NCLEX EAQ
False high blood pressure reading
-arm is unsupported -repeated assessments -deflating cuff too slow
5. Maintenance stage (behavioral change stages)
-begins six months after change has started -continues indefinitely
SATO2 need to knows:
-carbon monoxide artificially elevates the oxygen sat -nail polish interfere with the ability of the oximeter -IV dyes will artificially lower the oxygen sat -Skin pigmentation will overestimate the saturation
2. Contemplation stage (behavioral change stages)
-client begins to consider a change within the next six months as he or she develops more belief in the value of change
3. Preparation (behavioral change stages)
-client believes that advantages outweigh disadvantages of behavior change -client needs assistance planning for a change in the next month
1. Precontemplation stage (behavioral change stages)
-client may be defensive when confronted with information about the behavior -client does not intend to make any changes within the next six months
AGING ADULT
-decreased vasomotor response -diminished elasticity of blood vessels therefore do not respond quickly to changes from horizontal to vertical ---> orthostatic hypotension; Changing positions slowly allows the body to adjust, which prevents dizziness and loss of balance. -Usual fluid intake patterns can be maintained. Furosemide should be taken with meals to prevent gastric irritation. It is best to take it in the morning rather than at night so that sleep is not interrupted with the need to void. There is no link between furosemide and skin breakdown.
Hypertension symptoms
-headache and shortness of breath
4. Action (behavioral change stages)
-last up to six months -client actively engaged in strategies to change behavior while the nurse identifies barriers to change
Respite care
-offered at home, in day care settings, or in a health care institution that provides overnight care. -medicare does not cover respite care service and medicaid has strict requirements and eligibility. -Provide short-term relief or "time off" for people providing home care to an ill, disabled, or frail older adult.
Tertiary prevention
-preventing further disability or reduced functioning in the clients -achieving as high a level of functioning as possible -prevent complications and deteriorations in order to minimize the effects of long-term disease or disability -applied when client has a defect or disability that is permanent and irreversible -rehabilitative care instead of diagnosis and treatment
False low blood pressure reading
-stethoscope too firmly against antecubital fossa
Stages of experiencing a change in body image
1. initial reaction - shock 2. withdrawal phase - refuse to discuss the subject 3. acknowledgment phase - begin to acknowledge the condition and move through grieving 4. acceptance phase 5. rehabilitation phase
Assessment of pain
1. location 2. client's experience of pain and rate pain 0-10 3. precipitating factors 4. inspect area of tenderness
6-year-old blood pressure normal
105/65 mmHg
12-year-old blood pressure normal
110/65 mmHg
14-17 year old normal blood pressure
119/75 mmHg
resp rate
12-20
infant heart rate
120-160
According to Erikson's theory, at which age would a child develop self-control and independence?
18 months to 3 years old According to Erikson's theory, between the ages of 18 months and 3 years, a child develops self-control and independence. At the age of 3 to 6 years old, a child is highly imaginative. At the age of 6 to 12 years old, a child is engaged in tasks and activities. Between the ages of 12 and 19 years of age, a child can differentiate between identity and role confusion.
Body Temp Range and what temperature would client be shivering uncontrollably and experiencing memory loss, depression, and poor judgement?
36-38 is normal range below 35 client will exhibit those symptoms below 30 client will demonstrate lack of response to stimuli, slow respiration, and slow pulse *31-33 moderate hypothermia
Normal temp in Celsius
37 (98)
Adult heart rate
60-100
normal pulse
60-100
Adolescent heart rate
60-90
School-age child heart rate
75-100
Preschooler heart rate
80-110
Toddler heart rate
90-140
normal oxygen saturation
95-100%
1-year-old blood pressure normal
95/65 mmHg
A client who is suspected of having tetanus asks a nurse about immunizations against tetanus. Before responding, what should the nurse consider about the benefits of tetanus antitoxin?
A passive immunity is produced.
Myopia (nearsightedness)
A refractive error in which the eyeball is too long in relation to its focusing power; thus the point of focus for rays of light from distant objects is in front of the retina.
Hyperthyroidism; eye symptoms
Bulging eyes
Circulatory insufficiency.
