client" (family, individual, or community)

What is the difference between denotative and connotative meaning?

Denotative meaning is the dictionary definition of the word. (example: the word consequence means "a result or effect of an action or condition") Connotative meaning is the interpretation of the meaning of the word. (example: most people think of the word consequence as something negative)

What sort of health history information should you collect with regards to the vascular system?

Determine if the patient has leg cramps; numbness or tingling in the extremities; sensation of cold hands or feet; pain in the legs; or swelling or cyanosis of the feet, ankles, or hands. Ask patients if they wear tight-fitting garters or hosiery and if they sit or lie in bed with legs crossed. Assess the patient's medical history for heart disease, hypertension, phlebitis, diabetes, or varicose veins.

What should you ask about when performing a nursing history about the heart?

Determine the patient's history of smoking, alcohol intake, caffeine intake, use of prescription and recreational drugs, exercise habits, and dietary patterns including fat and sodium intake. Ask if the patient is taking medications for cardiovascular function and if he or she knows their purpose, dosage, and side effects. Assess for chest pain or discomfort, palpitations, excess fatigue, cough, dyspnea, edema of the feet, cyanosis, fainting, or orthopnea. If the patient reports chest pain, determine if it is cardiac in nature; anginal pain is usually a deep pressure or ache that is substernal and diffuse radiating to one or both arms, the neck, or the jaw. Determine if the patient has a stressful lifestyle. Assess for personal or family history of heart disease, diabetes, high cholesterol, hypertension, stroke, or rheumatic heart disease.

What is central sleep apnea (CSA)?

Dysfunction in the respiratory control center of the brain. Pauses in breathing happen in the respiratory and pulmonary systems at the same time. The brain stops sending signals to muscles that control breathing. Conditions that are associated with CSA include stroke, degeneration of the cervical spine, obesity, and encephalitis.

What are ways to promote health/safety in school age children?

Educate parents about the importance of children wearing seat belts whenever riding in a car; wearing helmets when riding a bicycle, skateboard, or scooter; and keeping adults informed of where they are. A child needs to know how to cross a street safely and to refrain from talking to or accepting rides or gifts from strangers. Teach children what to do if a stranger approaches and how to get help as well as how to avoid unsafe and isolated areas.

What inventions promote respiratory health in an *acute care* setting?

Encourage patients to sit up in bed routinely and to *cough and deep breathe every 1 to 2 hours* while awake to expand all lobes of the lungs and prevent atelectasis Manage post-surgery pain so that coughing is less painful If a critically ill patient is too weak or unable to cough up secretions, maintain the patient's airway by using suctioning techniques

How can you assess tissue perfusion?

Examine the condition of the skin, mucosa, and nail beds Look for cyanosis, clubbing of fingernails, changes in skin temperature, etc. The absence of hair growth over the legs indicates circulatory insufficiency.

How should you assess the external genitalia of a male patient?

Examine the penis and look for any redness or irritation. If the patient is uncircumcised, retract the foreskin or ask him to do so. The foreskin normally moves easily back to expose the glans penis. In some cases, the foreskin becomes tight and cannot be retracted (a condition called phimosis), increasing risk for inflammation and infection. The urethral meatus is a slitlike opening just below the tip of the penis. Inspect the glans penis and meatus for discharge, lesions, and inflammation. Following inspection, return the foreskin to the unretracted position.

What are infant, toddlers and preschool children most at risk for?

Falls, ingestion injuries (poison, foreign body ingestion, and medication), and burns.

What are signs of abnormally dry skin?

Flaking and scaling

What is a troche or lozenge?

Flat, round tablets that dissolve in the mouth to release medication; not meant for ingestion

What is dorsiflexion?

Flexion of toes and foot upward

What are the 2 forms of Ca2+ in blood?

Free and bound Bound Ca2+ is bound to albumin and other blood components and is inactive. Free (ionized) Ca2+ is available for physiological actions

What is the description of a Stage 3 pressure injury?

Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer, and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining (skin separates from the underlying tissue at the wound margins creating areas of tissue damage below the skin surface and less damage at the surface) and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, or bone is not exposed.

What is the description of a Stage 4 pressure injury?

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining, and tunneling often occur. Depth varies by anatomical location.

What are the components of the FICA assessment tool?

F—Faith or belief I—Importance of spirituality C—Individual's spiritual Community A—Interventions to Address spiritual needs

What is flatus?

Gas

CN IX

Glossopharyngeal Nerve - swallowing and phonation

How do you know if turgor is poor?

Grasp a fold of skin on the back of the forearm or sternal area with the fingertips and release. If it stays pinched or tented, the turgor is poor.

What is the Stage 2 hypertension systolic blood pressure range?

Greater than 160 mm Hg

What is alopecia?

Hair loss

How do you assess the Facial Nerve (CN 7)?

Have patient identify salty or sweet taste on front of tongue. Look for asymmetry as patient smiles, frowns, puffs out cheeks, and raises and lowers eyebrows.

How is a huff cough performed?

Have the patient sit or raise the head of the bed at least 45 degrees. The patient inhales slowly through the mouth while breathing through the diaphragm. The patient then forcefully exhales with his or her mouth open, creating a huff sound or saying the word "Huff." Have the patient repeat the huff process 2 to 3 times and then cough and expectorate the sputum

How do you examine pharyngeal structures?

Have the patient tip the head back slightly, open the mouth wide, and say "Ah" while the tip of a tongue depressor is placed on the middle third of the tongue.

What is competence?

Having the knowledge and skills to give safe nursing care

What changes are expected in the head and neck of an older adult?

Head: Nasal and facial bones sharp and angular; loss of eyebrow hair in women; men's eyebrows become bushier Eyes: Decreased visual acuity; decreased accommodation; reduced adaptation to darkness; sensitivity to glare; diminished light reflex Ears: Decreased pitch discrimination; diminished hearing acuity Nose and sinuses: Increased nasal hair; decreased sense of smell Mouth and pharynx: Use of bridges or dentures; decreased sense of taste; atrophy of papillae of lateral edges of tongue; occasionally change in voice pitch Neck: Thyroid gland nodular; slight tracheal deviation resulting from muscle atrophy

What is ethics of care philosophy?

Health care workers resolve ethical dilemmas by paying attention to relationships and stories of the participants and by promoting a fundamental act of caring. (Nel Nodding)

What causes dependent edema?

Heart failure

What causes distension of neck veins?

Heart failure (typically right-sided); fluid overload

What are ways to promote health/safety in adults?

Help adults understand their safety risks and guide them in making lifestyle modifications by referring them to resources such as classes to help quit smoking and for stress management or employee assistance programs. Encourage them to exercise regularly, maintain a healthy diet, practice relaxation techniques, and get adequate sleep

What substance transports oxygen?

Hemoglobin (Hgb) molecules

What is high-frequency chest wall compression (HFCWC)?

High-frequency chest wall compression (HFCWC) consists of an inflatable vest that is attached to an air-pulse generator. The vest airway clearance system loosens and removes secretions from the airway by delivering high-frequency, small-volume expiratory pulses to a patient's external chest wall.

What is congenital hip dysplasia?

Hip instability with limited abduction of hips and occasionally adduction contractures (head of femur does not articulate with acetabulum because of abnormal shallowness of acetabulum)

What is an example of therapeutic touch?

Holding a patient's hand while the patient is in pain

For which patients is home oxygen therapy indicated?

Home oxygen therapy is indicated in patients whose disease is stable with a PaO2 of 55 mm Hg or less or an arterial oxygen saturation (SaO2) of 88%.

What is clinical dehydration?

Hypernatremia in combination with ECV deficit

CN XII

Hypoglossal Nerve - tongue movement, strength

What are risks associated with temperature?

Hypothermia Heat exhaustion

What produces a PaCO2 greater than 45 mm Hg?

Hypoventilation

What causes central cyanosis?

Hypoxemia and/or hypoxia (late sign)

Why is this diagnostic statement wrong? Anxiety related to cardiac catheterization

Identify *the problem* caused by the treatment or diagnostic study rather than the treatment or study itself Correct diagnosis statement: Anxiety related to lack of knowledge about cardiac catheterization

Why is this diagnostic statement wrong? Anxiety related to cardiac monitor

Identify the patient *response* to the equipment rather than the equipment itself. Correct diagnosis statement: Deficient Knowledge regarding the need for cardiac monitoring

What special care should diabetic patients take regarding cuts, scrapes, or burns ?

If cuts, scrapes, or burns occur, treat them promptly and monitor them carefully. Wash the area and apply a nonabrasive or nonirritating antiseptic ointment. Cover the area with a dry, sterile pad. Teach patients to notify the HCP immediately if the injury does not begin to heal within 24 hours or if signs of infection develop.

What is the purpose of the analysis section?

If quantitative data such as physical measurements and scores on surveys are collected, statistical results from the study are explained. If a study involved collection of qualitative information such as audiotaped interviews or open-ended surveys, the analysis describes the major themes from the data.

When might you collect a wound culture?

If you detect clinical symptoms that suggest a wound infection such as increased erythema; increase in the amount and/or change in character of exudate; odor; increased local warmth; or systemic signs of infection such as fever, chills, or an increased WBC count.

What is urinary urgency?

Immediate and strong desire to void that is not easily deferred

What should you do if you suspect pulmonary embolus in a patient (i.e. the patient complains of shortness of breath or severe chest pain)?

Immediately place the patient in high-Fowler's position, check the patient's oxygen saturation, and apply oxygen. This complication is life threatening and requires prompt medical attention and activation of the Rapid Response Team if required by agency policy.

What is prediabetes?

Impaired glucose tolerance (IGT), impaired fasting glucose (IFG), or both A diagnosis of IGT is made if the 2-hour oral glucose tolerance test (OGTT) values are 140 to 199 mg/dL. IFG is diagnosed when fasting blood glucose levels are 100 to 125 mg/dL.

What do you do if a patient is unconscious and you need with regards to consent?

In a *non-emergency*, you need to obtain consent from a person legally authorized to give consent on his or her behalf In an *emergency*, however, health care providers may provide care to patients without consent if it is presumed that a reasonable person would have agreed to the same or similar treatment

Is sodium more abundant in the ICF or the ECF?

In the ECF Sodium is the most abundant cation in ECF but has a smaller concentration inside cells

What happens in the numbing phase of mourning?

In the numbing phase a person has periods of extremely intense emotion and reports feeling "stunned" or "unreal."

What is torticollis?

Inclining of head to affected side, in which sternocleidomastoid muscle is contracted

What is transient incontinence?

Incontinence caused by medical conditions that in many cases are treatable and reversible

What changes are expected in the thorax and lungs of an older adult?

Increased anteroposterior diameter; increased chest rigidity; increased respiratory rate with decreased lung expansion

What impedes diffusion?

Increased thickness of the alveolar capillary membrane impedes diffusion because gas takes longer to transfer across the membrane.

What is the difference between *independent* nursing interventions, *dependent* nursing interventions and *collaborative* interventions?

Independent nursing interventions are actions that nurses initiate Dependent nursing interventions are actions that require an order from a health care professional Collaborative interventions are therapies that require the combined knowledge, skill, and expertise of multiple health care professionals (also called interdependent nursing interventions)

What is the denial stage of grief?

Individuals in the denial stage act as though nothing has changed. They cannot believe or understand that a loss has occurred.

What are standard precautions?

Infection prevention measures you use with every patient regardless of diagnosis

What is an allogeneic transfusion?

Infusion of a donor's blood into a patient

What are dry powder inhalers (DPIs)?

Inhalers that hold dry powder medication and create an aerosol when a patient inhales through a reservoir. The reservoir holds a dose of the medication. Compared with MDIs, DPIs deliver more medication to the lungs

What are breath-actuated metered-dose inhalers (BAIs)?

Inhalers that release medication when a patient raises a lever and inhales. A BAI is a good choice for patients who have difficulty using pMDIs because the BAI eliminates the need for hand-breath coordination

What are pressurized metered-dose inhalers (pMDIs)?

Inhalers that use a chemical propellant to push the medication out of the inhaler, requiring a patient to apply about 5 to 10 lb of pressure to the top of the canister to administer the medication

What is an example of task-oriented touch?

Inserting a nasogastric tube (using touch to do a specific task)

What should a skin inspection include?

Inspecting for: 1) skin color 2) moisture 3) temperature 4) texture 4) turgor 5) abnormalities such as vascular changes; edema; phlebitis; and lesions.

Which publication brought patient safety to the forefront of healthcare in the United States?

Institute of Medicine (IOM) report (2000)

What safety instructions should you give patients about using electric heating pads?

Instruct patients to cover the pad with a flannel cover, towel, or pillowcase and to never apply pad directly to the skin. Remind patients to never use the high setting and to never lie on the pad. Advise the patient not to insert a safety pin through a heating pad to avoid electrical shock.

What should a diabetic patient wear at all times?

Instruct the patient to carry medical identification at all times indicating that he or she has diabetes. Police, paramedics, and many private citizens are aware of the need to look for this identification when working with sick or unconscious persons. Every person with diabetes is encouraged to wear a Medic Alert bracelet or necklace.

How is pursed-lip breathing performed?

Instruct the patient to sit up and then take a deep breath and exhale slowly through pursed lips, as if he or she were whistling.

What is the purpose of insulin?

Insulin promotes glucose transport from the bloodstream across the cell membrane to the cytoplasm of the cell. Cells break down glucose to make energy, and liver and muscle cells store excess glucose as glycogen.

What kind of insulin do insulin pumps use?

Insulin pumps use rapid-acting insulin

What is Stress Urinary Incontinence?

Involuntary leakage of small volumes of urine associated with increased intraabdominal pressure and urethral hypermobility or weakness of or injury to urinary sphincter (e.g., weak pelvic floor muscles, trauma after childbirth, radical prostatectomy)

What is Overflow Urinary Incontinence?

Involuntary loss of urine caused by overdistended bladder; often related to bladder outlet obstruction or poor bladder emptying caused by weak or absent bladder contractions

What is ataxic or biot respirations?

Irregular respirations of varying depths with irregular periods of apnea Poor prognosis; associated with severe brain injury

What is death?

Irreversible cessation of cardiovascular, respiratory, and brain function

What is the definition in a nursing diagnosis?

It describes the characteristics of the human response identified For example, the definition of the diagnostic label Fatigue is an "overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work at usual level" The definition can help you to identify the nursing diagnosis

What is it important to inspect the undersurface of the tongue and floor of the mouth?

It is a common site of origin for oral cancer lesions

What is the literature review or background?

It is a detailed background of previous studies and the level of evidence or clinical information that exists about the topic of the article.

What is metabolic acidosis?

It results from conditions that increase metabolic acids in the body or decrease the amount of base Diabetic ketoacidosis is a common cause of metabolic acidosis

Why is listening critical to caring?

It shows that the patient has the nurse's full attention and interest

What nursing interventions can promote elimination health in an immobile patient?

Keep the patient well hydrated without causing bladder distention and the reflux of urine into the ureters and renal pelvis Timely toileting prevents bladder distention Bladder retraining/Kegel exercises for incontinent patients Insertion of a straight or indwelling Foley catheter for patients with stroke or paralysis Have patients and family caregivers keep a record of the frequency and consistency of bowel movements. Patients should drink at least 6 to 8 glasses of water daily and eat fruits and vegetables to promote healthy bowel elimination initiate a bowel-training program (e.g., stool softeners, cathartics, or enemas) if necessary

What is dribbling?

Leakage of small amounts of urine despite voluntary control of micturition

What is the best position the patient should be in to hear low-pitched sounds in diastole?

