FUN EXAM 2 Ch 15,17,6,8,21
communication process
(BEGINNING OF CH 6) An exchange of information, feelings, needs, and preferences between two people
Afebrile
(BEGINNING OF CH. 17) Without fever.
b,c
How can you ensure privacy for school-age children and adolescents during a bath in the hospital setting? (Select all that apply.) a. Stand guard just inside the patient's door to prevent anyone from entering and embarrassing the patient. b. Place a "Bath in Progress" sign on the door to prevent interruptions. c. Always knock before you enter the patient's room. d. Lock the door to the patient's room or bathroom during the bath. e. Explain that this is a hospital and people will likely come in the room during the bath.
When you wash the extremities from distal to proximal, you help return blood to the heart, or promote venous return. This improves circulation because it prevents blood from pooling in the extremities, especially the legs, where clots can easily form.
How does giving a bed bath help increase the patient's circulation?
F (Decreases level of cellular oxygen)
Hypoxia decreases the pulse rate. (T/F)
1. After administration of IV medications that could affect vital signs. 2. Change in the level of consciousness. 3. Unstable postoperative condition. 4. Uncontrolled bleeding. 5. Pale, cold, & clammy skin. 6. Suspected shock, stroke, pulmonary embolism, heart attack, or any serious condition. 7. When something doesn't feel right about the patients condition. (sixth sense)
Identify at least two (7) situations in which you should not delegate assessment of vital signs to assistive personnel.
b
If a home health patient is unable to sit down in the bathtub or stand long enough for a shower, what could you do? a. Give instructions for the home health aide to perform a bed bath on every visit. b. Place a nonrusting lawn chair in the tub or shower and use a sprayer to bathe the patient. c. Have the patient sit on a chair near the tub and then use water from the tub to give them a partial bath. d. Use disinfectant wipes to wash the patient, throwing each one away after using it to cleanse an extremity.
a
If a resident in a long-term care facility has been incontinent but is not scheduled for a bath or shower until tomorrow, what will you do? a. Provide perineal care to prevent skin breakdown and odor. b. Change incontinent briefs without washing the skin. c. Wipe the perineal area with tissue and apply powder to mask any odor. d. Change the bathing schedule and give the patient a shower or tub bath now.
T
If intracranial pressure is increased, the pulse rate will decrease and the BP will increase. (T/F)
T
If peripheral pulses can be palpated with each cardiac contraction, the pulses are said to be "perfusing." (T/F)
b
If you are assigned to bathe a patient, how should you respond? a. Delegate the bath to assistive personnel so you can focus on your nursing responsibilities. b. Perform the bath as assigned, using it as an opportunity to further assess your patient. c. Ask the patient's family if one of them could help the patient bathe because you are very busy. d. Wait until nearly the end of your shift before you ask if the patient wants a bath today.
a,c,d
When cleaning dentures, you will do which of the following? (Select all that apply.) a. Line the sink with a towel or washcloth to create a soft surface in case the dentures slip. b. Use hot water to rinse the dentures before cleaning them to remove food particles. c. Use cool water when washing the dentures to prevent damage to them. d. Store them in a denture cup with cool water and a cleaning tablet if the patient wishes. e. Clean a partial denture with metal parts by soaking it in water containing a dissolved cleaning tablet.
Tachycardia
When the pulse rate is more than 100 bpm.
non verbal communication
The communication revealed through facial expressions, posture, body position, behavior, gestures, touch, and general appearance
verbal communication
The conscious use of words, either spoken or written
a,b,e
The functions of sebum include (select all that apply) a. Protecting the skin from cracking and drying. b. Lubricating the skin. c. Lowering the body temperature. d. Evaporating to cool the body. e. Lubricating hair.
Systolic pressure
The measurement of the pressure exerted against the walls of the arteries by the blood during contraction of the heart. (Top number)
Diastolic pressure
The measurement of the pressure exerted against the walls of the arteries by the blood during relaxation of the heart. (Bottom number)
c
The nurse is assessing a pediatric patient using the Wong-Baker FACES Pain Rating Scale. The pediatric patient shows the nurse a score of 4 on the Wong-Baker FACES scale. The nurse understands this to mean that it a. Hurts whole lot. b. Hurts a little bit. c. Hurts little more. d. Hurts even more. e. Hurts worst.
b
The nurse understands the FLACC rating scale measures how many categories? a. Four categories b. Five categories c. Six categories d. Three categories
activities of daily living (ADLs)
The preparations for the day, such as bathing, washing and styling hair, brushing and flossing teeth, dressing, and shaving, are referred to as ___________________.
febrile or hyperthermia
The state of having an elevated body temperature of 102.4°F (39.1°C) is known as having a fever. Another term meaning fever is ____________________________.
