300 Exam 1
Temperature can be affected by
-Age -Exercise -Circadian rhythm -stress -environment -fever
Basic care for cleints
-Anticipate a clients fall risks when choosing fall prevention strategies -Involve clients and families in the selection of fall prevention strategies -Always try restraint alternatives before using a restraint -Implement fall prevention protocols an provide client and family education -make sure they are positioned okay
When does one collect vital signs?
-Anytime a patient is admitted during healthcare visit -During an inpatient stay and for ongoing care -During a physical assessment -For any changes in the patients condtions -Pre--, Intra-, and postoperative -Before and after invasive procedures -Prior to and after administration of meds that impact cardiac, resp, or thermal regulation systems -Prior to and after certain interventions, such as suctioning -Before transfer to another unit or discharge
What are the health people 2020 goals?
-Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death -Achieve health equity, eliminate disparities and improve the health of all groups -Create social and physical environments that promote good health for all -Promote quality of life, healthy development and healthy behaviors across all life stages
Health Promotion Model
-Define health as a means of change -Individual characteristics and experiences, behavior specific knowledge and effect behavior outcomes
Holistic Health Model
-Dynamic Interaction of one social life, culture, spirit, and physical aspects -The belief that relationships exist among factors that influence health; a connection or interaction between the body and the environment promote health and healing -Addresses more emotional health EX: the patient wants emotional issues included in her plan of care.
Respirations and O2 can be affected by
-Exercise -Fever -Acute pain -Anxiety -Smoking -Body postition -Meds -Neurologic injury -Hemoglobin under 90 O2= emergency
Which primary muscle is used for the abduction of the wrist joint?
-Flexor carpi radialis -Extensor carpi radialis brevis -Extensor carpi radialis longus
Which leading health indicator would the nurse include in programs for health promotion and illness prevention according to Healthy People 2030? SELECT ALL THAT APPLY -Food insecurity -Homicides -Suicides -Childhood obesity -Fertility
-Food insecurity -Homicides -Suicides -Childhood obesity
Factors of Implementation
-Health promotion -Bathing and skin care -oral hygiene -care of the eyes, ears and nose -bedmaking -room environment -Medical asepsis -Acute and reservoir care -Positioning techniques -Fall prevention -Fires, Electrical hazards, Seizures, Disasters -Restorative and continuing care: walkers, canes, crutches
Health care-associated infections (HAIs) occur as the result of
-Invasive procedures -Antibiotic administration -Multidrug resistant organisms (MDROs) -Breaks in infection preventiona nd control activities
what is true about spine deformity
-Kyphsocis is the increased convexity in curvature of the thoracic spine -Lordosis is the exaggeration of the anterior convex curve of the lumbar spine -Scoliosis is the lateral S or C shape spinal column with vertebral rotation
Planning(outcome)
-Outcome (Patient participation is key) -Setting priorities (select priorities based on risk and patient characteristics) -Teamwork and collaboration (communication is essential)
What is primary prevention?
-Prevention of problems before they occur -Immunization- vaccines and educational programs for healthy eating
Factors of Diagnosis
-Risk of injury -Risk for infection -Impaired nutritional status -Impaired oral mucous membranes -Social isolation -Impaired tissue Integrity -Impaired mobility -Impaired mobility in bed -Acute or chronic pain
What is true about tendons
-They are fibrous brand connecting muscle to bone -are strong, flexible, and inelastic
Factors of assessment
-Through the patients' eyes -Risk factors -Clinical appearance -Medical therapy -Travel history -Mobility: sitting, ROM, gait, standing -Body Alignment -Cultural and socioeconomic factors -Health care environment -Patients home environment -Risk for falls -Skin -Hygiene
Standard precautions for infection control when providing client care
-Wear PPE -wash your hands before and after touching Pt -Clean all surfaces before letting anything touch it -Clean all medical supplied accordingly
Delegation
-after determining the patient is medically stable -verify that the UAP is competent and uses the proper technique for measuring vital signs -Reassess any unexpected(abnormal) values measured by the UAP -Report unexpected values to health care provider
Pathologic influence on mobility
-damage to the cerebellum causes problems with balance -Right sided cerebral hemorrhage cause left sided hemiplegia -complete transection of the spinal cord causes bilateral loss of voluntary motor control below the level of the trauma.