Chronically recurring ulcers in the lower legs or the feet accompanied by an absence of leg hair growth are serious signs
Sustained pattern
Constant body temperature continuously about 38 with little fluctuation
Kussmaul respirations
Deep, rapid breathing; usually the result of an accumulation of certain acids when insulin is not available in the body.
Sedative hypnotic physical findings of the skin (including alcohol)
Diaphoresis
GESELL'S THEORY
Growth in humans is both cephalocaudal and proximodistal. The cephalocaudal pattern describes the sequence in which growth is fastest at the top (from the head and then down). The proximodistal growth starts at the center of the body and moves toward the extremities. Poor nutrition or chronic disease often affect growth rate and result in smaller stature despite of the genetic blueprint. According to Gesell's theory of development, each child's pattern of growth is unique, and this pattern is directed by gene activity. According to Gesell's theory, genes direct the sequence of development, but environmental factors also influence development and result in developmental changes.
The student nurse prepares a concept map while caring for a client recovering from surgery. What is the first step that the student nurse should take when preparing the concept map?
Identify patterns reflecting the client's problem
Hypokalemia is associate with what clinical finding?
Muscle weakness
Opioids physical findings of the skin
Needle marks
Vesicular breath sounds
Normal breath sounds -quiet, soft, and inspiration sounds that are short and almost silent on expiration -heard over lung periphery
three-part nursing diagnostic label
P - problem E - etiology S - symptoms NANDA-1 label, related factor, and defining characteristics
HYPERTENSION
PRE: 120/80 - 139/89 BP mainly influenced by heart rate and cardiac output -when cardiac output and hematocrit are increased so does BP -increased cardiac output and increased hematocrit is at higher risk for stage 1 hypertension HEMATOCRIT LEVELS: men 45-52% women: 37-48% decreased cardiac output risk for hypotension
Relapsing pattern
Periods of febrile episodes coupled with periods of acceptable temperature values
Splinter hemorrhages
Red or brown linear streaks in the nail bed caused by minor trauma to nails, subacute endocarditis, or trichinosis
PCP - Phencyclidine physical findings of the skin
Red, dry skin
Normal BP
Systolic <120 Diastolic <80
According to Avedis Donabedian, which is the most important validator of quality and effectiveness of health care in a hospital?
The client outcomes achieved by the care provided
phlebitis signs
The symptoms of phlebitis include localized redness, tenderness, and swelling over the vein sites of the calves.
The nurse should flush the IV line with normal saline to maintain patency. The nurse should stop the insertion procedure when there is a break in technique.
This intervention helps prevent catheter-related bloodstream infections and provides high-quality care to the client. Nurse should change the IV line every 72-96 hours to prevent the risk of infection. The nurse should avoid inserting the catheter in the client's femur because it increases the risk of bloodborne infections. 18 gauge is not an appropriate size and increases the risk of phlebitis
Beau lines
Transverse depressions in nails indicating a temporary disturbance of nail growth
Input comonent
When the nurse assessing a client's medical records before surgery finds that the client is allergic to latex, this discovery is an example of the input component. When the nurse checks the medical records of the client for blood transfusion reaction before administering a blood transfusion, this action is an example of the input component.
A client with osteoporosis is encouraged to drink milk. The client refuses the milk, explaining that it causes gas and bloating. Which food should the nurse suggest that is rich in calcium and digested easily by clients who do not tolerate milk?