Auscultate
The term used to denote use of a stethoscope to listen to the blood pressure or breath sounds is ____________________________________________.
5th objective vital sign: oxygen saturation (SpO2) 1 subjective vital sign: presence and rating of pain
There are a total of six vital signs: five objective and one subjective. Four of the five objective vital signs include the blood pressure, temperature, pulse, and respirations. What is the fifth objective vital sign? What is the one subjective vital sign?
Seborrhea
Thick, oily scales on the scalp from overproduction of sebum.
c
Tidal volume is the measurement of a. The amount of blood contained in a person's vascular system. b. The volume of blood that is saturated with oxygen. c. The average amount of air inhaled in one breath. d. The volume of air exhaled with each breath. e. The volume of the internal respiration.
Lice
Tiny parasites that live on the scalp.
Brachial artery in the antecubital area of the arm.
To assess the blood pressure on the upper arm, you should place the stethoscope over which artery? Located at which site?
Feedback
To complete the communication process, a return message is sent by the receiver of the original communication to indicate the message has been received, processed, and comprehended
a,b,c,d
Under what circumstances would you decide not to delegate a bed bath to assistive personnel or a CNA? (Select all that apply.) a. When you need to assess the patient's abilities to participate in personal care. b. When you need to strengthen the nurse-patient relationship. c. When you need more information about the patient's skin condition. d. When the patient's condition is unstable. e. When the family is present and seems critical of the patient's care.
Omit back massage if the patient has certain heart conditions because the back massage can stimulate the vagus nerve and slow the heart rate. Also omit back massage if the patient has fractured ribs or vertebrae because the pressure could cause pain.
Under what circumstances would you omit giving a back massage to a patient?
b
What causes body odor? a. Sebum left on the skin for 24 hours or longer b. Bacteria breaking down sweat c. The presence of dead, keratinized cells on the body d. The presence of sweat in areas that are not open to air, such as armpits
b,c,e
What characteristic(s) of the pulse should you always assess? (Select all that apply.) a. Length of each beat b. Strength c. Rate d. Depth e. Rhythm of the beats
1. Rate 2. Depth 3. Rhythm/pattern 4. Respiratory effort
What four assessments should you make when assessing respirations?
The purpose of using 2% triclosan products helps to reduce patients who are prone to MRSA.
What is the importance of using 2% triclosan products on selected surgical patients?
a
What is the normal range for systolic blood pressure in a healthy 38-year-old adult? a. 100 to 120 mm Hg b. 90 to 140 mm Hg c. 60 to 90 mm Hg d. 100 to 140 mm Hg e. 80 to 120 mm Hg
Body's production of heat.
What is thermogenesis?
self care
When a patient is able to perform ADLs without assistance, the type of care is called _______________.
assisted care
When a patient needs some assistance with activities of daily living (ADLs), the type of care is called ___________________________.
F (should sound clearly & distinctly/strong)
When auscultated, the heart sounds should sound muffled and distant. (T/F)
a,c,e
When you provide oral care to an unconscious patient, you will (select all that apply) a. Position the patient on the left or right side with the bed flat. b. Use lemon glycerin swabs to clean the patient's lips and gums. c. Assess the mouth for lesions and sores. d. Use plenty of water to rinse the toothpaste from the teeth and gums. e. Keep a suction device on and ready for use.
a,d
Which heart valve(s) close(s) to produce the S1 sound? (Select all that apply.) a. Bicuspid valve b. Pulmonary valve c. Aortic valve d. Tricuspid valve
a,c,d
Which is true of bathing and caring for the skin of older adults? (Select all that apply.) a. Apply lotion frequently to prevent dryness. b. Bathe them frequently, one to two times per day. c. Keep the room warm during the bath to prevent chilling. d. Sebaceous and sweat glands produce less oil and sweat. e. Avoid bathing older adults while they are in the hospital; they can wait until after discharge to bathe.