Left lateral recumbent

What is knock-knee (genu valgum)?

Legs curved inward so that knees come together as person walks

When is less ADH released?

Less ADH is released when plasma osmolality decreases less water is resorbed, so it leaves the body in the urine and plasma osmolality returns to normal.

What is normal systolic blood pressure?

Less than 120 mm Hg

What are anaphylactic reactions?

Life threatening allergic reactions, characterized by sudden constriction of bronchiolar muscles, edema of the pharynx and larynx, severe wheezing, and shortness of breath. Some patients become severely hypotensive, necessitating emergency measureres

What position should a patient be in when examining the female genitalia and genital tract?

Lithotomy

What is a pressure injury?

Localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear.

What does a normal carotid pulse feel like?

Localized rather than diffuse Thrusting As the patient breathes no change occurs Rotation of the neck or a shift from a sitting to a supine position does not change the quality of the carotid artery Both carotid arteries normally are equal in pulse rate, rhythm, and strength and are equally elastic.

What are signs/symptoms of a wound infection?

Locally drainage is often yellow, green, or brown and may be odorous, depending on the causative organism. The wound edges appear tense, swollen, and painful, with redness extending beyond the immediate wound edge. Systemic signs include fever, general malaise, and an elevated WBC count.

What is Functional Incontinence?

Loss of continence from causes outside the urinary tract; usually related to functional deficits such as altered mobility and manual dexterity, cognitive impairment, or environmental barriers impairing ability to reach or use toilet

What is a maturational loss?

Losses people experience as they go through a lifetime of normal developmental processes Example: when a child goes to school for the first time he or she spends less time with his or her parents

How does immobility affect fluid and electrolyte balance?

Major shifts in blood volume occur in immobile patients. Diuresis (increased urine excretion) occurs as a result of the increased blood flow to the kidneys. Diuresis causes the body to lose electrolytes such as potassium and sodium and reduces serum calcium levels. Immobility increases calcium resorption (loss) from the bones causing hypercalcemia, a release of excess calcium into the circulation.

How does patient immobility affect nurses' health and safety?

Manually lifting and transferring patients contributes to the high incidence of work-related musculoskeletal problems and back injuries in nurses and other health care staff

How is a patient's spirituality affected by end of life?

Many patients question their beliefs about a higher power, their own journey through life, religion, and an afterlife

What infections require airborne precautions?

Measles, chickenpox (varicella), disseminated varicella zoster, pulmonary or laryngeal tuberculosis

What is a transdermal disk or patch?

Medicated disk or patch absorbed through skin slowly over long period of time (e.g., 24 hours)

What is a syrup?

Medication dissolved in concentrated sugar solution

What is capsule?

Medication encased in gelatin shell

What are maintenance medications?

Medications taken on a daily schedule to prevent acute distress; their effects start within hours of administration and last for a longer period of time than rescue inhalers

How do you assess an immobile patient's respiratory health?

Monitor the patient's respiratory rate and oxygen saturation. Inspect chest wall movements for symmetry Auscultate the lungs to identify regions of diminished and/or adventitious breath sounds. Identify presence of secretions

What is the purpose of magnesium?

Most of the Mg2+ in the body is in bones and inside cells. Mg2+ is essential for action of many enzymes and for normal action at neuromuscular junctions.

What is the purpose of calcium?

Most of the calcium in the body is in bone However, Ca2+ also influences the excitability of nerve and muscle cells and is necessary for muscle contraction and blood clotting.

What is the purpose of phosphate?

Most phosphate in the body is in bone and inside cells. Phosphate is needed to produce ATP, the energy source for cellular metabolism.

What is Rando's model of mourning?

Mourning is an action-oriented process involving *recognizing* the loss, *reacting* to the pain of separation, *reminiscence*, *relinquishing* old attachments, and *readjusting* to life after loss. Reminiscence is an important activity in grief and mourning. In reminiscence a person recollects and reexperiences the deceased and the relationship by mentally or verbally reliving and remembering the person and past experiences.

What is extension?

Movement increasing angle between two adjoining bones

What is pronation?

Movement of body part so that front or ventral surface faces downward

What is supination?

Movement of body part so that front or ventral surface faces upward

What is abduction?

Movement of extremity away from midline of body

How would you describe musculoskeletal pain?

Musculoskeletal pain is often present following exercise, rib trauma, and prolonged coughing episodes. Inspiratory movements aggravate the pain and are easily confused with pleuritic chest pain.

What are examples of nervous system diseases that result in hypoventilation?

Myasthenia gravis, Guillain-Barré syndrome and spinal cord trauma/disease These diseases impair nervous and muscular control, causing reduced ventilation.

Can you mix long-acting insulin with other insulins in the same syringe?

No!

Is it normal to hear sounds when auscultatng the carotid?

No!

Should intermediate-acting insulin (NPH) insulin be given as an IV?

No!

Should you use povidone-iodine (Betadine), hydrogen peroxide, and acetic acid to irrigate a clean, granular wound?

No! These solutions are toxic to fibroblasts, a key cellular component in wound healing

Do Good Samaritan Laws protect you if you do something at a scene of an accident for which you have no training?

No! Good Samaritan laws only provide immunity to a nurse who does what is reasonable to save a person's life

Should a patient always inject insulin in the exact same place?

No. Teach patients to rotate the injection within and between sites. This allows for better insulin absorption.

What is noninvasive ventilation?

Noninvasive ventilation (NIV) maintains positive airway pressure and improves alveolar ventilation without the need for an artificial airway. This mechanical ventilator alternative reduces and reverses atelectasis, improves oxygenation, reduces pulmonary edema, and improves cardiac function.

How do you assess an immobile patient's psychosocial status?

Observe for changes in emotional status (e.g., depression) and behavioral changes Assess patients' readiness to improve their level of independence Identify and correct any changes in a patient's sleep-wake cycle such as difficulty falling asleep or frequent awakenings Observe for changes in the use of normal coping mechanisms to adapt to immobilization

How should you assess the external genitalia of a female patient?

Observe the labia majora for swelling, redness, tenderness, rashes, lesions, or evidence of scratching. Using a gloved hand retract the labial folds. The labia minora is normally pink and moist. The urethral meatus appears as an irregular opening or slit close to the vaginal opening. Look for drainage and lesions, and ask the patient if there is discomfort. If there is drainage, note the color and consistency. The vaginal tissue in postmenopausal women may be dryer and less pink than in younger women.

What are clinical manifestations of type 2 diabetes?

Often non-specific, but could include: -polyuria -polydipsia -polyphagia -fatigue -recurrent infections -recurrent vaginal yeast or candidal infections -prolonged wound healing -visual changes

How should you assess the bladder?

On inspection you may observe a swelling or convex curvature of the lower abdomen (which indicates a very full bladder) On gentle palpation of the lower abdomen, a full bladder will feel smooth and rounded, and a patient may report a sensation of urinary urge tenderness or pain If you suspect an overfull bladder or incomplete emptying of the bladder, further assess the patient with a bladder scanner

What is osteoporosis?

Osteoporosis is a metabolic bone disease that causes a decrease in quality and quantity of bone

What is Incontinence caused by urinary retention called?

Overflow incontinence

What is the PES format?

P- Problem (NANDA-I label) E - Etiology or related factors S - Symptoms or defining characteristics Death Anxiety (P) related to anticipation of suffering (E), evidenced by increased expression of worries, difficulty breathing (S).

What is patient-controlled analgesia (PCA)?

PCA is a drug-delivery system that allows patients to self-administer opioids with minimal risk of overdose, when they need medication, and without repeated parenteral injections The goal is to maintain a constant plasma level of analgesic to avoid the problems of intermittent dosing.

What are Montgomery ties?

Paired adhesive straps applied to either side of a wound (usually abdominal) This provides a method of securing a bandage and subsequently changing it without having to replace the tape each time.

What does serosanguineous drainage look like?

Pale, more watery, a combination of plasma and red cells; may be blood streaked

What the key points of palliative care philosophy and practice?

Palliative care: • Affirms life and regards dying as a normal process • Neither hastens nor postpones death • Provides relief from pain and other distressing symptoms • Integrates psychological and spiritual aspects of patient care • Offers a support system to help patients live as actively as possible until death • Offers a support system to help families cope during the patient's illness and their own bereavement • Enhances the quality of life • Uses a team approach to meet the needs of patients and families

Papule

Palpable, circumscribed, solid elevation in skin

What is inflammation of skin at base of nail called?

Paronychia

What is the description of a Stage 2 pressure injury?

Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, and moist, or injury may manifest as an intact or ruptured serum-filled blister. Adipose (fat) is not visible, and deeper tissue is not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel

What are droplet precautions?

Patient: Private room or cohort patients Healthcare professional: Mask, gown and gloves

What are contact precautions?

Patient: Private room or cohort patients (see agency policy) Healthcare professional: gloves and gowns

What are airborne precautions?

Patient: Private room, negative-pressure airflow of at least 6-12 exchanges per hour via HEPA filtration Healthcare professional: Respiratory protection device, n95 respirator (depending on condition)

Which patients should not be kept in the supine position?

Patients who are confused, agitated, experiencing a decreased level of consciousness, or at risk for aspiration

Which type of patients may have fluid restrictions?

Patients who have hyponatremia usually require restricted water intake so their kidneys can resolve the imbalance. Patients who have very severe ECV excess may have both sodium and fluid restrictions.

Which patients are most at risk for developing skin lesions in a hospital or extended care setting?

Patients who: 1) are neurologically impaired 2) are chronically ill 3) are orthopedic patients 4) have diminished mental status 5) have poor tissue oxygenation 6) have low cardiac output 7) have inadequate nutrition

What do post-modern theories about grief say?

People do not grieve in predictable, linear stages, and they do not necessarily complete the grieving tasks. Instead they move back and forth between stages, experience phases in an overlapping manner, or do not exhibit typical emotions (e.g., depression or anger) or grief behaviors. People rarely "get over" a significant loss but instead learn to live with loss. They can experience distress associated with the loss for a lifetime.

What is the difference between an *actual loss* and a *perceived* loss?

People experience an *actual loss* when they can no longer touch, hear, see, or have near them valued people or objects. Example: the death of a pet A *perceived loss* is internal and identified only by the person experiencing it. Example: a person perceives that she is less loved by her parents

What are marginalized groups?

People who are more likely to have poor health outcomes and die earlier because of a complex interaction between: 1) their individual behaviors 2) the environment of the communities in which they live 3) the policies and practices of health care and government system 4) the clinical care they receive

What are Cheyne-Stokes respirations?

Periods of increasing depths of breathing followed by period of apnea Seen in seriously ill patients, typically with brain injury or drug-associated respiratory distress; may be seen in children and older adults during sleep

How would you describe pleuritic chest pain?

Peripheral and usually radiates to the scapular regions. Inspiratory maneuvers such as coughing, yawning, and sighing aggravate pleuritic chest pain. An inflammation or infection in the pleural space usually causes pleuritic chest pain. Patients often describe it as knifelike or sharp, and it increases in intensity with inspiration.

How can you tell petechiae from other red spots?

Petechiae do not blanch (turn white) when you press on or near them

What are risks associated with the use of restraints?

Pressure injuries, pneumonia, constipation, and incontinence Also, loss of self-esteem, humiliation, and agitation

What are ways to promote health/safety in older adults?

Prevent falls teach older adults to keep living areas well lighted and free of clutter, keep eyeglasses in good condition, and avoid night driving. Teach older adults about the proper handling and storage of medications and safe methods of scheduling and taking them Help family caregivers understand the nature of dementia

What effect does immobility have the development of clots?

Prolonged recumbence (a position of lying down at rest) leads to circulatory fluid volume loss with a fluid shift to the thoracic area. The patient begins to diurese (excrete more urine) because of protein loss. With a decrease in plasma volume the hematocrit will increase but then fall as the red blood cell mass later decreases.

How should you assess the perineal skin?

Regularly assess skin exposed to moisture, especially urine, for signs of incontinence-associated skin damage (IAD). Observe for erythema in areas exposed to moisture, which is most commonly noted in the labia in women, in the scrotum in men, and in the inner thigh and buttock region in both women and men. Be sure to thoroughly assess patients when they tell you they are experiencing burning, itching pain in these areas.

What are adults most at risk for (with respect to safety)?

Related to lifestyle habits People abusing substances more likely to have a car accidents People who are stressed are at a greater risk for accidents and stress-related illnesses such as headaches, depression, gastrointestinal disorders, and infections

What is the goal of withdrawal of life-sustaining treatments?

Remove treatments that are not beneficial and may be uncomfortable

What should you do if you work for a provider who has illegally prescribed and/or dispensed controlled substances?

Report these activities, or else you are legally accountable for aiding and abetting the provider

What are Kussmaul respirations?

Respiration usually greater than 35 breaths/min Breaths deep in nature; associated with metabolic acidosis states such as diabetic ketoacidosis

What is ventricular tachycardia?

Rhythm may be regular or irregular; rate 150-250 beats/minute; P wave is difficult to see on ECG, if present; QRS complex wide and bizarre and greater than 0.12 seconds in duration

What are adolescents most at risk for (with respect to safety)?

Risk-taking behaviors such as smoking, drinking alcohol, and using drugs Fatal crashes because of their immaturity and driving inexperience

How do you assess balance?

Romberg test Ask the patient to stand with feet together, arms at the sides, both with eyes open and with eyes closed. Expect slight swaying of the body in the Romberg test. A loss of balance (positive Romberg) causes a patient to fall to the side.

What is external rotation?

Rotation of joint outward

What is administrative law?

Rules and regulations developed and enforced by state regulatory agencies including the State Boards of Nursing. State Boards of Nursing are authorized by state Nurse Practice Acts to set rules, regulations, and guidelines that specifically define the standard of care in nursing practice

What should you determine about a patient's head and neck when taking a nursing history?

See if there is a recent history of: 1) head trauma 2) neurological symptoms such as headache, dizziness, seizures, poor vision, or loss of consciousness Review the patient's occupation, participation in contact sports, and use of protective head gear.

What is an ointment (salve or cream)?

Semisolid, externally applied preparation, usually containing one or more medications

What are symptoms of a myocardial infarction?

Severe or crushing chest pain, jaw pain, left arm pain, shortness of breath, and diaphoresis; Some people, particularly women, present with nonspecific symptoms of discomfort, weakness, and fatigue.

The following are examples of which therapeutic communication technique? "I see you didn't eat any breakfast." "You are clenching your jaw." "I see you've been organizing your papers."

Sharing observations

What changes are expected in the integument of an older adult?

Skin color: Brown age spots and spotty pigmentation in areas exposed to sun; pallor even in absence of anemia Moisture: Dry, scaly Temperature: Extremities cooler; perspiration decreased Texture: Decreased elasticity; wrinkles; folding, sagging Fat distribution: Decreased on extremities; increased on abdomen Hair: Thinning and graying on scalp; axillary and pubic hair and hair on extremities sometimes decreased; facial hair in men decreased; chin and upper lip hair present in women Nails: Decreased growth rate

What problems do sleep deprivation cause?

Sleep deprivation affects immune function, metabolism, nitrogen balance, and protein catabolism. A loss of REM sleep often leads to confusion and suspicion. Prolonged sleep loss alters various body functions (e.g., mood, motor performance, memory, equilibrium) Individuals with sleep problems are also more likely to have chronic diseases such as hypertension, diabetes, and obesity.

What are parasomnias?