Implementation of Immobility
-deep breathing every 1-2 hrs. -Never event- a condition acquired in the hospital that Medicare or other third parties won't cover. this includes deep vein thrombosis. -Passive ROM is to be used when a patient is not able/allowed to use a joint and ROM should never go past the point of resistance
Physical activities has a positive influence in most activities such as:
-elevate modd -helps quite smoking -boost energy levels manage stress
which food item is a good food source of calcium?
-green, ,leafy vegetables -yogurt -cheese
why it important for proper positioning and movement for the client?
-helps prevent ulcers forming -ROM is important -Mobility
Diagnoses for immoblity
-impaired airway clearance -impaired sleep -risk of impaired skin integrity -risk for constipation -social isolation
Infection types
-latrogenic(from procedure) -Exogenous (outside environment) -Endogenous (normal flora over grow probs due to broad spectrum antibiotics)
side-lying (lateral) position
-laying on side -recommend for Pts with pressure injury risk
prone position
-lying on stomach -prevents cervical extension, flexion, supports lumbar spins -is used for acute respiratory trouble
developmental changes concerning immobility
-prolonged immobilization in older adults delays gross motor skills -Immobilization in older adults is only caused by degenerative disease
What function is true of the skeletal system?
-provide support -regulate calcium -protect vital organs
Inflammation
-signs of local inflammation/infection are the same -Vascular and cellular response (leukocytes engulf foreign bacteria) Exudates: serous--> Sanguineous (blood containing) --> Purulent (which blood cells, bacteria) -Tissue Repair(damage cells replaced with healthy ones)
CNS damage that can cause immobility
-stroke -spinal cord damage -Parkinson's -huntingtons
three planes of the body and their movement
-the frontal plane: movements are abduction of arms; eversion and inversion -the transverse plane: movements are internal and external rotation of hips; pronation and supination -the sagittal plane: movements are flexion and extension
situational awareness in ensuring a safe client environment
-wash your hands -be aware that infectious disease can exist on any fomite reservoir -infection can be spread via airborne droplets so cover nose when sneezing -RACE (rescue, alarm, confine, extinguish/evacuate) -PASS(pull pin, aim at base, squeeze handle, sweeping motion)
Pulse scale
1 weak/threading 2 normal 3 strong 4 bounding
Pulse is affected by
1. Change in BP 2. Inc. Temp 3. Poor blood O2 4. Exercise 5. Prolonged application of heat 6. Acute or Chronic Pain 7. Emotions 8. Meds -Tachycardia and Bradycardia(slows down HR) -asystole=no HR
The infectious Process
1. Incubation period (transmission to first S/S) 2. Prodromal stage (onset symptoms to specific symptoms) 3. Illness stage (specific symptoms) 4. Convalescence (acute symptoms disappear, PPE is used)
Transtheoretical model of change (6months)
1. Precontemplation 2. Contemplation 3. Planning 4. Action 5. Maintenance
Assessment tree
1. Safety 2. ABCs (airway, breathing, circulation) 3.Maslow bottom tier 4. Maslow Top tier
Maslow's Hierarchy of Needs
1. Self-actualization 2. Esteem 3. Social 4. Safety - Physical safety -Psychological safety 5. Physiological -O2 -Fluids -Nutrition -Body Temp -Elimination (bowels, GI, urinary) -Shelter -Sex
Describe cartilage
nonvascular, supporting connective tissue located chiefly in joints
Adolescents safety risks
peers have a stronger influence, smoking, alcohol, risk taking behaviors, drugs, vehicle accidents, drowning, sexual diseases, suicide
what causes a patient to be prone to infection?
periodontal membrane -which lies below the gum margins, surround the teeth and holds them in place -weaken with aging
The nursing team leader intervenes when a staff nurse delegates which task to assisstive personnel (AP)?
preparation of a sterile field
describe the importance of quality and safety in client care
reduces likelihood of spreading HAI's like UTI and pnuemonia
Which patient behavior indicated that a patient who smokes is in the preparation stage of the Transtheoretical Model of Change?
Think the advantage of quitting smoking outweigh the disadvantages.