a,d
Which of the following are composed of dead, keratinized cells? (Select all that apply.) a. Hair b. Sebum c. Sweat d. Nails e. Oil glands
a,b,c,d,e,g,h
Which of the following are generally performed as part of morning care (a.m. care)? (Select all that apply.) a. Hair care b. Bath c. Shaving d. Oral care e. Back massage f. Washing hands and face only g. Dressing or changing the gown h. Straightening or changing linens
b,c,f,g
Which of the following assessments provide data regarding the quality of circulation to a patient's extremities? (Select all that apply.) a. Oral temperature b. Strength of pedal dorsalis pulse c. Skin temperature of hands and feet d. Pulse rate e. Blood pressure f. Color of nailbeds g. Capillary refill time
b,d
Which of the following patients have one or more vital signs that are outside normal range? (Select all that apply.) a. A 28-year-old male with BP 118/76, P 66 regular and strong, R 17, SpO2 98%, and denies pain or discomfort b. A 93-year-old female with BP 102/62, P 48 regular and weak, R 22, SpO2 92%, and denies pain c. A 15-year-old female with BP 114/68, P 80 regular and strong, R 20, SpO2 99%, and denies pain or discomfort d. A newborn male with AP 174 regular and distinct, R 70, SpO2 89%
medulla oblongata
Which part of the central nervous system can affect the rate of heart contractions? a. Left temporal lobe b. Pons c. Hypothalamus d. Medulla oblongata
d
While you are assisting a patient with a bed bath, you notice a purplish blotching on the skin of the lower legs and feet. This is an indication of a. A reaction to medications. b. Increased heat in the legs and feet. c. Infection. d. Decreased circulation to the legs and feet.
You can wrap one or two gauze squares around a tongue blade and tape them in place to pad it. Then you can insert it in the side of the patient's mouth and rotate it so the blade is vertical instead of flat. This will hold the patient's mouth open while you perform oral care.
While you are giving mouth care to an unconscious male patient, he keeps biting down on the sponge stick and toothbrush. What can you do about this problem?
Leukoplakia
White patches on the tongue or oral mucosa that can be precancerous.
Vasodilation
Widening of blood vessels.
You need to determine whether this is a good time to do the bath or if the patient prefers to wait until later when she is less fatigued. You also need to determine whether there are cultural concerns about you, as a male, assisting a female with a bath. You can ask if other male staff members have assisted her with personal care. If you have no background information on this, you will need to communicate with the patient or her family regarding objections to you assisting her. Assuming there are no objections, you will need to stay in the room and assist with this bath rather than walking out and leaving it for her to do by herself. Remember to preserve the patient's modesty at all times during the bath.
You are a male nursing student assigned to care for a female patient from China. She is on bedrest and is experiencing pain and nausea from chemotherapy to treat non-Hodgkin's lymphoma. Communication is difficult, and you are not sure if she understands everything that you say. When you ask if she can do her own bed bath, she nods yes. You set up everything for her and leave the room. When you return 45 minutes later, she is asleep and the bathwater looks untouched. What will you do about this situation? *Give the rationales for your actions *
Mitered corner
A ______________________________ is used to anchor the linens more firmly than if they were only tucked at the foot of the mattress.
ocular prosthesis
A custom-made ______________________________ fits the empty eye socket when no implant is in place.
Hypoxemia
A decreased blood level of oxygen.
Stridor
A high-pitched crowing respiratory sound. (common in children)
Draw sheet
A narrow sheet with two narrow hems at each end that is positioned horizontally across the bed, extending from the patient's shoulders to the knees, is called a ______________________________.
c
A patient has an intravenous (IV) drip containing heparin to prevent his blood from clotting. You are assisting him with personal care. Which action will you take? a. Shave him with a disposable razor in the direction of hair growth. b. Shave him with an electric razor in the direction of hair growth. c. Shave him with an electric razor, moving in circular motions over the beard. d. Delay shaving this patient until the IV heparin is discontinued.
Apnea
A period of no respirations.
Bradypnea
A respiratory rate that is less than 12 per minute.
F (They're fever reducing)
Antipyretics are medications given for hypertension. (T/F)
Bradycardia
Apical heart rate below 60 bpm.
Pulse deficit
Apical heart rate is higher than radial pulse rate.
F (it rises in the late afternoon)
Based on the circadian rhythm, the body's temperature normally drops 1°F to 2°F in the late afternoon. (T/F)
38.1 & 37.7 C
C= (F-32) / 1.8 Convert 100.6 & 99.8 F
Dyspnea
Having difficulty breathing.
Hypoxia
Decreased level of cellular oxygen.
Hematocrit
Dehydration decreases the water content of the blood, raising the proportion of red blood cells to plasma, which increases viscosity of the blood. What laboratory test provides the measurement of red blood cell concentration? ________________________________
Stroke volume: the amount of blood the heart pumps from the left ventricle from 1 contraction. Cardiac output: the total amount of blood pumped from the left ventricle in 1 minute.
Describe the difference between cardiac output and stroke volume.
Place the patient in modified Trendelenburg position (with the legs elevated higher than the heart), but do not lower the patients head.