Sleep disorders that can occur during arousal from REM sleep or partial arousal from NREM sleep. These disorders include sleepwalking, sleep eating, night terrors, nightmares, teeth grinding, and bed-wetting.

What is a suppository?

Solid dosage form mixed with gelatin and shaped in form of pellet for insertion into body cavity (rectum or vagina); melts when it reaches body temperature, releasing medication for absorption

What are risks associated with anticipatory grief?

Some family members begin withdrawing emotionally from the patient as a self-protective mechanism, leaving the patient with less support as death approaches. Also, if a person thought to be near death survives longer than anticipated, others can have difficulty reconnecting or feel resentful that the stressors associated with anticipating a death continue.

What is cancer pain?

Some patients with cancer have acute and chronic pain. The pain is nociceptive or neuropathic. Nociceptive pain is more common and is the result of tissue injury. Neuropathic pain is related to peripheral nerve injury.

What is an agnostic?

Someone who believes that any ultimate reality is unknown or unknowable

What is an atheist?

Someone who does not believe in the existence of God

How can you test a patient's memory?

State clearly and slowly the names of three unrelated objects. After stating all three, ask the patient to repeat each. Continue until the patient is successful. Later in the assessment ask the patient to repeat the three words again. The patient should be able to identify the three words.

What is statutory law?

Statutes that have been enacted by legislative bodies at the federal and the state levels (e.g. HIPPA and the Affordable Care Act)

How long should you stay with a patient when administering blood?

Stay during the first 15 minutes, the time when a reaction is most likely to occur. After that time period continue to monitor the patient and obtain vital signs periodically during the transfusion as directed by agency policy

What are the 7 steps of processing an ethical dilemma?

Step 1: Is This an Ethical Dilemma? Step 2: Gather All Relevant Information Step 3: Examine and Determine Your Values and Opinions About the Issues Step 4: State the Problem Clearly Step 5: Consider Possible Courses of Action Step 6: Negotiate the Outcome Step 7: Evaluate the Action

What is the storytelling technique?

Storytelling is when a patient tells you a story about his/her experience or you tell your own story. Storytelling conveys culture, combining personal experience with the commonalities of all human experiences A story helps you identify the real problems affecting a patient's health status and find culturally appropriate ways to intervene

What is the difference between subjective and objective data?

Subjective date are patients' verbal descriptions of their health problems (things only a patient can experience such as pain) Objective data are observations or measurements of a patient's health status (such as pulse or the size of a wound)

What are neurotransmitters?

Substances that affect the sending of nerve stimuli. They either excite or inhibit nerve transmission.

What technique is indicated if coughing does not effectively clear respiratory tract secretions?

Suctioning

What are signs/symptoms of Extracellular Fluid Volume Excess?

Sudden weight gain (overnight), edema (especially in dependent areas), full neck veins when upright or semi-upright, crackles in lungs If severe: confusion, pulmonary edema

What are signs/symptoms of Extracellular Fluid Volume Deficit?

Sudden weight loss (overnight), postural hypotension, tachycardia, thready pulse, dry mucous membranes, poor skin turgor, slow vein filling, flat neck veins when supine, dark yellow urine If severe: thirst; restlessness; confusion; hypotension; oliguria (urine output below 30 mL/hr); cold, clammy skin; hypovolemic shock

The following is an example of which therapeutic communication technique? The patient completes his testing and returns to the acute care unit. The nurse states, "Today we assessed your right calf area because you had a deep vein thrombosis, or a clot in your right calf vein. As your health care provider reported, there is swelling in the vein, but no clot formation is evident right now. This tells us your treatment is working. We will remove your IV (intravenous catheter) and send you back to rehabilitation. The doctor is going to order a prescription for medication to help prevent this inflamed area from developing another clot. You will start taking this new medication when you get back to the rehabilitation unit."

Summarizing

What are varicosities?

Superficial veins that become dilated, especially when legs are in a dependent position They are common in older adults because the veins normally fibrose, dilate, and stretch They are also common in people who stand for prolonged periods. Varicosities in the anterior or medial part of the thigh and the posterolateral part of the calf are abnormal.

What effect do antidepressants and stimulants have on sleep?

Suppress REM sleep and decrease total sleep time

What doe diaphoresis mean?

Sweating

What is the second heart sound (S2)?

The "dub" sound, caused by the aortic and pulmonic valves closing

What are the four dimensions of spiritual well-being as defined by Rowold?

The *personal dimension* refers to how you relate with yourself in finding meaning and purpose in life. The *communal dimension* relates to the quality of your interpersonal relationships. The *environmental dimension* describes how you interact in the world, including your sense of awe with the environment. The *transcendental dimension* refers to the relationship between you and some higher power (e.g., God, Buddha).

What 5 signs would indicate a vascular occlusion?

The 5 p's 1) pain 2) pallor 3) pulselessness 4) paresthesias 5) paralysis

What is the atrioventricular (AV) node?

The AV node mediates impulse transmission between the atria and the ventricles. Delaying the impulse at the AV node before transmitting it through the bundle of His and ventricular Purkinje network assists atrial emptying.

What is myocardial contractility?

The ability of the heart to contract and eject blood from the ventricles and prepare for the next contraction

What is judgement?

The ability to form an opinion and to draw sound conclusions based on your study of the situation

What is stroke volume?

The amount of blood ejected from the ventricle with each contraction

What is cardiac output (CO)?

The amount of blood ejected from the ventricles per minute

What is preload?

The amount of blood remaining in the ventricles at end of diastole, before the next contraction

What is the dose (in terms of infection)?

The amount of pathogen required to cause an infection in the host

What is a costal angle?

The angle formed by the blending together of the costal margins at the sternum. It is usually no more than 90 degrees, with the ribs inserted at approximately 45-degree angles.

What is the precordium?

The area in the center of the chest (immediately in front of the heart)

What can happen if the body's metabolic rate remains high for a long period of time?

The body begins to break down protein stores resulting in muscle wasting and decreased muscle mass. Respiratory muscles such as the diaphragm and intercostals are also wasted. The body attempts to adapt to the increased CO2 (hypercapnia) levels by increasing the rate and depth of respiration to eliminate the excess CO2. The patient's work of breathing increases, and the patient eventually displays signs and symptoms of hypoxemia, such as anxiety and restlessness.

Why does severe fluid loss affect the heart?

The body tries to adapt by increasing the heart rate and constricting peripheral vessels to increase the volume of blood returned to the heart and the cardiac output.

Why should you not palpate or massage the carotid arteries vigorously?

The carotid sinus sends impulses along the vagus nerve. Stimulating the vagus nerve causes a reflex drop in heart rate and blood pressure, which causes syncope (light-headedness) or circulatory arrest.

What effect does severe hypoxia have on breathing and respiration rates?

The central mechanisms that regulate breathing fail in severe hypoxia, leading to: 1) irregular respiration 2) Cheyne-Stokes respiration 3) apnea, and respiratory 4) cardiac failure.

What is shear?

The force exerted against the skin while the skin remains stationary and the bony structures move

What is the gate control theory of pain?

The gate control theory suggests that gating mechanisms along the central nervous system can regulate and possibly block pain impulses The gating mechanism occurs within the spinal cord, thalamus, reticular formation, and limbic system. The brain determines whether the gate will be open or closed, either increasing or decreasing the intensity of the ascending pain impulse. The theory suggests that pain impulses pass through when the gate is open and not while it is closed. Closing the gate is the basis for nonpharmacological pain-relief interventions.

What is wrong with this outcome statement? "Patient will be able to ambulate the hospital corridor."

The goal is not timed. "Patient will be able to ambulate the hospital corridor in two days"

What is utilitarianism?

The greatest good for the greatest number of people

What is Process S?

The homeostatic process, which primarily regulates the length and depth of sleep

What are type 1 diabetes patients' insulin needs?

The individual with type 1 diabetes requires insulin from an outside source (exogenous insulin) to sustain life. Without insulin, the patient will develop diabetic ketoacidosis.

What is local anesthesia?

The loss of sensation to a localized body part

What is the cardiac index?

The measure of adequacy of cardiac output; cardiac index equals cardiac output divided by patient's body surface area

What are examples of healing environment in the Caring Assessment Tool (CAT)?

The nurses... • Check up on me. • Pay attention to me when I am talking. • Make me feel comfortable. • Respect my privacy. • Treat my body carefully.

What are examples of basic human needs in the Caring Assessment Tool (CAT)?

The nurses... • Make sure I get food. • Help me with routine needs for sleep. • Help me feel less worried.

What are examples of affiliation needs in the Caring Assessment Tool (CAT)?

The nurses.... • Are responsive to my family. • Talk openly with my family. • Allow my family to be involved.

What are examples of mutual problem solving in the Caring Assessment Tool (CAT)?

The nurses.... • Help me understand how I am thinking. • Ask me how I think treatment is going. • Help me explore alternative ways of dealing. • Ask me what I know. • Help me figure out questions to ask.

What are examples of encouraging manner in the Caring Assessment Tool (CAT)?

The nurses.... • Support my beliefs. • Encourage me to ask questions. • Help me to see some good. • Encourage me to go on. • Help me deal with bad feelings

What is wrong with this outcome statement? "Ambulate patient in the hall 3 times a day."

The outcome is written as an intervention Correct outcome statement: "Patient ambulates in the hall 3 times a day by 4/22."

Where does the chain of infection start?

The pathogen

What does it mean if a patient has neutropenia?

The patient has a low WBC count

What does it mean if a patient is symptomatic?

The patient has clinical signs and symptoms

What does it mean if you hear no breath sounds?

The patient has collapsed or surgically removed lobes

Which muscles stabilize the urethra and contribute to urinary continence?

The pelvic floor muscles

What happens during the reorganization phase of mourning?

The person accepts that the loss is permanent The person accepts unaccustomed roles, acquires new skills, and builds new relationships.

What might happen if you are assessing the patient's heart, and he/she is anxious?

The person may have tachycardia, which would be an inaccurate finding

What is perception (in reference to pain)?

The point in time when a patient becomes aware of the pain and attaches meaning to it.

What is back-channeling?

The practice of giving positive comments such as "all right," "go on," or "uh-huh" to the speaker

What is anticipatory grief?

The process of "letting go" before an actual loss or death has occurred

What is fellowship?

The relationship that an individual has with other people, including immediate family, close friends, associates at work or school, fellow members of a church, and neighbors. More specifically this includes the extent of the community of shared faith between people and their support networks.

What is the goal of relieving symptoms and suffering for a patient (in addition to providing pain medication or cleaning a wound, etc)?

The relief of symptoms and suffering includes implementing caring nursing actions that give a patient: 1) comfort 2) dignity 3) respect 4) peace

What is afterload?

The resistance of the ejection of blood from the left ventricle

What is ischemic vascular dementia (IVD) ?

The second most common form of dementia. It can be characterized by either an abrupt loss of function, usually from a stroke, or general slowing of cognitive abilities.

What should the transfusion rate be when blood is administered?

The transfusion rate usually is specified in the health care provider's orders. Ideally 1 unit of whole blood or packed RBCs is transfused in 2 hours. Lengthen the time to 4 hours if a patient is at risk for ECV excess. Beyond 4 hours there is an increased risk for bacterial contamination of the blood.

What is the preferred site for IM injections?

The ventrogluteal muscle is the preferred and safest site for all adults, children, and infants, especially for large volume, viscous and irritating medications

What happens in the yearning and searching phase of mourning?

The yearning and searching phase evokes emotional outbursts, tearful sobbing, and acute distress. To move forward people need to experience this painful phase of grief. Common physical symptoms include tightness in the chest and throat, shortness of breath, a feeling of weakness and lethargy, insomnia, and loss of appetite.

How does immobility affect the muscles?

There is a decrease in muscle mass (atrophy) and tension Body composition changes (decreases in lean body mass and increased body fat) The body loses muscle strength when muscles atrophy from inactivity decreased passive ROM development of contractures; footdrop

What is the peak of action for long-acting insulins?

There is no peak of action (for most people) with long-acting insulins

Why is the IV bolus, or "push," the most dangerous method for administering medications?

There is no time to correct errors A bolus may cause irritation to the lining of blood vessels.

What should remember about administering oxygen to patients with COPD and hypercapnia (high CO2 levels)?

These patients have adapted to the higher CO2 level, and the CO2-sensitive chemoreceptors are no longer sensitive to increased CO2 as a stimulus to breathe. Administering excessive oxygen to patients with COPD and hypercapnia satisfies the oxygen requirement of the body and may negate the stimulus to breathe, resulting in hypoventilation.

What do the Privacy Rules dictate?

These standards create patient rights to consent to use and disclose protected health information, inspect and copy one's medical record, and amend mistaken or incomplete information. In addition, the standards require all hospitals and health agencies to have specific policies and procedures in place to ensure compliance with the standards

What do the nephrons do?

They are the functional unit of the kidneys They remove waste products from the blood and play a major role in the regulation of fluid and electrolyte balance

What are state Nurse Practice Acts?

They define the scope of nurses' professional functions and responsibilities

Why does spirituality often play a more pronounced and important role in the lives of older adults?

They face an increased number of life transitions Older adults often experience many losses, including the loss of a home, spouse, friends, and siblings.

Why is this diagnostic statement wrong? Patient needs high-protein diet related to potential alteration in nutrition

This statement identifies a goal, and a nursing diagnosis should identify a problem Correct diagnosis statement: Imbalanced Nutrition: Less Than Body Requirements related to inadequate protein intake

What does "knowing the patient" mean?

To know a patient means that you: 1) avoid assumptions 2) focus on the patient 3) engage in a caring relationship that reveals information and cues that facilitate critical thinking and clinical judgments

What are the goals of palliative care?

To relieve suffering and support the best possible quality of life for patients with chronic and life-threatening conditions and their family members

What is the treatment for hypoxia?

Treatment aims to correct the cause and may include: 1) oxygen therapy 2) cardiac and respiratory stimulant drugs 3) mechanical ventilation.

CN V

Trigeminal Nerve - facial, motor, sensory function

What should be done before applying restraints to a patient?

Try other alternatives If alternatives do not work, a physician's order based on a face-to-face assessment of a patient is required If a restraint is needed, always use the least restrictive device. Because restraints limit a patient's ability to move freely, make clinical judgments appropriate to the patient's condition and agency policy.

What should you do if a pulse is difficult to palpate?

Use an ultrasound (Doppler) stethoscope

What infections require contact precautions?

VRE and MRSA, Clostridium difficile, Shigella, and other enteric pathogens; major wound infections; herpes simplex; scabies; varicella zoster (disseminated); respiratory syncytial virus in infants, young children, or immunocompromised adults

What causes peripheral cyanosis?

Vasoconstriction and diminished blood flow; hypoxemia

What are symptoms of right-sided heart failure?

Venous congestion in the systemic circulation, distended jugular veins and peripheral edema.

What is retraction?

Visible sinking in soft tissues of chest that lie between and around firmer tissue (e.g., cartilage and bony ribs)

What is Watson's transpersonal theory of caring?

Watson's theory is a holistic model that describes a conscious recognition that caring for a person involves sensitivity, respect, and a high moral and ethical commitment. The emphasis is on the nurse-patient relationship. Caring becomes almost spiritual.

What is faith?

What allows a person to have firm beliefs about something despite the lack of physical evidence.

When is the need for palliative care indicated?

When a diagnosis of a life-limiting illness is made

What is a singe (one-time) order?

When a health care provider orders a medication to be given only once at a specified time

What are prn orders?

When a health care provider orders a medication to be given only when a patient requires it for a specific situation, such as pain, nausea, or constipation.