Yogurt
4+ pulse
a bounding pulse
Clubbing of nails
a change of the angle between the mail and nail base -softening of the nail bed and enlarged finger tips with flattened nails are signs of clubbing nails -seen in conditions of oxygen deficiency, such as heart or pulmonary diseases
Vesicle
a circumscribed elevation of the skin that is filled with serous fluid and a lesion size of less than 1cm
Koilonychia
a malformation of the nails in which the outer surface is concave or scooped out like the bowl of a spoon (concavely curved) -iron deficiency anemia and syphilis
2+ pulse
a normal and expected pulse
Crackles
abnormal breath sounds -soft, crackling, bubbling sounds produced by air moving across fluid in the alveoli
Rhonchi
abnormal breath sounds heard over the large airways of the lungs -consist of a low pitch and are caused by the movement of secretions in the larger airways; usually clear with coughing
Tumors; eye symptoms
abnormal eye protrusions
Maturity
accepting multiple solutions to a problem
Occupational health services
aim to increase worker productivity, decrease absenteeism, and reduce the use of costly medical care; include a complete program designed for health promotion and accident or illness prevention in the workplace
Hypocalcemia
allows sodium to move freely into cells because typically calcium ions block the movement of sodium; this increases excitability of the nervous system; initially symptoms are paresthesias, this can lead to tetany if untreated
True Fever
alteration in the hypothalamic set point; pyrogens act as antigens that trigger the immune system response; hypothalamus reacts by raising the set point; pyrogens are removed; heat loss responses
Postconventional reasoning level
and individual begins thinking about what an ideal society would be like;individual finds a balance between basic human rights and obligations and societal rules and regulation; an individual moves away from moral decisions based on authority or conformity to groups to define their own moral values and principles
Self-regulation
applicable when the nurse when the nurse identifies was to improve his or her own performance
During general anesthesia the lungs
are not fully inflated during surgery and the cough reflex is suppressed, so mucus collects within airway passages.
Lithotomy poistion
assess and examine female genitalia
Prone position
assess the musculoskeletal system
Nursing care for a client in skeletal traction
assessing pin sites every shift and as needed needed weight for a client is prescribed by the physician, not as desired nurse should ensure that the knots are not tied to the pulley and move freely. The performance of range of motion is indicated for all joints except the ones proximal and distal to the fracture because the area is immobilized by the skeletal traction to promote healing and prevent further injury and pain
The NIC (nursing interventions classifications)
assigns codes for entering various interventions followed by nurse to reduce client's illness
Systematicity
being organized and focused
Infiltration of IV site
blanched skin, edema of 15.2 cm, cool temperature, and pain at the site
somatic pain
bone, joint, muscle, skin, or connective tissue and is usually aching or throbbing in quality and well localized
Circulatory overload
can occur if IV solutions are infused too rapidly or in great amounts
Pustule
circumscribed elevation of the skin that is similar to a vesicle but filled with pus and varies in size
Acceptance Stage
client frequently detaches from the environment and may become indifferent to family members; the family may take longer to accept the inevitable death than does the client
Hypothyroidism; hair symptoms
coarseness of the hair of the eyebrows and the failure of the eyebrows to extend beyond the temporal canthus
NANDA
codes for nursing diagnoses
Related factor
condition or etiology that gives a context for defining characteristics
Cold causes the blood vessels to
constrict, which reduces the leakage of fluid into the tissues and prevents swelling and therefore muscle spasms. promotes analgesia but not circulation may numb nerves but does not dilate blood vessels
Gamma globulin
contains most of the antibodies circulating in the blood. When injected into an individual it prevents a specific antigen from entering a host cell. It does not stimulate antibody production and does not affect antigen-antibody function.
Alcohol, other sedative hypnotics, IV opiods physical findings of the skin
contusion, abrasion, cuts, scars
Presbyopia
decreased accommodative ability of the lens that occurs with aging
hypoventilation
decreased rate and depth of air movement into the lungs
Contact dermatitis
delayed immune response that occurs 12-48 hours after exposure
1+ pulse
diminished or barely palpable pulse
injury to cranial nerve III
drooping of the eyelids
Bilateral jugular venous pressures higher than 2.5 cm are considered
elevated and are a sign of right-sided heart failure One sided pressure elevation is caused by obstruction
Nodule
elevated solid mass, deeper and firmer than a papule and of 1-2 cm in diameter
Conventional Reasoning level
emphasis is given on social rules and community-centered approach
School health services
emphasize program management, interdisciplinary collaboration, and community health principles
health promotion
encourages the client to maintain the present levels of health; good nutrition and regular exercise are examples
Deontology
examines a situation for the presence of essential right or wrong; actions can be decided as right or wrong based on their "right-making characteristics"
Referred pain
experienced in clients with tumors, felt in another part of the body
Remittent pattern
fever spikes and falls without returning to normal temperature levels.
intermittent pattern
fever spikes are interspersed with normal temp values
Client admitted to the mental health unit involuntarily, the nurse should
file with the court within 96 hours of the initial detention
Macule
flat, nonpalpable change in skin color, which is smaller than 1 cm
Performance improvement
focuses on evaluating current performance in order to initiate a qualitative change. A team designing a strategy for improving the performance of nurses when administering injections would be a performance improvement also a team implementing a new system to improve the performance of nurses to prevent infections during wound debridement is another example. Also evaluating the effectiveness of a weekly professional training programs is also performance improvement.