Describe the first intervention you should perform when a patient faints because of low blood pressure.
Elevated hypertension is used to describe a consistent pattern of systolic pressure between 120 & 130 mm Hg. It's considered a precursor of hypertension.
Describe what is meant by elevated hypertension and include the pressure range to which it refers.
Muscle contractions normally produce about 25% of body heat in resting state. Shivering, an involuntary skeletal muscle response, can raise heat production 4 to 5 minutes the normal amount. Newborns cannot shiver and must have external sources of warmth to maintain body heat.
Explain why a person shivers when experiencing hypothermia. Why does a newborn infant not shiver when the body temperature is below normal?
Aspirin administered to children (below 15 yrs) with viruses have been associated with development of Reye's syndrome, an acute and possibly fatal childhood disease that affects the CNS & liver.
Explain why you should not administer aspirin products to children younger than 15 years.
98.6 & 104.2 F
F= (1.8C) + 32 Convert 37 & 40.1 C
Orthopnea
Inability to breathe without sitting upright.
d
It is important to stay with a patient during the first bath or shower after surgery because the patient may a. Be unsteady while standing and sitting. b. Have an increase in pain when moving about. c. Cause the incision to open up when getting in the water. d. Experience vasodilation and become dizzy or faint.
1. Diabetes 2. Kidney disease 3. Age 4. Race 5. Exertion/exercise 6. Rest 7. Circadian rhythm 8. Anxiety, stress, or emotions 9. Medications 10. Nicotine, caffeine, stimulants 11. Obesity 12. Overhydration/Dehydration 13. Hemorrhage 14. Increased intracranial pressure
List at least eight (14) factors that can affect blood pressure.
shared meaning
Mutual understanding of the meaning of a message
11/07/28 0700 BP 148/94, Oral T 99.8 F (37.7 C), P 95 irreg. and strong, R 27 and unlabored, SpO2 98% on RA. C/O Rt. flank pain @ 6 on 0-10 ----R. Casillas LVN
On November 7, 2028, at 7:00 a.m., you assessed your patient's vital signs and found the systolic blood pressure to be 148, diastolic pressure to be 94, oral temperature to be 99.8˚F (37.7°C), pulse rate to be an irregular but strong 95 bpm, and respirations to be 27 per minute. Her oxygen saturation on room air was 98%. She reports pain in her right flank area, assessed as a 6 on a pain rating scale of 0 to 10. Document your findings on the nurse's note form. (END OF CH. 17)
Lesions
Open areas.
special mouth care
Oral care for patients whose conditions result in a need for more frequent care and who need assistance with this care is referred to as ________________________.
Apical pulse
Pulse taken near the apex of the heart. Located at the left midclavicular line & 5th intercostal space.
Eupnea
Respirations that are between 12 and 20 per minute, have a regular rhythm, and are of the same depth, neither deep nor shallow. (normal breathing)
Venous return
Return of blood from the extremities back to the heart.
Vital signs should support instance of orthostatic/positional hypotension b/c of pooling of blood in lower extremities, decreasing blood delivery to brain resulting in syncope. Actions should include assessing vital signs (which should show decreased blood pressure and increased pulse rate). You could also elevate patients feet slightly above heart level (modified Trendelenburg). A cool moist cloth could be placed on the forehead or neck for comfort. Patient needs reassurance that this is not uncommon in their condition. Orthostatic hypotension could have been prevented by having the patient sit before getting up with the legs dangling for a couple minutes (assess the patient), then have them get up and stand for a bit (assess the patient) before walking them. This lets the body adjust to blood pressure avoiding sudden drops.
Sheryl Stephens, a 61-year-old female patient who is only a few hours postoperative after having received sedating medication as part of a general anaesthesia, presses her call light and requests to get up to the bathroom to urinate. Ms. Stephens received sedating medication as part of general anesthesia for her procedure. After reviewing the physician's orders to verify that she may get up, you begin to assist her to get out of bed for the first time since surgery. After taking several steps, you notice she is becoming pale as she tells you that she feels like she is going to faint. You assist her immediately back to the bed where you help her to lie down. What do you expect to find on assessing her vital signs? What has she most likely experienced, and what should you do to handle the situation? What might you have done in an attempt to prevent this episode from occurring?
Finding should reflect poor cardiac output. This could include a faint pulse volume/strength that is difficult to feel or categorized as 1+. Pulses might also be thready or feeble and obliterate with light pressure. Pulses could be too weak to palpate at all, requiring use of Doppler ultrasound to detect them.