What is "diabulimia"?

When a patient intentionally decreases their dose of insulin or omits the dose.

What is fecal impaction?

When a patient is unable to expel the hardened feces retained in the rectum it results from unrelieved constipation

What is hypothermia?

When a person's core body temperature falls below 96.8 degrees F (36 degrees C)

What are physiological responses to pain?

When acute pain impulses travel up the spinal cord toward the brainstem and thalamus, the *autonomic nervous system* is stimulated. Acute pain of low-to-moderate intensity and superficial pain cause the fight-or-flight response from the *sympathetic branch of the autonomic nervous system* and results in transient physiological responses If pain is unrelenting, severe, or deep, typically involving visceral organs, the *parasympathetic nervous system* is activated.

What is a perineural local anesthetic infusion?

When an unsutured catheter from a surgical wound placed near a nerve or groups of nerves connects to a pump containing a local anesthetic.

What is edema?

When areas of the skin become swollen from fluid buildup in the tissues

When should you wear disposable gloves?

When there is a risk for exposing the hands to blood, body fluids, mucous membranes, nonintact skin, or potentially infectious material on objects or surfaces

What is extracellular fluid volume (ECV) excess?

When there is too much isotonic fluid in the extracellular compartment

What is extracellular fluid volume (ECV) deficit?

When there is too small a volume of isotonic fluid in the vascular and interstitial areas

What does the ANA Social Media Policy recommend?

When using social media sites, a nurse should never name or describe a patient, never post an image of a patient, and never disparage a fellow employee or employer

When is a care plan discontinued?

When you determine that expected outcomes and goals were met, and you confirm this evaluation with the patient whenever possible.

What is a process measurement?

When you monitor if the process or protocol was implemented as planned

What is a descriptor in a diagnostic label?

Words that further support the nursing diagnosis For example, "impaired" in impaired physical mobility Also: compromised, decreased, delayed, or ineffective.

Can a person be spiritual and not have a religion or believe in a higher power?

Yes!

Is spirituality important for atheists and agnostics?

Yes! Atheists search for meaning in life through their work and relationships with others. It is important for agnostics to discover meaning in what they do or how they live because they find no ultimate meaning for the way things are.

What is cyanosis?

a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood

What is bioethics?

a branch of ethics within the field of health care. The study of bioethics has grown over the last 50 years, beginning with the emergence of technologies related to organ transplant

What is an abstract?

a brief summary of the article that summarizes: 1) the purpose of the study or clinical review 2) the type of study 3) major themes or findings 4) the implications for nursing practice.

What is a chest tube?

a catheter inserted through the rib cage into the pleural space to remove air, fluids, or blood; to prevent air or fluid from reentering the pleural space; or to reestablish normal intrapleural and intraplumonic pressures

What is delirium?

a change in mental status (temporary)

What is a nutrient?

a chemical substance that provides nourishment and affects metabolic and nutritive processes

What is diabetes mellitus?

a chronic multisystem disease characterized by hyperglycemia related to abnormal insulin production, impaired insulin utilization, or both.

What is a nursing diagnosis?

a clinical judgment concerning a human response to health conditions and/or life processes or vulnerability for that response by an individual, family, or community that a nurse is licensed and competent to treat

What is a problem-focused nursing diagnosis?

a clinical judgment concerning an undesirable human response to a health condition and/or life process that exists in an individual, family, group, or community Examples: fatigue or death anxiety

What is a health-promotion nursing diagnosis?

a clinical judgment concerning motivation and desire to increase well-being and actualize human health potential Example: readiness of enhanced comfort

What is a risk nursing diagnosis?

a clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions and/or life processes Examples: risk for falls

What is a pneumothorax?

a collapse of the lung caused by collection of air or other gas in the pleural space

What is negative-pressure wound therapy (NPWT)?

a combination dressing (foam and transparent film) with negative pressure via suction to help wound healing

What is hypoglycemia unawareness?

a condition in which a person does not experience the warning signs and symptoms of hypoglycemia until the glucose levels reach a critical point

What does critical thinking mean?

a continuous process characterized by open-mindedness, continual inquiry, and perseverance combined with a willingness to look at each unique patient situation and identify the assumptions that are true and relevant

What is a misdemeanor?

a crime that, although injurious, does not inflict serious harm (e.g. shoplifting, parking car illegally, etc.)

What is respiratory alkalosis?

a decreased PaCO2 and increased pH (greater than 7.45) that reflect the deficit of carbonic acid (H2CO3) in the blood Caused by hyperventilation

What is an insulin pump?

a device that delivers a continuous subcutaneous insulin infusion through a small device worn on the belt, in a pocket, or under clothing

What is connectedness?

a dimension of spirituality that is related to the human need of belonging

What is ecchymosis?

a discoloration of the skin resulting from bleeding underneath, typically caused by bruising

What is sleep apnea?

a disorder characterized by a lack of airflow through the nose and mouth for periods ranging from 10 seconds to 1 to 2 minutes during sleep.

What is oppression?

a formal and informal system of advantages and disadvantages tied to membership in social groups

What is dementia?

a generalized impairment of intellectual functioning that interferes with social and occupational functioning

What is vibration?

a gentle shaking pressure applied to the chest wall only during exhalation to shake secretions into larger airways.

What is a concept map?

a graphical representation that shows connections between concepts (such as a nursing diagnosis) that relate to a central subject (such as a patient's health problems). Developing a concept map helps you critically think about your patients' nursing diagnoses, their relationship to one another, and their effect on the nursing care plan

What is a care bundle?

a group of interventions related to a disease process or condition These interventions, when executed together, result in better patient outcomes than when implemented individually.

What is the health care information system (HIS)

a group of systems used within a health care organization to support and enhance health care An HIS consists of two major types of information systems: a clinical information system (CIS) and an administrative information system

What does a swooshing sound mean when auscultating the heart?

a heart murmur

What is wheezing?

a high-pitched musical sound caused by high-velocity movement of air through a narrowed airway. It is present in asthma, acute bronchitis, or pneumonia.

What is atrial natriuretic peptide (ANP)?

a hormone that opposes the action of aldosterone and promotes vasodilation. ANP causes sodium and water to be excreted in the urine, decreasing ECV slightly

What is documentation?

a key communication strategy between health care professionals and a vital element of nursing practice It consists of all information entered into the medical record

What is normal flora?

a large number of microorganisms residing on the surface and deep layers of the skin, in the saliva, and on the oral mucosa and intestinal walls

What is diabetic ketoacidosis (DKA)?

a life-threatening condition resulting in metabolic acidosis

What is a tension pneumothorax?

a life-threatening situation that occurs from rupture in the pleura when air accumulates in the pleural space more rapidly than it is removed. Air is trapped in the pleural cavity between the chest wall and the lung. The volume of trapped air increases with each inspiration and is unable to escape with expiration, causing increased pressure on the lung, heart, and blood vessels of the thorax

What is hyperosmolar hyperglycemic syndrome (HHS)?

a life-threatening syndrome that can occur in the patient with diabetes who is able to produce enough insulin to prevent DKA, but not enough to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion

What is an osmolality imbalance?

a loss or excess of only water, which affects the concentration (osmolality) of the body fluids

What is acanthosis nigricans?

a manifestation of insulin resistance It can appear as a velvety light brown to black skin thickening, predominantly seen on flexures, axillae, and the neck.

What is a rapid improvement event (RIE) (or rapid improvement assessment)?

a method used by businesses including health care agencies to change a process quickly to solve a problem or improve efficiency. People involved in the process come together to determine solutions for improvement, and one idea is quickly implemented and evaluated to determine if it was effective. If it was not effective, another solution is implemented.

What is restless leg syndrome (RLS)?

a neurological sensorimotor disorder that causes an irresistible urge to move the legs while they are at rest, sitting or lying.

What is reflection?

a part of critical thinking that involves purposefully reviewing a situation to discover its purpose or meaning For example: • How did I act? • Why did I take such an action? • What could I have done differently? • What should I do in a similar situation in the future?

What is a health disparity?

a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage

How is a cascade cough performed?

a patient takes a slow, deep breath and holds it for 2 seconds while contracting the expiratory muscles. Then the patient opens the mouth and performs a series of coughs throughout exhalation, thereby coughing at progressively lowered lung volumes.

What is informed consent?

a patient's agreement to allow a procedure such as surgery based on a full disclosure of the risks, benefits, alternatives, and consequences of refusal

What is a ureterostomy?

a permanent incontinent urinary diversion created by transplanting the ureters into a closed-off portion of the intestinal ileum. The other end of the ureters come out onto the abdominal wall, forming a stoma Patients have no sensation or control over the continuous flow of urine through the ileal conduit, requiring the effluent (drainage) to be collected in a pouch.

What are examples of necessary losses?

a person leaves behind family members to begin college but makes new friends and begins a meaningful career the death of a loved one

What is motor (or expressive) aphasia?

a person understands written and verbal speech but cannot write or speak appropriately when attempting to communicate

What is autonomy?

a person's independence Providers agree to respect an individual's right to determine a course of action. The respect pertains to patients as well as to providers. Respect for autonomy also refers to providers and provider relationships with institutions.

What is vocation?

a person's work or daily activities

What is a value?

a personal belief about the worth a person holds for an idea, a custom, or an object. The values that the person holds reflect cultural and social influences.

What is a compress?

a piece of gauze dressing moistened in a prescribed warmed solution

What is a urinal?

a plastic or metal receptacle for urine

What is recumbence?

a position of lying down at rest

What is leukoplakia?

a precancerous lesion seen in heavy smokers and alcoholics (thick white patches)

What is a standing order?

a preprinted document containing orders for conducting routine therapies, monitoring guidelines, or diagnostic procedures for specific patients with identified clinical problems.

What is a joint contracture?

a preventable, abnormal, and possibly permanent condition characterized by limited movement or fixation of the joint

What is medication reconciliation?

a process in which you compare the medications that your patient took in the previous setting (e.g., home or another nursing unit) with the current medication orders whenever there is a transition in care (e.g., discharge or transfer) and when a new medication is ordered

What is the bulbar conjunctiva?

a protective thin mucous membrane covering the sclera (not cornea)

What is inflammation?

a protective vascular reaction that involves a cascade of physiological responses that neutralize and eliminate pathogens or necrotic tissues and establishes a means of repairing body cells and tissues.

What is reactive hyperemia?

a redness of the skin resulting from dilation of the superficial capillaries Reactive hyperemia blanches (turns light in color). Blanching erythema is an area of erythema that becomes white (blanches) when compressed by a finger. This hyperemia usually resolves without tissue loss if pressure is reduced or eliminated.

What is hypovolemia?

a reduced circulating blood volume resulting from extracellular fluid losses that occurs in conditions such as shock and severe dehydration

What is hypovolemia?

a reduced circulating blood volume resulting from extracellular fluid losses that occurs in conditions such as shock and severe dehydration.

What is Body Mass Index (BMI)?

a reliable indicator of health based on weight status BMI is calculated by dividing weight in kilograms (kg) by height in meters squared (m2).

What is an incident report (aka occurrence report)?

a report that is completed wheneveran incident occurs

What is an ampule?

a sealed glass capsule containing a liquid, especially a measured quantity ready for injecting

What is a suprainfection?

a secondary infection usually caused by an opportunistic pathogen, such as a fungal infection after the antibiotic treatment of another infection

What is a felony?

a serious offense that results in significant harm to another person or society in general

What is a data cluster?

a set of signs or symptoms gathered during assessment that you group together in a logical way

What is dependent edema around the feet and ankles a sign of?

a sign of venous insufficiency or right-sided heart failure Could also be present in a person who spends a lot of time standing

What is a condom catheter?

a soft, pliable condomlike sheath that fits over the penis, providing a safe and noninvasive way to contain urine. Most external catheters are made of soft silicone that aids in reducing friction

What is a physiologically hypotonic solution?

a solution that is less concentrated than normal blood after they are infused Causes cells to swell Example: dextrose 5% in water (D5W)

What is a physiologically hypertonic IV solution?

a solution that is more concentrated than normal blood Causes cells to shrink Example: 3% sodium chloride solution

What is a physiologically isotonic solution?

a solution with the same osmolality as normal blood Example: 0.9% sodium chloride solution

What is hypoxia?

a state of inadequate tissue oxygenation

What is spiritual distress?

a state of suffering related to the impaired ability to experience and integrate meaning and purpose in life through connectedness with self, others, art, music, literature, nature, and/or a power greater than oneself

What is dyspnea?

a subjective feeling of breathlessness as reported by the patient, or it can be observable labored breathing with shortness of breath

What is a transfer report?

a type of hand-off report that involves the nurse on the sending unit communicating information about a patient to the nurse on the receiving unit.

What is a change-of-shift report?

a type of hand-off report that occurs at the end of each shift. this report provides the transfer of relevant information from nurses who have completed a shift of care to nurses about to begin a shift of care

What is a suprapubic catheter?

a urinary drainage tube inserted surgically into the bladder through the abdominal wall above the symphysis pubis

Where can hospice care be provided?

a variety of locations - home, inpatient, acute and long-term care facilities, rehab centers, etc.

What is hypernatremia?

abnormally high Na+ concentration in ECF caused by loss of relatively more water than salt or gain of relatively more salt than water

What is hypermagnesemia?

abnormally high blood Mg2+ level the result of excess Mg2+ intake or decreased Mg2+ excretion with oliguric renal disease

What is hyperchloremia?

abnormally high blood chloride level, which occurs with some types of acidosis, some renal conditions, and other electrolyte imbalances. It also has no unique signs and symptoms.

What is hyponatremia?

abnormally low Na+ concentration in the ECF, which occurs from gaining relatively more water than salt or losing relatively more salt than water

What is hypomagnesemia?

abnormally low blood Mg2+ level often occurs with chronic alcoholism and causes increased neuromuscular excitability

What is hypochloremia?

abnormally low blood chloride level It frequently is associated with alkalosis and conditions that cause loss of hydrochloric acid (vomiting, nasogastric suction, and gastric fistula drainage). It always occurs with other imbalances and has no unique signs and symptoms.

What is hypocalcemia?

abnormally low blood concentration of total Ca2+ or ionized Ca2+.

What pH value is alkaline (basic)?

above 7 (the higher the number, the more alkaline)

What are the 3 functions of the large intestine?

absorption, secretion, and elimination

What are examples of factors that influence a person's susceptibility to an infection?

age, nutritional status, presence of chronic disease, trauma, and smoking.

Is a solution with a lower concentration of H+ acidic or alkaline?

alkaline the lower the concentration of H+ ions, the more alkaline the solution and the higher the pH. Normal pH range of arterial blood is 7.35 to 7.45

Which herbs and supplements *may* lower blood glucose?

aloe, α-lipoic acid, cinnamon, chromium, garlic, and ginseng Teach patients to use herbs and supplements with caution, since they may affect blood glucose.

What is colloid osmotic pressure (oncotic pressure)?

an *inward-pulling* force caused by the presence of protein molecules

What is hypoxemia?

an abnormal deficiency in the concentration of oxygen in *arterial blood*

What is a hemothorax?

an accumulation of blood in the pleural space, usually as the result of trauma. It produces a counterpressure and prevents the lung from full expansion

What is a thrombus?

an accumulation of platelets, fibrin, clotting factors, and cellular elements of the blood attached to the interior wall of a vein or artery, sometimes occluding the lumen of the vessel.