While assessing the axillary temperature for which reason would the nurse raise the patients arm away from the torso?
To inspect for the presence of lesions
Health promotion
behavior of an individual motivated by a personal desire to increase well-being and health potential
acceptable Blood pressure ranges for a healthy adult
can be less than 120/80
Which term is used to describe an infection that can be transmitted directly from one person to another?
communicable disease
what factor leads to skin maceration
constant moisturizing
What is teritary prevention?
correction and prevention of deterioration of a disease state -teaching insulin administration in the home- attending cardiac rehabilitation sessions
Which factory may make it difficult to identify an acceptable site for the placement of the pulse oximeter probe?
decreased cardiac output.
which condition is caused by tooth decay
dental caries
Illness
deviation from health
A purple wrist band stand for
do not resuscitate
Older adults safety risks
effects of medication, acute or chronic disease, falling
The nurse inserts the thermometer probe into the anus of the patient up to 3 cm in the direction of the umbilicus which rationale would direct this nursing intervention?
ensuring exposure to blood vessels
in which part of the skin does the normal flora reside?
epidermis
What is secondary prevention?
focuses on individual who are experiencing health problems or illness and who are at risk of developing complications or worsening conditions. -early detection and intervention -screening for sexual transmitted disease
which assistive device would the nurse use to reduce surface area and friction when patients are unable to assist with moving up in bed?
full body sling
inflamed gums
gingivitis
which condition is observed in a patient who has gingivitis?
gum inflammation
bad breath
halitosis
which stage of behavioral change is a patient exhibiting when they join a fitness club and attend aerobics class 3 nights a week?
Action
Health Belief Model
Addresses the relationship between a person's beliefs and behaviors. -individual factors -modifying factors -likelihood of action
The incidence of suicidal tendancy is highest in which age group?
Adolescents
Blood Pressure affected by
Age Stress Ethnicity (higher in minorities-high with African Americans and Hispanics) gender meds activity/weight smoking
Mode of transmission
Aire droplet touch vehicles vectors
According to the AHA, a red wristband is given for which category?
Allergies
Body will inflame area and use a mixture of specific and nonspecific defense such as:
Antibodies Lymphocytes Membranes(skin) Normal Flora (large intestine) Sebum Saliva Tearing Gastric juices Normal flora causing low pH in vaginal area Cilia in respiratory tract
The nurse would suspect which cause of an older patients health care-associated exogenous infection?
Aspergillus
Nursing Process
Assessment Diagnosis Planning Implementation Evaluation
Which laboratory parameter typically remains normal during infection?
Basophil count
which organism causes antibiotic induced diarrhea?
Clostridium difficile
which microorganism causes gas gangrene?
Clostridium perfringens
According to the World Health Organization (WHO) which statement is the definition of health?
Complete physical, mental, and social well being
In which stage of the Transtheoretical Model of change would a patient have mixed feelings about quitting smoking?
Contemplation
Genetic Determinants (Single gene disorders)
Cystic Fibrosis- Phenylketonuria- Sickle cell- Anemia- Hemophilia A- Familial Hypercholesterolemia- Huntington Disease
The National Quality Forum is collecting information from a health care agency about serious reportable events that have occurred. Which event would be listed as a care management event?
Death caused by medication error
Modifying Factors
Demographic- age, race, ethnicity Psychosocial- social class, peer pressure
A condition that impairs the healing function of skin
Diabetes mellitus
Which finding is a serious reportable even included in the National Quality Forum (NQF) list?
Disability associated with electrical shock at a health care agency.
a statement that describes a patient who is in the pre-contemplation stage to quit smoking
Does not intent to quit smoking this year.
Genetic Determinants (Chromosomal Disorders)
Down syndrome- Klinefelter syndrome- Turner syndrome
which personal strategy would the nurse implement to combat compassion fatigue and promote resiliency? -Work through the stress by scheduling extra shifts -Engage in regular work activities -Establish a work-family balance -Engage in sporadic relaxation activities
Establish a work family balance
Frequency of vital signs
Every 4-8 hrs for stable patients Every 15-60 minutes sfor postprocedure or postoperative patients Every 5 minutes or continuously for critical or unstable patients
what is a common debilitating contracture?