You are caring for Brent Hammond, a 71-year-old male with heart failure. As a result of this disease, his heart's ability to pump blood is markedly decreased, resulting in less cardiac output than normal. When you assess Mr. Hammond's apical pulse, two radial pulses, and two dorsalis pedis pulses, what characteristics of these various pulses might you expect to obtain in your findings?
Date: 9-1-28 Time: 1017 Wife expressed concern regarding patient's inability to bathe at home due to shortness of breath in the shower and inability to get out of the tub. Instructed to place a rustproof lawn chair or bench in shower so the patient can sit down while showering. Suggested that she obtain a terrycloth robe for patient to don after the shower so he won't be short of breath while drying off. Also suggested use of lawn chair or bench in the tub and a handheld sprayer attached to tub faucet rather than him sitting down in the tub. Patient nodded several times during discussion. Wife verbalized plans to obtain a shower chair and terrycloth robe. ------------R. Casillas LVN
You are caring for a 76-year-old male patient with a diagnosis of congestive heart failure and diabetes. His wife tells you that he cannot bathe or shower at home because he gets too short of breath in the shower and cannot get up if he sits down in the bathtub. She tries to help him wash up, but it is difficult for her and him. You teach the patient and his wife ways to conserve his energy during bathing and offer alternatives to standing in the shower or sitting down in the tub. Document your teaching on the nurse's note form (Fig. 15.1). Be sure to include an evaluation of the patient's and his wife's learning. (END OF CH. 15)
c
You are caring for a patient who has had a left mastectomy. While you are assisting the patient with her bath, she says, "I can't imagine looking in the mirror and feeling good about myself again. No matter how I look, I will still be missing my breast." How will you respond? a. "Yes, you are correct. You will be forever changed by this surgery." b. "You will get used to this change, and after reconstructive surgery you will be like new again." c. "Tell me more about how you feel that your life will be different after this surgery." d. "You are worrying more than you need to. No one will know unless you tell them."
b
You are caring for a patient with a nasogastric tube who is unable to take food or fluids by mouth. How often will you perform oral care for this patient? a. Oral care is unnecessary because the patient is not eating or drinking anything. b. Every 2 hours c. Every 4 hours d. Every 8 hours
d
You are preparing to assist a conscious patient with oral care. The patient has had a stroke, causing partial paralysis of her throat. Once the toothpaste, toothbrush, water, and emesis basin are set up on the overbed table, what will you do? a. Instruct the patient to brush her teeth and spit into the emesis basin, then leave the room. b. Ask a family member to assist the patient if she needs help while you are out of the room. c. Brush the patient's teeth for her, then instruct her to rinse her mouth with water and mouthwash while you prepare for the partial bath. d. Stay with the patient in case she chokes while performing oral care, and assist her as needed.
d
You are providing personal care to a patient with diabetes. Her toenails are a bit long. What will you do? a. Do nothing to her toenails because you could cause her to have an infection if you damage her toes. b. Clip her toenails carefully straight across but do not file them. c. Clip her toenails carefully in a rounded shape to help prevent ingrown toenails. d. File her toenails straight across but do not clip them.
b
Your patient has multiple body piercings with jewelry in place. He has been in a motor vehicle accident and is scheduled for magnetic resonance imaging (MRI) of his left arm and left leg. Which question will you ask this patient? a. Do I have your permission to remove the jewelry from your piercings before your MRI? b. Are the metals in your jewelry nonmagnetic stainless steel or titanium? c. You understand that you will need to remove all of the jewelry from your piercings before you go for an MRI, don't you? d. How long has the jewelry in your piercings been in place?
b
Your patient is slightly confused. He has activity orders to be up in the chair three times per day. He is unstable on his feet when he walks or stands for more than a few minutes. What type of bath will you plan to give this patient? a. Bed bath b. Assisted or help bath c. Tub bath d. Shower
a,d
Your patient's BP while sitting was 140/82. Upon standing, the patient became dizzy, and her BP dropped to 108/68. This condition is known as which of the following? (Select all that apply.) a. Orthostatic hypotension b. Secondary hypotension c. Pulse pressure hypotension d. Postural hypotension e. Essential hypotension
Nits
______________________________ are clear bumps affixed tightly to the hair shaft and are the eggs of lice.
Tinea capitis
______________________________, a fungal infection that causes a round area of hair loss with a lesion, is also called ringworm.
Cheyne-Stokes respiration
_____________________________________ is the term used to describe a repetitious pattern of respirations that begin shallow, gradually increase in depth and frequency to a peak, and then begin to decrease in depth and frequency until slow and shallow, followed by a period of apnea lasting from 10 to 60 seconds.