For which conditions is heat contraindicated?

an active area of bleeding (risk for continued bleeding) or an acute localized inflammation such as appendicitis (risk for rupture)

What is a collaborative problem?

an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's status nurses intervene in cooperation with social workers, dietitians, or personnel from other health care disciplines

What is delirium?

an acute confusional state that requires prompt assessment. It is a potentially reversible cognitive impairment that often has physiological causes such as electrolyte imbalance, hypoglycemia, infection, and medications.

What is a peer-reviewed article?

an article submitted for publication and reviewed by a panel of experts familiar with the topic or subject matter of the article.

What is a stoma?

an artificial opening made into a hollow organ

What is spirituality?

an awareness of one's inner self and a sense of connection to a Supreme Being, nature, or some purpose greater than oneself

What might a chalky white discoloration of the tooth enamel indicate?

an early sign of caries formation

What is cultural knowledge?

an education base about culturally diverse groups

What is the Braden scale?

an evidence-based tool that looks at various factors that put patients at risk for developing a pressure ulcer. Includes: sensory perception moisture activity mobility nutrition friction shear

What is kyphosis?

an exaggeration of the posterior curvature of the thoracic spine (also called hunchback)

What is systolic heart failure?

an inability of the ventricle to adequately eject blood

What is hypokalemia?

an inadequate level of K+ in the blood

How can the dawn phenomenon be prevented?

an increase in insulin or an adjustment in administration time

What effect does immobility have on the respiratory rate?

an increase in respiratory rate

What is hyperventilation?

an increase in respiratory rate, resulting in excess amounts of CO2 elimination

What is diarrhea?

an increase in the number of stools and the passage of liquid, unformed stools

What is respiratory acidosis?

an increased PaCO2 and an increased hydrogen ion concentration (pH less than 7.35) that reflect the excess carbonic acid (H2CO3) in the blood Caused by hypoventilation

How does immobility affect the heart?

an increased heart rate (resting tachycardia) with the heart rate rising slightly each day

What is lordosis?

an increased lumbar curvature (also called swayback)

What is osteomyelitis?

an infection of the bone osteomyelitis may be present in stage 4 pressure injuries

What is an enema?

an instillation of a solution into the rectum and sigmoid colon to primarily promote defecation by stimulating peristalsis

What is an otoscope?

an instrument for visual examination of the eardrum and the passage of the outer ear

What is a related factor?

an integral component of all problem-focused nursing diagnoses; it is associated with a patient's actual or potential response to the health problem and can change by using specific nursing interventions For example, for the nursing diagnosis "fatigue", the related factor could be "chronic disease process" related factors are not listed for risk diagnoses

What is false imprisonment?

an intentional tort that may occur when the nurse restrains a patient, either chemically or physically, without following hospital policy or procedure

What is therapeutic communication?

an interactive dynamic process involving verbal and nonverbal exchanges between a nurse and patient The goal of therapeutic communication is to develop a relationship with a patient to meet health-related goals

What is presence?

an interpersonal process that is characterized by sensitivity, holism, intimacy, vulnerability, and adaptation to unique circumstances examples of presence are showing a caring attitude, demonstrating your willingness to listen and talk, or just being physically present

What is osmotic pressure?

an inward-pulling force exerted by the particles in any fluid compartment the pressure needed to stop the movement of water across the membrane

What is the Glasgow Coma Scale (GCS)?

an objective measurement of consciousness on a numerical scale

What is an outcome?

an observable effect of an intervention

What is a nursing-sensitive outcome?

an outcome that focuses on how patients and their health care problems are affected by nursing interventions; it looks at the effects of interventions within the scope of nursing practice Examples: • Symptoms (e.g., pain, fatigue, nausea). • Functional status (e.g., activity tolerance, ability to perform activities of daily living). • Safety (e.g., incidence of falls, infections, pressure injuries). • Psychological distress (e.g., anxiety, depression)

What is a sentinel event?

an unexpected occurrence involving death or serious physical or psychological injury of a patient

What parameters should be looked at when assessing any wound?

anatomical location, extent of tissue involvement (full-thickness or partial-thickness loss), size (dimensions and depth of wound), tissue type (viable or nonviable) and percentage of wound tissue (e.g., viable versus nonviable), volume and color of wound exudate, and condition of surrounding skin

What might be the cause of excessively oily hair?

androgen hormone stimulation

What could the presence of bruit in the abdominal area indicate?

aneurysms or stenotic vessels

What are disordered eating behaviors (DEB) that can occur in people with both type 1 and type 2 diabetes?

anorexia, bulimia, binge eating, excessive restriction of calories, and intense exercise

What are signs/symptoms of hypercalcemia?

anorexia, nausea and vomiting, constipation, diminished reflexes, lethargy, decreased level of consciousness, personality change; cardiac arrest if severe

What is ADH?

antidiuretic hormone It regulates osmolality of body fluids by influencing how much water is excreted in urine The hypothalamus controls release of ADH from the posterior pituitary gland

What types of medications are used to treat urinary incontinence?

antimuscarinics or anticholinergics

What is urinary incontinence (UI)?

any involuntary loss of urine

What is enteral nutrition (EN)?

any method of feeding that uses the gastrointestinal (GI) tract to deliver part or all of a person's caloric requirements

What is a nursing intervention?

any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes

When inspecting the carotid artery, what might an absence of a pulse wave indicate?

arterial occlusion (blockage) or stenosis (narrowing)

What should you do if you find scars or induration on a person's skin?

ask the patient if there has been recent skin injury

What position should the patient be in when assessing the vertebrae?

ask the patient to bend at the waist, arms hanging down

What is silent aspiration?

aspiration that occurs without a cough

How should you assess the kidneys?

assess for tenderness by gently percussing the costovertebral angle (the angle formed by the spine and twelfth rib)

How often should a respiratory assessment be done for acutely ill patients with restricted activity?

at least every 2 hours

Where is the point of maximal impulse (PMI) palpable in adults and children older than 7?

at the fifth intercostal space at the left midclavicular line

Where is the point of maximal impulse (PMI) palpable in children younger than 7?

at the fourth intercostal space at the left midclavicular line

What might diminished or unequal carotid pulsations indicate?

atherosclerosis (plaque buildup in arteries) or other forms of arterial disease

What is lipodystrophy?

atrophy or hypertrophy of subcutaneous tissue

What is timed voiding?

attempt voiding according to the clock, not according to urge

How can portals of exit be controlled?

avoid talking, sneezing, or coughing directly over a surgical wound or sterile dressing field teach patients to protect others when they sneeze or cough and give patients disposable wipes or tissues to control spread of microorganisms Try not to work with patients who are highly susceptible to infection if you have a cold or other communicable infection. using standard precautions when handling body fluids such as urine, feces, and wound drainage Wear clean gloves if there is a chance of contact with any blood or body fluids and perform hand hygiene after providing care bag contaminated items appropriately

What is urinary reflux?

back flow of urine into the ureters and pelvis of the kidney caused by an obstruction of urine flow

What is bacteriuria?

bacteria in the urine

What is active listening?

being attentive to what a patient is saying both verbally and nonverbally

What pH value is acidic?

below 7 (the lower the number, the more acidic)

What is the normal arterial bicarbonate level?

between 22 and 26 mEq/L

What is the normal venous bicarbonate level?

between 24 to 30 mEq/L

When is the best time to auscultate the abdomen?

between meals

Where are bronchovesicular sounds heard?

between the scapulae

What are signs/symptoms of hypokalemia?

bilateral muscle weakness, abdominal distention, decreased bowel sounds, constipation, dysrhythmias

What are signs/symptoms of hyperkalemia?

bilateral muscle weakness, transient abdominal cramps, diarrhea, dysrhythmias; cardiac arrest if severe

What is a pulmonary embolism?

blood clot in the lungs DVT puts a person at risk for a pulmonary embolism

What is bruit?

blowing or swishing sound caused by turbulent blood flow through a narrowed vessel

What are symptoms of sleep deprivation?

blurred vision, decreased reflexes, slow response time, headaches, memory problems, confusion, and irritability.

What are cherry angiomas?

bright red, raised spots (expected skin changes with aging)

What are examples of portals of entry?

broken skin, mucous membranes, genitourinary tract, GI tract, and respiratory tract.

What are the 2 types of acid produced by cellular metabolism?

carbonic and metabolic *Carbonic acid* (H2CO3) arises from the carbon dioxide (CO2) that cells produce. *Metabolic acids* are all other acids produced by cells that are not carbonic acid such as lactic acid and citric acid

What are circulatory system factors that could alter cardiac functioning?

cardiac rate, rhythm, strength of contraction, blood flow through the chambers, myocardial blood flow, and peripheral circulation

What are vascular access devices (VADs)?

catheters or infusion ports designed for repeated access to the vascular system Devices for long-term use include central lines, peripherally inserted central catheters (PICCs), and implanted ports.

What are caries?

cavities

What are the 6 sections of the large intestine?

cecum, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum

What causes constipation?

changes in diet, medications, mobility, inflammation, environmental factors (e.g., unavailability of toilet facilities or lack of privacy), and lack of knowledge about regular bowel habits

How would you know if a patient is experiencing hyperglycemia due to the Somogyi effect?

check blood glucose levels between 2:00 and 4:00 AM for hypoglycemia The patient may report headaches on awakening and recall having night sweats or nightmares.

What is angina pectoris?

chest pain caused by inadequate flow of blood and oxygen to the heart

What type of events are mandatory for all health care providers to report?

child, spousal, or elder abuse; rape; gunshot wounds; attempted suicide; and certain communicable diseases unsafe or impaired professionals

Which are the major anions within body fluids?

chloride (Cl−) bicarbonate (HCO3-) phosphate (PO3 and other forms)

What increases output of Mg2+ in the feces?

chronic diarrhea and undigested fat

What is insomnia?

chronic difficulty falling asleep, frequent awakenings from sleep, or nonrestorative sleep It is commonly experienced by patients diagnosed with depression

What factors may cause malnutrition in older adults?

chronic illness, anorexia, slowed digestion and peristalsis, decreased physical and cognitive function, ability to feed self, medication side effects, loss of dentition, and xerostomia

What is idiopathic pain?

chronic pain in the absence of an identifiable physical or psychological cause or pain perceived as excessive for the extent of an organic pathological condition.

What is Process C?

circadian rhythms ("biological time clocks"), which influence the internal organization of sleep and timing and duration of sleep-wake cycles

What is torts?

civil wrongful acts or omissions against a person or a person's property that are compensated by awarding monetary damages to the individual whose rights were violated

How can you create privacy for a patient when voiding?

closing the door and bedside curtains; asking visitors to leave a room when a bedside commode, bedpan, or urinal is used; and masking the sounds of voiding with running water.

What are clavicles?

collar bones

What is normal or uncomplicated grief?

commonly expected emotional and behavioral reactions to a loss (e.g., resentment, sorrow, anger, crying, loneliness, temporary withdrawal from activities)

What are social determinants of health?

conditions in which people are born, grow, live, work, and age (including conditions within a health care system)

What are microvascular complications?

conditions that result from thickening of the vessel membranes in the capillaries and arterioles in response to conditions of chronic hyperglycemia Although microangiopathy can be found throughout the body, the areas most noticeably affected are the eyes (retinopathy), kidneys (nephropathy), and nerves (neuropathy)

What is negligence?

conduct that falls below the generally accepted standard of care that a reasonably prudent person would provide under similar circumstances Example: a driver's failure to stop at a clearly identified stop sign

What is cultural skill?

conducting a cultural assessment of a patient, and a culturally based physical assessment

Which patients are often kept in prone position?

critically ill patients on mechanical ventilation and who have acute respiratory distress syndrome (ARDS)

What factors influence each person's definition of spirituality?

culture, development, life experiences, beliefs, and ideas about life

What is angiopathy?

damage to blood vessels

What is a laceration?

damage to the dermis and epidermis and is a torn, jagged wound. The depth and location of the laceration affect the extent of bleeding

What color urine would you expect for patients with liver disease?

dark amber urine (because they have high concentrations of bilirubin (urobilinogen))

How does immobility affect the GI?

decreased fluid intake and appetite Decreased bowel motility hypercalcemia further presses peristalsis Severe constipation can result

What physiological changes make older adults susceptible to infection?

decreased immunity, dry mucous membranes, decreased secretions, and decreased elasticity in tissues

What are signs/symptoms of metabolic acidosis?

decreased level of consciousness (confusion, lethargy, coma), abdominal pain, dysrhythmias, increased rate and depth of respirations (compensatory hyperventilation)

What are consequences of dysphagia?

dehydration, malnutrition, and pneumonia; increased length of hospital stay, health care cost, morbidity, and mortality

What are intentional torts?

deliberate acts of wrongful conduct Example: assault and battery

What are three common conditions affecting cognition in older adults?

delirium, dementia, and depression

What are emotional effects of immobilization?

depression, social isolation, sleep-wake disturbances, and impaired coping

What items are not considered restraints?

devices such as orthopedically prescribed devices, protective helmets, or methods that involve physically holding a patient to conduct an examination or test, protecting a patient from falling out of bed, or permitting a patient to participate in activities without the risk of physical harm

How does immobility affect urinary elimination?

difficulty voiding because of positioning restrictions urinary stasis develops (the renal pelvis fills before urine enters the ureters) Urinary stasis increases a patient's risk for urinary tract infection (UTI) and renal calculi or calcium stones

What is osmosis?

diffusion of water across a semipermeable membrane from a compartment of lower particle concentration to one that has a higher particle concentration Osmosis continues until the particle concentration is equal in both fluid compartments.

What are hemorrhoids?

dilated, engorged veins in the lining of the rectum

What should you do if phlebitis develops?

discontinue the IV line and insert a new line in another vein. Warm, moist compresses on the site of phlebitis offer some relief to patients

What are macrovascular complications?

diseases of the large and medium-size blood vessels that occur with greater frequency and with an earlier onset in people with diabetes Macrovascular diseases include cerebrovascular, cardiovascular, and peripheral vascular disease.

What are signs/symptoms of hypoventilation?

dizziness, occipital headache on awakening, lethargy, disorientation, decreased ability to follow instructions, dysrhythmias, hypertension, seizures, and possible coma or cardiac arrest.

What should you always do if there is a deviation from the standard of care such as when a patient or visitor falls or an error is made?

document the event or incident in the form of an occurrence report/incident report

What are living wills?

documents that provide instructions about a patient's wishes in certain situations, including withholding or withdrawing life-sustaining procedures in patients who are terminally ill.