Footdrop
which term describes people reacting in different ways because of attitudes about a sickness
illness behavior
When providing education about the course of infection, which stage does the nurse describe at the interval when a patient manifests signs and symptoms specific to a type of infection?
illness stage
Chain of infection
Infectious agent reservoir portal of exit means of transmission portal of entry and susceptible host.
While caring for a patient with osteoporosis, the nurse finds that the patient has increased convexity in the curvature of the thoracic spine, which postural abnormality is the patient likely to have?
Kyphosis
which postural abnormality indicates and exaggeration of the anterior convex curve of the lumbar spine?
Lordosis - this is also a temporary condition caused by pregnancy
According to the Transtheoretical model of change during which stage of change would the nurse help a patient integrate lifestyle changes?
Maintenance
Which organism would the nurse include when listing portal of exit through the reproductive tract?
Neisseria gonorrhoeae
the nurse has difficulty hearing sounds of a patient who is 80 years old. which factor explains the muffled heart sounds?
increased air space in the lungs
passive strategies of health promotion
individuals gain from the activities of others without acting themselves. -fortification of milk with vitamin D, fluoridation of municipal water, production of cereal with vitamin A
According to the National Quality Forum, which event is included under patient protection events?
infant discharge to an unauthorized person
Which safety precaution would be followed by a patient infected with Hep A?
Practicing hand hygiene
In which stage of the Transtheoretical Model of change would a patient display defensive behavior when the nurse provides information about limiting alcohol use?
Precontemplation
After measuring the temperature of the temporal artery, the nurse cleans the sensor with the alcohol swab. which rational would direct the nurses action?
Preventing transmission of microorganisms
Which concept describes the nurse providing information to a group of healthy adolescents about contraception and the risk of human immunodeficiency virus (HIV) infection?
Primary prevention
which stage of the infection process can be described as the onset of nonspecific a disease because microorganisms are growing and multiplying?
Prodromal stage
Wellness
is the optimal state of health -Physical-Mental-Spiritual-Emotional-Social-Environmental -the active pursuit of activities, choices and lifestyles that lead to a state of holistic health
Contracture
is the shortening of the connective tissue and is an abnormal and possibly permanent condition characterized by decrease range of joint motion
which microorganisms causes wound infection and pneumonia?
S. aureus
Which level of need according to Maslow is being addressed when the nurse discusses with the elderly couple about removing the throw rugs and low footstool and improving the lighting in the home?
Safety and security
which microorganism is associated with an exogenous infections?
Salmonella
Health People determinants
Social Individual behaviors Biology Genetics Policymaking and health
sims
lateral with one knee and thigh up
Adult safety risks
lifestyle habits, alcohol, smoking, high level stress
supine position
lying on the back -for good alignment -firm mattress supports spine -shoulders supported, elbows highly flexed
Which patient response would the nurse expect when the patient is in the action stage of the transtheoretical model of change?
may find previous habits become barrier to change
Physiologically immobility can lead to
respiratory changes(Pneumonia) cardiovascular changes(Orthostatic hypotension, increases cardiac workload, Thrombus formation= VTE risks) Musculoskeletal changes(muscle=constipation, skeletal=joint contracture) Urinary elimination changes(UTI, renal calculi) Integumentary changes(Ischemia -no sun=no Vit D) Psychological changes(emotional, sensory, emotional) GI changes(negative nitrogen)
A yellow wristband stand for
risk for falls
in the pyramid of Maslow's hierarchy of needs, which need of the patient is placed at the highest level?
self-actualization
Fowler position
semi-sitting positions -knees slightly elevated -supports flexion of knees, hips plus curvature of spine- normal degrees is 45-90 degrees -semi fowler position is used for cleaning teeth also in these positions its 30-45 degrees
Quaternary
serves to protect patients from medical interventions that are likely to cause more harm than good. -identify risk of meds, diagnose functional disorders, continue to assess
What should the patients position be when measuring rectal temperature with an electronic thermometer?
side lying position with the upper leg flexed to promote comfort
What positions is recommended for measuring BP who have orthostatic hypertension?
sitting and supine
Portal of entry
skin
Portal of exit
skin blood mucous membranes GI tract Respiratory tract
Which circumstance can cause contracture of a joint?