What does diplopia mean?

double vision

What is effluent?

drainage

What is a clinical inference?

drawing conclusions from related pieces of patient data and previous experience with similar evidence

What are hydrocolloid dressings?

dressings that are made of gelling agents and have an adhesive wound surface

What are hydrogel dressings?

dressings that contain a high percentage of water and are used when wounds require moisture they are available in sheets, spray bottles, or a gel in a tube (amorphous)

What does ptosis mean?

drooping eyelid

What are sedatives and hypnotics?

drugs that induce and/or maintain sleep

What are laxatives and cathartics?

drugs that induce the emptying of the intestinal tract (cathartics are often stronger)

What is xerostomia?

dry mouth

What is the first section of the small intestine?

duodenum

What does EHR stand for?

electronic health record

How can reservoirs be eliminated or controlled?

eliminate sources of body fluids, drainage, or solutions that possibly harbor microorganisms

What is a cultural encounter?

engaging with patients from diverse backgrounds

What is an ileostomy?

entire colon is removed and a stoma is created from the ileum

How often should you change tubing for continuous IV lipids?

every 24 hours

How often should patients with diabetes check their blood glucose during times of illness?

every 4 hours

How often should you change tubing containing blood products?

every 4 hours

How often should you empty a catheter drainage bag?

every 8 hours or as needed

What does qh mean?

every hour

What are symptoms of dyspnea?

exaggerated respiratory effort, use of the accessory muscles of respiration, nasal flaring, and marked increases in the rate and depth of respirations

What are symptoms of OSA?

excessive daytime sleepiness, fatigue, morning headaches, irritability, depression, difficulty concentrating, and decreased sex drive

What are recommendations about breastfeeding?

exclusive breastfeeding for approximately 6 months, with the continuation of breastfeeding for at least 1 year or as long as mutually desired by mother and infant

What are the 2 types of radiation therapy?

external beam radiation and brachytherapy (internal implanted radiation)

What is chest physiotherapy (CPT)?

external chest wall manipulation using postural drainage, percussion, vibration, high-frequency chest wall compression (HFCWC), or all of these for helping patients mobilize pulmonary secretions

What are nonstarch polysaccharides?

fiber

What do kidneys do?

filter waste products of metabolism from the blood

What is spiritual health?

finding a balance between their life values, goals, and belief systems and their relationships within themselves and with others

What are words to describe the contour of a lesion?

flat, raised, or depressed

What is a triple-lumen catheter used for?

for continuous bladder irrigation or when it is necessary to instill medications into a patient's bladder. One lumen drains the bladder, a second lumen inflates the balloon, and a third lumen delivers irrigation fluid into the bladder.

What is Quality improvement (QI) and performance improvement (PI)?

formal approaches to analyze health care-related processes (the terms are used interchangeably) An organization monitors specific quality outcomes and, when findings suggest potential problems, it institutes formal QI/PI initiatives.

What are examples of long-acting insulins?

glargine (Lantus, Toujeo) detemir (Levemir) degludec (Tresiba)

What is the Braden Scale?

highly reliable tool that identifies patients at greatest risk for pressure injuries It is composed of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear

What does the stomach produce and secrete?

hydrochloric acid (HCl), mucus, the enzyme pepsin, and intrinsic factor

What is the dawn phenomenon?

hyperglycemia that is present on awakening Two counterregulatory hormones (growth hormone and cortisol), which are excreted in increased amounts in the early morning hours, may be the cause of this phenomenon.

What (conditions) result from hyperventilation?

hypocapnia and respiratory alkalosis

What does excessive infusion of D5W cause?

hyponatremia with confusion, lethargy, and possibly seizures

What is the major sleep center in the body?

hypothalamus

What is a dangerous side effect of oxygen therapy for patients with COPD and hypercapnia?

hypoventilation

What (conditions) result from hypoventilation?

hypoxia or hypercapnia and respiratory acidosis.

Where does perfusion of oxygenated blood occur?

in the capillary beds of the organs and tissues

What is collaborative care?

involving family, family caregivers, significant others, and clergy to lend support to the patient

Wheal

irregularly shaped, slightly elevated area; small, localized area of edema on the surface of the skin;

What is cystitis?

irritation of the bladder

What is parenteral nutrition (PN)?

is the feeding of nutritional products to a person intravenously, bypassing the usual process of eating and digestion

What causes dysrhythmias?

ischemia, valvular abnormalities, anxiety, and drug toxicity (e.g., digoxin toxicity); Dysrhythmias also occur as a result of excess caffeine, alcohol, or tobacco use; following cardiothoracic surgery; or as a complication of acid-base or electrolyte imbalance, such as altered serum potassium levels

What are the 2 types of fluid imbalance?

isotonic (volume) and/or osmolality (concentration) imbalances

Why is chronic NSAID use is not recommended?

it is associated with gastrointestinal bleeding, renal insufficiency, and bleeding tendencies

What are signs and symptoms of a local inflammatory reaction to insulin?

itching, erythema, and burning around the injection site

What are Good Samaritan Laws?

laws that limit liability and offer legal immunity if a nurse helps at the scene of an accident.

What are standards of care?

legal guidelines for minimally safe and adequate nursing practice

What is a primary lesion?

lesions that occur as initial spontaneous manifestations of a pathological process such as an insect bite

What is normal diastolic blood pressure?

less than 80 mm Hg

What is a pressure injury?

localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device

How should you assess an immobile patient's metabolic functioning?

measure intake and output and review laboratory data to evaluate fluid and electrolyte status Assess the patient's nutritional status to determine the risk for nitrogen imbalance Measure height and weight and take anthropometric measurements Observe speed of healing for wounds (if any)

What are definable characteristics?

observable cues and inferences that cluster as manifestations of a problem-focused or health promotion diagnosis or syndrome

Where are vesicular sounds heard?

over the periphery of the lungs

Where do you hear bronchial sounds?

over the trachea

Why should you caution patients against the abuse of nasal medications?

overuse leads to a rebound effect in which the nasal congestion worsens

What is dyspnea that occurs when a patient is sleeping?

paroxysmal nocturnal dyspnea (PND)

What are rituals?

participation in a religious group or private worship, prayer, participating in sacraments such as baptism or communion, fasting, singing, meditating, scripture reading, making offerings or sacrifices, or enjoying nature.

Is osmosis an active or passive process?

passive it does not require energy from cells

What is diffusion?

passive movement of electrolytes or other particles from an area of higher concentration to one of lower concentration

For which patients is Fowler's position good for?

patients with cardiac and respiratory problems

What are examples of structural abnormalities which can impair oxygenation?

pectus excavatum (funnel chest), kyphosis or scoliosis

What are examples of Nurse Practice Act violations that carry criminal penalties?

practicing nursing without a license and misuse of controlled substances

What common conditions increase metabolism as a normal body response?

pregnancy, infection, fever, wound healing, and exercise Most people are able to meet increased oxygen demands and do not display signs of oxygen deprivation.

What are other terms that have been used in the past for a pressure injury?

pressure sore, pressure ulcer, decubitus ulcer, or bedsore

Where does absorption of dietary Mg2+ take place?

primarily in the terminal ileum

What is necrobiosis lipoidica diabeticorum?

red-yellow lesions, with atrophic skin that becomes shiny and transparent revealing tiny blood vessels under the surface

What does it mean to "critically appraise the evidence"?

review each source of evidence carefully to: 1) determine its scientific worth 2) determine the strength of any study methods (when appropriate) 3) identify the level of evidence from each source 4) summarize your findings 5) determine if the evidence is conclusive regarding your practice question

What increases renal Mg2+ excretion?

rising blood alcohol

Which are the major cations within body fluids?

sodium (Na+) potassium (K+) calcium (Ca2+) magnesium (Mg2+)

What do vesicular sounds sound like?

soft, breezy, and low pitched, The inspiratory phase is about 3 times longer than the expiratory phase

What is slough?

soft, moist, devitalized tissue that may be yellow, tan, or green and either loose or firmly adherent

What is advocacy?

speaking up for patients A nurse "promotes, advocates for, and protects the rights, health, and safety of the patient." Advocacy can also take the form of engagement with public policy

What are transmission-based precautions?

special isolation precautions for patients with communicable infections

What is ideal body weight (IBW)?

standard norms for normal height-weight relationships

What are carbohydrates?

starches and sugars obtained mainly from plant foods, with the exception of lactose

What is a urinary diversion?

surgical creation of an alternate route for excretion of urine; it is constructed from a section of intestine to create a storage reservoir or conduit for urine

What are symptoms of infiltration?

swelling (from increased interstitial fluid), paleness, and coolness (from decreased circulation) around the venipuncture site Pain may occur

What are the 2 phases of the cardiac cycle?

systole (contraction - blood is ejected from the ventricles into the systemic circulation) diastole (relaxation - blood fills the ventricles)

What are signs/symptoms of hyperventilation?

tachycardia, shortness of breath, chest pain, dizziness, light-headedness, decreased concentration, paresthesia, circumoral and/or extremity numbness, tinnitus, blurred vision, and disorientation

What is beneficience?

taking positive action to help others the best interest of a patient remains more important than self-interest

What is percussion?

tapping the body with the fingertips to produce a vibration that travels through body tissues

What is an ileus?

temporary cessation of peristalsis A patient cannot eat or drink fluids without causing abdominal distention, nausea, and vomiting

What is the manuscript narrative?

the "middle section" of a manuscript

What is linguistic competence?

the ability to communicate effectively and convey information in a manner that is easily understood by diverse audiences

What is a microorganism's virulence?

the ability to produce disease

What is asepsis?

the absence of disease-producing microorganisms

What is respiration?

the act of breathing with the exchange of oxygen and carbon dioxide (CO2) during cellular metabolism

What is workplace violence?

the act or threat of violence, ranging from verbal abuse to physical assault, directed toward persons at work or on duty

What is fidelity?

the agreement to keep promises and is based on the virtue of caring Example: if you assess a patient for pain and then offer a plan to manage the pain, you to do your best to provide follow-up that includes continuous reevaluation of pain levels

What is tidal volume?

the amount of air exhaled after a normal inspiration

What is residual volume?

the amount of air left in the alveoli after a full expiration

What is base excess (or deficit)?

the amount of blood buffer (hemoglobin and bicarbonate) present in the blood

What is negative nitrogen balance?

the amount of nitrogen excreted from the body is greater than the amount of nitrogen ingested Can result from immobility

What is hope?

the anticipation of a continued good or an improvement or lessening of something unpleasant

What is the purpose of the results and conclusion section?

the author describes the findings from the study and explains whether a hypothesis is supported or how a research question is answered and/or the author explains the clinical implications for the topic presented

What is the major buffer in ECF?

the bicarbonate buffer system, which buffers metabolic acids

What organs are most sensitive to hypoxia?

the brain, heart, and liver

What is geriatrics?

the branch of health care dealing with the physiology and psychology of aging and with the diagnosis and treatment of diseases affecting older adults

What is catabolism?

the breakdown of large substances into simpler units (e.g., breaking down stored glycogen to yield individual units of glucose)

What is anabolism?

the building of more complex substances from smaller particles (e.g., synthesis of proteins from amino acids).

What is etiology?

the cause, set of causes, or manner of causation of a disease or condition In a nursing diagnoses, the etiology is the related factor

What does hemostasis mean?

the cessation of bleeding by vasoconstriction and coagulation

What is health literacy?

the degree to which individuals have the capacity to obtain, process, and understand basic health information and the services needed to make appropriate health decisions

What is Medical nutrition therapy (MNT)?

the diagnosis, therapy, and counseling services provided by an RDN for disease management

What is a durable power of attorney for health care?

the document designates an individual, also known as a *health care proxy* or a surrogate, who can give consent for health care treatment when the patient is no longer able

What is fluid homeostasis?

the dynamic interaction between fluid intake and absorption, fluid distribution, and fluid output

What does turgor mean?

the elasticity of the skin

What is depolarization?

the electrical event occurring just before contraction of the cardiac chambers

What is grief?

the emotional response to a loss

What is the basal metabolic rate (BMR)?

the energy needs of a person at complete physiological, mental, thermal, and emotional rest after awakening

What is malpractice?

the failure to use the same care that a reasonably prudent nurse would use under the same or similar circumstances Professional negligence

When a patient is converted from an IV to an oral form of opioid, why is the dose of the oral opioid is usually much higher than the IV dose?

the first-pass effect When a patient takes oral opioids, the opioids go to the liver first, where most of the medication is inactivated.

What is hydrostatic pressure?

the force of a fluid pressing *outward* against the walls of its container capillary hydrostatic pressure is an *outward-pushing* force

What is ethnic and cultural identity?

the frame in which individuals identify consciously or unconsciously with those with whom they feel a common bond because of similar traditions, behaviors, values, and beliefs

What is non-maleficence?

the fundamental agreement to do no harm The health care provider tries to balance the risks and benefits of care, while striving at the same time to do the least harm possible.

Who is legally responsible for providing information about the procedure and obtaining a patient's informed consent?

the health care provider who is performing the surgery or medical procedure

What is a medical diagnosis?

the identification of a disease condition based on an evaluation of physical signs, symptoms, history, and diagnostic tests and procedures.

What is diastolic heart failure?

the inability of the ventricle to relax and fill with blood during diastole

What is urinary retention?

the inability to partially or completely empty the bladder

What is aspiration?

the inadvertent entry of food, fluid, or medication into the respiratory tract when it is intended for GI administration

What is a therapeutic effect?

the intended or desired physiological response of a medication

What is an infection?

the invasion of a susceptible host (e.g., a patient) by potentially harmful microorganisms (pathogens), resulting in disease.

What is forced vital capacity?

the maximum amount of air that can be removed from the lungs during forced expiration

What is debridement?

the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue

What is ventilation?

the movement of air in and out of the lungs

What is diffusion?

the movement of gases between the alveoli and the bloodstream

What is the diagnostic label?

the name of the nursing diagnosis as approved by NANDA-I it describes the essence of a patient's response to a health condition in as few words as possible

What is filtration?

the net effect of several forces that move fluid across a membrane

What is priority setting?

the ordering of nursing diagnoses or patient problems considering their urgency and importance to establish an order for nursing actions

What does osmolality mean?

the overall particle concentration of a solution it is measured as the number of particles per kilogram of water, reported in milliosmoles per kilogram (mOsm/kg)

What is dishiscence?

the partial or total separation of layers of skin and tissue above the fascia in a wound that is not healing properly.

What is PaCO2?

the partial pressure of carbon dioxide in arterial blood and reflects the amount of H2CO3 in the blood

What is PaO2?

the partial pressure of oxygen in arterial blood When PaO2 is within normal range, it has no primary role in acid-base regulation

What would you suspect if a patient had distended jugular veins when sitting at a 45-degree angle?

the patient has right-sided heart failure

What is SaO2 (oxygen saturation)?

the percentage of hemoglobin molecules that are carrying as much oxygen as is possible (saturated)

What is implentation?

the performance of nursing interventions necessary for achieving the goals and expected outcomes of nursing care

What is repolarization?

the period of time when the heart is resting and the chambers are filling

What could happen if you or a health care provider performs a procedure on a patient without informed consent?

the person who performed the procedure can be liable for battery

What is urinary catheterization?

the placement of a tube through the urethra into the bladder to drain urine

What is justice?

the principle of fairness a commitment to fair treatment and fair distribution of health care resources

What is diabetic retinopathy?

the process of microvascular damage to the retina as a result of chronic hyperglycemia, nephropathy, and hypertension in patients with diabetes

What is a pulse deficit?

the radial pulse is slower than the apical pulse

What does an ECG monitor?

the rate, regularity, and path of the electrical impulse through the conduction system; however, it does not reflect the muscular work of the heart.

What is anemia?

the reduction in number of RBCs or a decrease in Hgb, the oxygen-carrying protein of RBCs; Acute blood loss or certain chronic diseases can result in anemia.

What is electrolyte homeostasis?

the relationship between electrolyte intake and absorption, electrolyte distribution, and electrolyte output To maintain electrolyte balance, electrolyte intake must equal electrolyte output and the electrolyte distribution must be normal

What influences the concentration of Na+ in ECF?

the relative amount of water

Through which four organs does fluid output occur?

the skin, lungs, GI tract, and kidneys

What is muscle tone?

the slight muscular resistance felt as you move the relaxed extremity passively through its ROM

What are intercostal spaces?

the spaces between the ribs

What is an autopsy?

the surgical dissection of a body after death to determine cause of death or how the person died or to contribute to knowledge of the disease.

What is religion?

the system of organized beliefs and worship that a person practices to outwardly express spirituality the "state of doing," or a specific system of practices associated with a particular denomination, sect, or form of worship

What is the cornea?

the transparent, colorless portion of the eye covering the pupil and iris

What is perfusion?

the transport of oxygenated blood to the cells and tissues

What is the urethra?

the tube that leads from the bladder to the outside of the body

What does inspection mean?

the use of vision to distinguish normal from abnormal findings

What is a hand-off report?

the verbal and written exchange of pertinent information during this transition of care

What is the purpose of flow sheets?

they document routine activities such as daily hygiene care, vital signs, and pain assessments

What nursing interventions can promote cardiovascular health in an immobile patient?

thromboprophylaxis (Adherence to prescribed anticoagulants, proper positioning, and safe use of antiembolic stockings help reduce thrombus formation) Educate patients about anticoagulants Have patient maintain adequate hydration by drinking water or juice and avoiding alcoholic beverages Patients benefit from long-term lifestyle modifications including smoking cessation, achieving a body mass index that is 25 kg/m2, maintaining a normal blood pressure, achieving glycemic control, and managing lipid levels teach patients to avoid crossing the legs, sitting for prolonged periods of time, wearing tight clothing that constricts the legs or waist, putting pillows under the knees, and massaging the legs

What is lateral violence?

uncivil behaviors in a professional setting such as: 1) withholding information 2) making snide remarks 3) demonstrating nonverbal expressions of disapproval such as raising eyebrows or making faces

What are signs and symptoms of a true insulin allergy?

urticaria and possibly anaphylactic shock (A true insulin allergy is rare)

What is infiltration?

when IV fluids leak into the subcutaneous tissue around the venipuncture site because the catheter tip no longer is in the vein

What is a verbal order (VO)?

when a health care provider gives therapeutic orders to an RN while they are standing in proximity to one another

when is oral replacement of fluids contraindicated?

when a patient: 1) has a mechanical obstruction of the GI tract 2) is at high risk for aspiration 3) has impaired swallowing

What is nitrogen balance?

when nitrogen intake equals that of nitrogen output The body uses nitrogen for building, repairing, and replacement of body tissue

What is the fourth heart sound (S4)?

when the atria contract to enhance ventricular filling

What is myocardial ischemia?

when the coronary artery does not supply sufficient blood to the heart muscle (myocardium)

What is urinary stasis?

when the renal pelvis fills before urine enters the ureters

What is hypoventilation?

when ventilation is inadequate to meet the oxygen demands of the body or to have it eliminate CO2

What is an isotonic deficit or excess?

when water and sodium are lost or gained in equal proportions, affecting the volume of the ECF

What is evisceration?

when wound layers separate below the fascial layer and visceral organs protrude through the wound opening MEDICAL EMERGENCY!

When should you consult with another member of the health care team?

when you identify a problem that you cannot solve using your own knowledge, skills, and resources

How should you measure a lesion?

with a clear, flexible ruler divided in centimeters. Measure lesions in height, width, and depth.

What are risk factors for developing gestational diabetes?

women who are: -obese -are of advanced maternal age - have a family history of diabetes

What is the commitment level of critical thinking?

you anticipate the need to make choices without assistance from others you accept accountability for the decisions you make. you choose an action or belief based on the alternatives available and stand by your choice.

What do you need to do to effectively care for your patients' spiritual needs?

you need to be comfortable with your own spirituality

How often should an immobile patient be repositioned?

you reposition patients as needed and at least every 2 hours if they are in bed and every 15 to 20 minutes if they are sitting in a chair or wheelchair

What is the normal range of base excess/deficit?

±2 mmol/L A higher positive value indicates alkalosis, and a lower negative value indicates acidosis

What are features of plain language (the type of language you should use when communicating with patients)?

• "You" and other pronouns • Active voice • Short sentences • Common, everyday words • Easy-to-read design features (in written materials) Plain language makes any information you are providing easy to read, understand, and use.

What are the steps of using the acronym LEARN to help foster cultural desire?

• *L*isten to the patient's perception of the problem. Be nonjudgmental and use encouraging comments such as, "Tell me more" or "I understand what you are saying." • *E*xplain your perception of the problem. • *A*cknowledge not only the differences between the two perceptions of the problem but also the similarities. Recognize the differences, but build on the similarities. • *R*ecommendations must involve the patient. • *N*egotiate a treatment plan, considering that it is beneficial to incorporate selected aspects of the patient's culture into the plan.

What are signs of death?

• Absence of breathing and heartbeat • Bowel and bladder release • Unresponsiveness • Eyes fixed on a certain spot • Dilated pupils

What are nursing diagnoses associated with oxygenation alterations?

• Activity Intolerance • Ineffective Airway Clearance • Ineffective Breathing Pattern • Decreased Cardiac Output • Fatigue • Impaired Gas Exchange • Risk for Infection • Ineffective Peripheral Tissue Perfusion

What are common nursing diagnoses regarding sleep issues?

• Acute Confusion • Ineffective Coping • Fatigue • Insomnia • Disturbed Sleep Pattern • Sleep Deprivation • Ineffective Health Maintenance • Readiness for Enhanced Sleep

What are causes of hypoglycemia?

• Alcohol intake without food • Too little food—delayed, omitted, inadequate intake • Too much diabetes medication • Too much exercise without adequate food intake • Diabetes medication or food taken at wrong time • Loss of weight without change in medication • Use of β-adrenergic blockers interfering with recognition of symptoms

What are common nursing diagnoses related to spiritual health?

• Anxiety • Ineffective Coping • Fear • Hopelessness • Powerlessness • Spiritual Distress • Risk for Spiritual Distress • Readiness for Enhanced Spiritual Well-Being

What are common nursing diagnoses related to administering meds?

• Anxiety • Ineffective Health Maintenance • Deficient Knowledge (Medication Self-administration) • Noncompliance (Medications) • Impaired Swallowing • Impaired Memory

What are recommendations for preventing needlestick injuries?

• Avoid using needles when effective needleless systems or sharps with engineered sharps injury protection (SESIP) safety devices are available. • Do not recap any needle after medication administration. • Plan safe handling and disposal of needles before beginning a procedure. • Immediately dispose of needles, needleless systems, and SESIP devices into puncture-proof, leak-proof sharps disposal containers. • Maintain a sharps injury log that includes the following: type and brand of device involved in incident, location of incident (e.g., department or work area), description of incident, and a way to protect privacy of the employees who have had sharps injuries. • Attend educational programs on bloodborne pathogens and follow recommendations for infection prevention, including receiving the hepatitis B vaccine. • Participate in the selection and evaluation of SESIP devices with safety features within your institution whenever possible.

What are Nurse Caring Behaviors as Perceived by Families?

• Being honest • Advocating for patient's care preferences • Giving clear explanations • Keeping family members informed • Asking permission before doing something to a patient • Providing comfort: offering a warm blanket, finding food a patient can swallow, rubbing a patient's back • Reading to patient passages from religious texts, a favorite book, cards, or mail • Providing for and maintaining patient privacy • Assuring the patient that nursing services will be available • Helping patient to do as much for self as possible • Teaching the family caregiver how to keep the patient physically comfortable

What effect do beta-adrenergic blockers have on sleep?

• Cause nightmares and insomnia • Cause awakening from sleep

What effect does nicotine have on sleep?

• Causes decrease in sleep time • Causes nighttime awakenings • Causes difficulty staying asleep

What problems can develop if a patient is left in the supine position for too long?

• Cervical flexion from a too thick pillow being placed under the head • Pressure over the occiput from the head staying flat on the mattress • Shoulders unsupported and internally rotated • Elbows extended • Thumb not in opposition to the fingers • Hips externally rotated • Feet unsupported • Unprotected pressure points at the vertebrae, coccyx, elbows, heels, and occipital region of the head

What are common nursing diagnoses related to grief, loss and the end of life?

• Death Anxiety • Ineffective Denial • Fear • Grieving • Complicated Grieving • Hopelessness • Social Isolation • Spiritual Distress

What effect do anticonvulsants have on sleep?

• Decrease REM sleep • Cause daytime drowsiness

What are possible nursing diagnoses for patients with fluid, electrolyte, and acid-base alterations?

• Decreased Cardiac Output • Acute Confusion • Risk for Electrolyte Imbalance • Deficient Fluid Volume • Excess Fluid Volume • Risk for Imbalanced Fluid Volume • Impaired Gas Exchange • Risk for Injury

What are pathological conditions that affect urinary elimination?

• Diabetes mellitus, multiple sclerosis, and stroke can alter bladder contractility and the ability to sense bladder filling. Patients experience either bladder overactivity or deficient bladder emptying. • Arthritis, Parkinson disease, dementia, and chronic pain can interfere with timely access to a toilet. • Spinal cord injury or intervertebral disk disease (above S1) can cause the loss of urine control because of bladder overactivity and impaired coordination between the contracting bladder and the urinary sphincter. • Prostatic enlargement (e.g., benign prostatic hyperplasia) can cause obstruction of the bladder outlet, which results in urinary retention.

How do you apply topical medications to the mucous membranes?

• Direct application of a liquid or ointment (e.g., instilling eyedrops, gargling, or swabbing the throat). • Insertion of a medication into a body cavity (e.g., placing a suppository in the rectum or vagina or inserting medicated packing into the vagina). • Instillation of fluid into a body cavity (e.g., eardrops, nose drops, or bladder and rectal instillation). The fluid is retained. • Irrigation of a body cavity (e.g., flushing eye, ear, vagina, bladder, or rectum) with medicated fluid. The fluid is not retained. • Spraying a medication into a body cavity (e.g., instillation into nose and throat).

What are emergency interventions for a patient with DKA?

• Ensure patent airway. • Administer O2 via nasal cannula or non-rebreather mask. • Establish IV access with large-bore catheter. • Begin fluid resuscitation with 0.9% NaCl solution 1 L/hr until BP stabilized and urine output 30-60 mL/hr. • Begin continuous regular insulin drip 0.1 U/kg/hr. • Identify history of diabetes, time of last food, and time and amount of last insulin injection.

What should you communicate with someone who is visually impaired?

• Ensure that patient has access to glasses—corrective lenses and/or magnifying lenses. • Communicate verbally before touching the patient. • Orient the patient to sounds in the environment. • Ensure that lighting is adequate for patient to see speaker. • Identify yourself when entering the room and notify patient when leaving the room. • Modify written handouts to accommodate degree of visual impairment. • Offer audiotapes for instructional information

What should you communicate with someone who is hearing impaired?

• Ensure that patient has access to working hearing aids and glasses. • Reduce environmental noise and distractions. • Speak at a normal volume and avoid shouting. • Rephrase instead of repeat if misunderstood. • Punctuate speech with facial expression and gestures. • Provide a sign language interpreter if needed.

What are safety guidelines for applying heat and cold therapy?

• Explain the sensations that patient will feel during the procedure. • Instruct patient and/or family caregiver to report changes in sensation or discomfort immediately. • Provide a timer, clock, or watch so that patient can help you time the application. • Be sure nurse call system is in an accessible location within patient's reach. • Refer to institution policy and procedure manual for safe temperatures and duration of therapy. • Do not allow patient to adjust temperature settings. • Do not allow patient to move an application or place his or her hands on the wound site. • Do not place patient in a position that prevents movement away from the temperature source. • Do not leave patient who is unable to sense temperature changes or move from the temperature source unattended.

What are common nursing diagnoses regarding urinary elimination?

• Functional Urinary Incontinence • Stress Urinary Incontinence • Urge Urinary Incontinence • Risk for Impaired Skin Integrity • Risk for Infection • Toileting Self-Care Deficit • Impaired Urinary Elimination • Urinary Retention

How is hyperglycemia treated?

• Get medical care • Continue diabetes medication as prescribed • Check blood glucose frequently and check urine for ketones; record results • Drink fluids at least on an hourly basis • Contact HCP regarding ketonuria

What physical sensations are symptoms of normal grief?

• Hollowness in the stomach • Tightness in the chest • Tightness in the throat • Oversensitivity to noise • Sense of depersonalization ("Nothing seems real.") • Feeling short of breath • Muscle weakness • Lack of energy • Dry mouth

What are the 7 Joint Commission 2018 Hospital National Patient Safety Goals

• Identify patients correctly. • Improve staff communication. • Use medicines safely. • Use alarms safely. • Prevent infection. • Identify patient safety risks. • Prevent mistakes in surgery.

What are guidelines you should follow when consulting with another member of the health care team?

• Identify the general problem area. • Choose an appropriate nurse, social worker, dietitian, or other professional to help you identify the problem. • Provide the consultant with relevant information and resources about the problem area. • Do not prejudice or influence consultants. C • Be available to discuss the consultant's findings and recommendations. • Include the consultant's recommendations in the care plan.

What are patient recommendations for prevention and early detection of diabetes mellitus?

• Increase level of exercise because physical activity reduces the risk of type 2 diabetes. • Maintain a healthy weight because obesity increases the risk of type 2 diabetes. • If overweight, lose weight and participate in a regular exercise program to reduce the risk of diabetes. • Choose foods that are low in fat content, total calories, and processed foods and high in whole grains, fruits, and vegetables. • If overweight and over age 45, get screened for diabetes.

What effect do benzodiazepines have on sleep?

• Increase sleep time • Increase daytime sleepiness

What problems can develop in a patient who remains in place in Fowler's or semi-Fowler's position for more than 2 hours?

• Increased cervical flexion because the pillow at the head is too thick and head thrusts forward • Extension of the knees, allowing a patient to slide to the foot of the bed causing shear against the skin. • Pressure on the posterior aspect of the knees, decreasing circulation to the feet • External rotation of the hips • Arms hanging unsupported at a patient's sides • Unsupported feet or pressure on the heels • Unprotected pressure points at the sacrum and heels • Increased shearing force on the back and heels when you raise the head of the bed greater than 60 degrees

What are common nursing diagnoses related to immobile patients?

• Ineffective Airway Clearance • Risk for Constipation • Risk for Disuse Syndrome • Risk for Falls • Impaired Bed Mobility • Impaired Physical Mobility • Impaired Sitting • Risk for Impaired Skin Integrity

What are common nursing diagnoses related to pain?

• Ineffective Coping • Fatigue • Impaired Physical Mobility • Dressing Self-Care Deficit • Anxiety • Social Isolation • Risk for Delayed Surgical Recovery

What are common nursing diagnoses associated with diabetes?

• Ineffective health management related to deficient knowledge of diabetes management and lack of understanding of diabetes management plan • Risk for unstable blood glucose levels related to infrequent blood glucose monitoring and lack of following diabetes management plan • Risk for injury related to decreased tactile sensation, episodes of hypoglycemia • Risk for peripheral neurovascular dysfunction related to vascular effects of diabetes

Which materials are considered infectious or medical waste?

• Infectious waste such as cultures of infectious organisms or waste from highly infectious patients • Pathological waste such as discarded human tissue, organs, and body parts • Blood and blood products • Sharps, including discarded needles, syringes, scalpels, and blood vials • Chemicals used for laboratory preparation and disinfectants • Genotoxic waste from cytotoxic drugs used in cancer treatment • Radioactive diagnostic material

What effect do hypnotic medications have on sleep?

• Interfere with reaching deeper sleep stages • Provide only temporary (1 week) increase in quantity of sleep • Sometimes cause "hangover" feeling during day • In some cases worsen sleep apnea in older adults

When selecting an IM site, what should be considered?

• Is the area free of infection or necrosis? • Are there local areas of bruising or abrasions? • What are the locations of underlying bones, nerves, and major blood vessels? • What volume of medication is to be administered? • Can you position a patient anatomically and comfortably so as to access the site?