the muscle fibers become shortened because of disuse
For which condition would the nurse wear gloves and a gown when in the patients room?
the patient's infection can be transmitted to the nurse via blood or body fluids
Proper hygiene care requires an understanding of the anatomy and physiology:
the skin, the feet, hands and nails, the oral cavity, the hair, the eyes, the ears, and nose
when the forearm is fixed in a position of full supination the hand
the use of the hand is limited
Which statement made by the patient would indicate effective teaching regarding the transmission of HIV?
the virus can be spread to another person by contact with body fluids
The nurse locates different anatomical landmarks to identify the point of the apical impulse. Which rational would direct this nursing action?
to hear heart sounds clearly
developmental changes in adults
when healthy has the necessary musculoskeletal development and coordination to carry out their activities of daily living when periods of prolonged immobility occur all physiological system are at risk
Describe ligaments
white, shiny, flexible bands of fibrous tissue
Which activity represents secondary prevention?
a home health care nurse visits a patient home to change a wound dressing
At what age in years does the respiratory system begin to decline in healthy people
25 years of age
the nurse expects which neutrophil count in an acute suppurative infection?
75%
Older adult temperature range
95-97 Fahrenheit 35-36.1 Celsius
A patient with oxygen saturation of less then 90% should be in what positions?
A high Fowler position
active strategies of health promotion
a person is actively involved in the measure taken to improve a condition and reduce the risk of disease. -health programs
Developmental changes in older adults
a progressive loss of total bone mass results from decreased physical activity hormonal changes and bone resorption the effect of bone losses weaker bones→ they walk more slowly, smaller steps
Genetic Determinants (Multifactorial Disorders)
Cancer, Coronary heart disease, Hypertension, Stroke
A patient is a long-term smoker. Which health risk factor does nurse anticipate?
Cardiovascular disease
Client centered care
Care that is respectful of and responsive to individual patient preferences, needs, and values
Which microorganisms causes gastroenteritis and urinary tract infection?
E. coli
Five social determinants outlined in the Healthy People 2020
Economic stability Education Social and community context Health and health care Neighborhood and built environment
Which patient behavior reflects the contemplation stage of change?
Has started considering a change in their behavior.
Which parameter would the nurse focus on when using the Transtheoretical Model of Changes to help treat a patient?
Health behaviors
Which condition is an example of communicable disease that can be asymptomatic?
Hepatitis C virus(HCV)
Biological determinants
Men: Autism- Kidney stones- Parkinsons disease- Pancreatitis Women: Alzheimer's disease- UTI- Multiples sclerosis- Migraines
Health
Mental Emotional Spiritual
What foot problem is common in middle aged women?
Morton's neuroma -which causes burning, numbness, and pain of the foot on weight bearing
hip ball and socket joint, which ROM would be asked to perform
Move the leg back toward the medial position
which microorganisms causes gonorrhea and pelvic inflammatory disease?
N. gonorrhoeae
Likelihood of action
Perceived benefits/barriers to preventive action
individual perceptions
Perceived susceptibility or seriousness of disease
According to the National Quality Forum, which even is considered a care managment event?
Stage III pressure injury acquired after admission to a health care agency
which condition is a serious reportable event included in the National Quality Forum (NQF) list?
Surgery performed on the wrong site
Vital ranges for adults
Temp: 95-99 F Pulse:60-100 Respirations: 12-20 SpO2: >95% BP: 90-<120(syst) 60-<80(Diast)
Vital ranges for Older Adults
Temp: 98.6-100.4 F Pulse:60-100 Respirations: 15-20 SpO2: >95% BP: 90-<120(syst) 60-<80(Diast)
When assessing the patient's respiration, for which reason would the nurse elevate the bed to 60 degrees in a sitting position
To promote ventilatory movement
what is a significant cause of bleeding in the oral cavity?
Trauma
A patient with postural hypotension is hospitalized. Which safety measure would the nurse implement during ambulation?
Use of gait belt
HIV infected is transmitted through which mode of transmission?
Vehicles
The nurse recalls that purulent exudate from a patients inflamed incision site contains which substance?
White Blood Cells