What are the advantages of volume-controlled infusions?

• It reduces the risk of rapid-dose infusion by IV push. Medications are diluted and infused over longer time intervals (e.g., 30 to 60 minutes). • It allows for administration of medications (such as antibiotics) that are stable for a limited time in solution. • It allows for control of IV fluid intake.

How can you control entry of pathogens through wounds?

• Keep draining wounds covered to contain drainage. • Clean outward from wound site using clean swab for each application

What are fire intervention guidelines for healthcare agencies?

• Keep phone number for reporting fires visible on the telephone at all times. • Know fire drill and evaluation plan of an agency. • Know location of all fire alarms, exits, extinguishers, and oxygen shut-off.

What are potential problems for a patient who is kept in Sims' position for too long?

• Lateral flexion of the neck • Internal rotation, adduction, or lack of support to the shoulders and hips • Lack of support for the feet • Lack of protection for pressure points at the ilium, humerus, clavicle, knees, and ankle

What are potential problems for a patient who is kept in 30 degree lateral position for too long?

• Lateral flexion of the neck • Spinal curves out of normal alignment • Shoulder and hip joints internally rotated, adducted, or unsupported • Lack of support for the feet • Lack of protection for pressure points at the ear, shoulder, anterior iliac spine, trochanter, and ankles • Excessive lateral flexion of the spine if the patient has large hips and a pillow is not placed superior to the hips at the wais

Which instructions should be given to patients with diabetes regarding exercise?

• Learn how exercise and food affect your blood glucose levels. • Remember that exercise will usually lower your blood glucose level. • Begin an exercise program after approval from HCP.

What are signs of *impending* death?

• Minimal intake of food or water • Increased sleeping and decreased consciousness • Disorientation and restlessness • Decreased urinary output and/or incontinence • Cool hands and feet • Noisy breathing • Irregular breathing patterns with long pauses

What can a nurse do to foster spiritual caring?

• Mobilizing hope for the patient and the nurse • Finding an understanding of illness, symptoms, or emotions that is acceptable to the patient • Assisting the patient in using social, emotional, or spiritual resources • Recognizing that caring relationships connect us human to human

Which instructions should be given to patients with diabetes regarding blood glucose?

• Monitor your blood glucose at home and record results in a log. • Take your insulin, OA, and/or noninsulin injectable agent as prescribed. • Take insulin consistently, especially when you are sick. • Keep an adequate supply of insulin on hand at all times. • Obtain A1C blood test every 3-6 mo as an indicator of your long-term blood glucose levels. • Be aware of symptoms of hypoglycemia and hyperglycemia. • Carry some form of rapid-acting glucose at all times so that you can treat hypoglycemia quickly. • Instruct family members how and when to use glucagon if patient becomes unresponsive because of hypoglycemia.

What are potential problems for a patient who is kept in prone position for too long?

• Neck hyperextension • Hyperextension of the lumbar spine • Plantar flexion of the ankles • Unprotected pressure points at the chin, elbows, hips, knees, and toes

Which instructions should be given to patients with diabetes regarding general things?

• Obtain an annual eye examination by an ophthalmologist. • Obtain annual urine monitoring for protein. • Examine your feet at home. • Wear comfortable, well-fitting shoes to help prevent foot injury. Break in new shoes gradually. • Always carry identification that says you have diabetes. • Have other medical problems treated, especially high BP and high cholesterol. • Have a yearly influenza vaccination. • Quit or never start smoking cigarettes or using nicotine products. • Avoid applying heat or cold directly to your feet. • Avoid going barefoot. • Keep skin moisturized by applying cream to surfaces of feet, but not between toes.

What are guidelines for TOs and VOs?

• Only authorized staff (who are identified in a written policy by each agency) receive and record telephone and verbal orders. • Clearly identify the patient's name, room number, and diagnosis. • Use clarification questions to avoid misunderstandings. • Write TO (telephone order) or VO (verbal order), date and time received, name of patient, the complete order transcribed exactly as stated, and the name of physician or health care provider and nurse. • Read back all telephone and verbal orders to physician or health care provider • Follow agency policies; some institutions require telephone and verbal orders to be reviewed and signed by two nurses. • The health care provider cosigns each telephone and verbal order within the time frame required by each agency (usually 24 hours)

What are restraint alternatives?

• Orient patients and family members to the environment; explain all procedures and treatments. • Provide companionship and supervision; • Offer diversionary activities • Assign confused or disoriented patients to rooms near nurses' stations and observe them frequently. • Use calm, simple statements and physical cues as needed. • Use de-escalation, time-out, and other verbal intervention techniques • Provide appropriate visual and auditory stimuli • Remove cues that promote leaving the room • Promote relaxation techniques and normal sleep patterns. • Institute exercise and ambulation schedules • Attend frequently to needs for toileting, food and liquid, and pain management. • Camouflage IV lines • Evaluate all medications and ensure timely and effective pain management. • Eliminate bothersome treatments as soon as possible. • Use protective devices such as hip pads, helmet, skid-proof slippers, and nonskid strips near bed.

What are the 12 domains of culture you should use to guide you in doing a cultural assessment?

• Overview (country of origin and current residence) • Communication • Family roles and organization • Workforce issues • Biocultural ecology (skin color, heredity, genetics, drug metabolism) • High-risk behaviors (e.g. tobacco) • Nutrition • Pregnancy and childbearing practices • Death rituals • Spirituality—(e.g. religious practices) • Health care practices • Health care providers (e.g. perceptions of providers)

What does PASS mean with respect to using a fire extinguisher?

• P - Pull the pin. Hold the extinguisher with the nozzle pointing away from you and release the locking mechanism. • A - Aim low. Point the extinguisher at the base of the fire. • S - Squeeze the lever slowly and evenly. • S - Sweep the nozzle from side to side.

What are the core beliefs of hospice programs?

• Patient and family as the unit of care • Coordinated home care with access to inpatient and nursing home beds when needed • Symptom management • Provision of an interdisciplinary care team • Medical and nursing services available at all times • Bereavement follow-up after a patient's death • Use of trained volunteers for visitation and respite support

What are the advantages of epidural anesthesia?

• Production of excellent analgesia • Occurrence of minimal sedation • Long-lasting pain relief with fewer opioid doses • Facilitation of early ambulation • Avoidance of repeated injections • No significant effect on sensation • Little effect on blood pressure or heart rate • Fewer pulmonary complications

What are principles that should be taught to patients about food safety?

• Proper refrigeration, storage, and preparation of food decrease risk of foodborne illnesses. Store perishable foods in refrigerators to maintain freshness. • Thaw frozen foods in the refrigerator. • Wash hands for at least 15 seconds before preparing food. • Rinse fruits and vegetables thoroughly. • Avoid cross-contamination of one food with another during preparation, especially with poultry. • Use separate cutting boards for vegetables, meat, and poultry. • Cook foods adequately to kill any residual organisms. • Refrigerate foods at 4° C (40° F) within 2 hours of cooking; label leftovers with the date.

What equipment is needed for a complete neurological assessment?

• Reading material • Vials of aromatic substances (e.g., orange, peppermint extract, coffee) • Opposite tip of cotton swab broken in half or paper clip for testing ability to distinguish sharp from dull • Snellen eye chart • Penlight • Vials containing sugar, salt, and lemon with applicators • Tongue blade • Two test tubes containing hot and cold water for temperature sensation testing • Cotton balls or cotton-tipped applicators • Tuning fork • Reflex hammer • Familiar objects such as coins, keys, or paperclips

What should you communicate with someone who is cognitively impaired?

• Reduce environmental distractions while conversing. • Prioritize communication over other tasks. • Get patient's attention before speaking. • Use simple sentences and avoid long explanations. • Avoid shifting from subject to subject. • Ask one question at a time. • Allow time for patient to respond. • Include family and friends in conversations when appropriate.

What are nursing interventions during the termination phase?

• Remind the patient that termination is near. • Evaluate goal achievement with the patient. • Reminisce about the relationship with the patient. • Separate from the patient by relinquishing responsibility for his or her care. • Achieve a smooth transition for the patient to other caregivers as needed.

What are nursing interventions during the preinteraction phase?

• Review available data including medical and nursing histories. • Talk to other caregivers who may have information about the patient. • Anticipate health concerns or issues that may arise. • Identify a location and setting that fosters comfortable, private interaction. • Plan enough time for initial interaction.

What are common nursing diagnoses related to wounds?

• Risk for Infection • Impaired Bed Mobility • Impaired Physical Mobility • Imbalanced Nutrition: Less Than Body Requirements • Acute Pain • Impaired Skin Integrity • Risk for Impaired Skin Integrity • Ineffective Peripheral Tissue Perfusion

What should you do if you suspect a transfusion receaction?

• STOP the transfusion immediately, even when you just suspect a reaction. • Remove blood component and tubing containing blood product. Replace them with new primed tubing with a container of 0.9% sodium chloride (normal saline). Connect tubing to hub of IV catheter. • Caution: Do not turn off the blood and simply turn on the 0.9% (normal saline) that is connected to the Y-tubing infusion set. This would cause blood remaining in the Y-tubing to infuse into the patient. Even a small amount of mismatched blood can cause a major reaction. • Maintain patent IV line using 0.9% normal saline. • Remain with the patient, observing signs and symptoms and monitoring vital signs every 5 minutes. • Immediately notify the health care provider or emergency response team. • Notify blood bank. • Prepare to perform CPR and administer emergency drugs such as antihistamines, vasopressors, fluids, and corticosteroids per health care provider's order or protocol. • Save the blood container, tubing, attached labels, and transfusion record for return to the blood bank. • Obtain blood and first voided urine specimens per health care provider's order or protocol. Note: If patient is unable to void, insert a catheter to obtain urine specimen. • Document the transfusion reaction, description, treatment, and outcome.

What are nursing interventions during the orientation phase?

• Set the tone for the relationship by adopting a warm, empathetic, caring manner. • Recognize that the initial relationship may be casual, uncertain, and tentative. • Expect the patient to test your competence and commitment. • Closely observe and expect to be closely observed by the patient. • Begin to make inferences and form judgments about the patient's messages and behavior. • Assess the patient's health status. • Prioritize patient problems and identify patient goals. • Clarify the patient's role and your role. • Form contracts with the patient to specify roles. • Let the patient know when the relationship will end.

What should you communicate with someone who does not speak English?

• Speak to patient in a normal tone of voice (shouting may be interpreted as anger). • Establish a method for patient to signal desire to communicate (nurse call system or bell). • Avoid using family members, especially children, as interpreters. • Provide professional interpreter/translator as needed: • Use a person familiar with patient's culture and with health care if possible. • Allow plenty of time for interpreter to transmit messages. • Communicate directly to patient and family rather than to interpreter. • Ask one question at a time. • Avoid making comments to interpreter about the patient or family (they may understand some English). • Develop a communication board, pictures, or cards using words translated into English for patient to make basic requests (e.g., pain medication, water, elimination). • Have a dictionary (e.g., English/Spanish) available if patient can read. • Provide written materials in English and in patient's primary language.

What are risk factors for DVT?

• Surgery • Trauma • Long periods of not moving (bed rest, sitting, long car or airplane trips) • Cancer and cancer therapy • Past history of deep vein thrombosis • Increasing age • Pregnancy and postpartum period 4-6 weeks after giving birth • Use of birth control methods that contain estrogen or hormone therapy for menopause symptoms • Certain illnesses including heart failure, inflammatory bowel disease, and some kidney disorders • Hypertension • Hyperlipidemia • Nephrotic syndrome • Autoimmune disease including systemic lupus erythematosus • Obesity • Smoking • Varicose veins • Having a tube in a main vein • Having thrombophilia

What are Worden's 4 Tasks of Mourning?

• Task I: Accept the reality of the loss. • Task II: Work through the pain of grief. • Task III: Adjust to the environment in which the deceased is missing. • Task IV: Emotionally relocate the deceased and move on with life.

How can you control entry of pathogens through the urinary tract?

• Teach women to clean perineum and rectum by wiping from area of least contamination (urinary meatus) toward area of most contamination (rectum). • Do not allow urine in drainage bags and tubes to flow back into bladder. Never raise drainage system above level of bladder. • Keep points of connection between catheter or drain and tubing closed.

Before you administer a medication, you must ensure that the MAR clearly shows what information?

• The patient's full name. • The full name of the ordered medication (without abbreviations of medication names). • The time the medication is to be administered. • The dosage, route, and frequency of administration.

What are the patient's rights with respect to medication administration?

• To be informed of the name, purpose, action, and potential undesired effects of a medication • To refuse a medication regardless of the consequences • To have qualified nurses or physicians assess a medication history including allergies and use of herbals • To be properly advised of the experimental nature of medication therapy and give written consent for its use • To receive labeled medications safely without discomfort in accordance with the six rights of medication administration • To receive appropriate supportive therapy in relation to medication therapy • To not receive unnecessary medications • To be informed if medications are a part of a research study

How can you help prevent catheter-associated UTIs?

• Use aseptic technique with sterile equipment when inserting urinary catheters into patients in an acute care setting. • Secure indwelling catheters to prevent movement and pulling on the catheter. • Maintain a closed urinary drainage system. • Maintain an unobstructed flow of urine through the catheter, drainage tubing, and drainage bag. • Keep the urinary drainage bag below the level of the bladder at all times. • Avoid dependent loops in urinary drainage tubing. • Prevent the urinary drainage bag from touching or dragging on the floor. • When emptying the urinary drainage bag, use a separate measuring receptacle for each patient. Do not let the drainage spigot touch the receptacle. • Before transfers or activity, drain all urine from tubing into bag and empty drainage bag. • Empty the drainage bag when half full. • Perform routine perineal hygiene daily and after soiling. • Obtain urine samples using the sampling port. Cleanse the port with disinfectant. Use a sterile syringe/cannula. • Ensure quality improvement programs alert providers when a patient has a catheter and include regular educational programming about catheter care.

What are common expected outcomes for patients with diabetes?

• Verbalize key elements of the therapeutic regimen, including knowledge of disease and treatment plan • Describe self-care measures that may prevent or slow progression of chronic complications • Maintain a balance of nutrition, activity, and insulin availability that results in stable, safe, and healthy blood glucose levels • Experience no injury resulting from decreased sensation in feet • Implement measures to increase peripheral circulation

What are characteristics of REM sleep?

• Vivid, full-color dreaming occurs. • Stage usually begins about 90 minutes after sleep has begun. • Stage is typified by autonomic response of rapidly moving eyes, fluctuating heart and respiratory rates, and increased or fluctuating blood pressure. • Loss of skeletal muscle tone occurs. • Gastric secretions increase. • It is very difficult to arouse sleeper. • Duration of REM sleep increases with each cycle and averages 20 minutes.

What are questions you can ask yourself to develop critical thinking skills during clincal?

• What did I learn from the experience? • Did I respond appropriately in this situation? If not, how should I have responded? • Were there consequences to my actions? What were they, and whom did they affect? • Why did I react as I did? What was I thinking at that moment? • How might I react differently in the future? • Was I working from just instinct or from evidence-based practices?

Which instructions should be given to patients with diabetes regarding food choices?

• Work with a dietitian to create an individualized meal plan. • Make healthy food choices most of the time and eat regular meals at regular times. • Choose foods low in saturated and trans fat. Know your cholesterol level. • Limit the amount of alcohol you drink. • Be aware that excessive amounts of alcohol may lead to unpredictable low blood glucose reactions. • Avoid fad diets. • Limit regular soda and fruit juice.