Quality Improvement
focuses on studying and improving the processes of providing healthcare services to clients. An example of this improvement is a team of nurses trying to determine the cause for delays of client admission into special units.
Clients with organ failure
follow the long-term limitations with intermittent serious episodes trajectory
Clients with cancer
follow the short period of evident decline disease trajectory
3+ pulse
full, strong pulse
Tropia (eye turn)
generally occurs at birth
Heat Stroke
giddiness, excessive thirst, nausea, and increased heart rate
Nursing theory
helps to identify the focus, means, and goals of practice. Theories give a perspective for assessing clients' situations and organizing data and methods for analyzing and interpreting information
client is admitted to hospice
if death is expected within 6 months
Hypersensitivity
immediate allergic reaction that occurs due to chemicals that are used to make gloves
Anaphylactic shock
immediate allergic reaction that occurs due to natural rubber latex
Application of nursing theory
in practice depends on the knowledge of nursing and other theoretical models, how they relate to one another, and their use in designing nursing interventions
Later recumbent position
indicated in clients to assess the heart
Lawrence Kohlberg's Theory of Moral Development - Social Contract Orientation stage
individual follows societal law, but also recognizes the possibility of changing the law to improve society
Lawrence Kohlberg's Theory of Moral Development - Instrumental Relativist Orientation stage
individual identifies that there is more than one right view. The views of a person can be different from others.
Lawrence Kohlberg's Theory of Moral Development - Punishment and Obedience Orientation stage
individual notices that punishment is a proof of being wrong; this perception changes when the individual steps into instrumental relativist orientation stage
Lawrence Kohlberg's Theory of Moral Development - Good Boy-Nice Girl Orientation stage
individual wants to win consent and maintain the expectations of one's immediate group
Paronychia
inflammation of skin at base of nail
Phlebitis
inflammation of the inner layer of a vein Findings: redness, tenderness, pain, and warmth along the course of the vein starting at the access point
Blood and blood products for transfusion should be
infused/diluted only with 0.9% normal saline solution, solutions other than normal saline are incompatible and may cause RBC destruction by hemolysis
Interpretation
involved in the orderly collection of data
Interpretation
involves clarifying any data about which the nurse is uncertain
Content components
involves information about the nursing interventions for clients with specific heath care problems. ex. nurse in charge asks the nurse to check the IV tubing for air bubbles to prevent air emboli; When the nurse understands that many clients practice polypharmacy by purchasing prescribed medications from multiple stores, this understanding is an example of the content component. When the nurse knows that clients with airborne diseases should be placed in an airborne infection isolation room (AIIR) to prevent spread of pathogens, this knowledge is an example of the content component.
Evaluation
involves reflecting on the nurse's own behavior
Explanation
involves supporting findings and conclusions
Explanation
involves using knowledge and experience to choose strategies to use to care for clients
Cheyne-Stokes
irregular respiratory rate and depth characterized by alternating periods of apnea and hyperventilation
Occlusion
is characterized by pain, pallor, pulselessness, paresthesias, and paralysis.
Calcium
is important for blood coagulation. When tissue damage occurs, serum calcium is necessary to promote coagulation by activating certain clotting factors. Calcium acts as a catalyst in the clotting process in both the extrinsic and intrinsic pathways. Responsible for a number of body functions, such as bone health, blood clotting, and muscle contraction, and nerve impulses. Not directly relation to bile and blood production or digestion of fats
Wheel
localized edema, usually caused by a mosquito bite. irregular in shape and have elevated surface
Infants of age 10-12 months
may be able to hold a pencil and may be able to place objects into a container
Infants of age 6-8 months
may be able to transfer objects from hand to hand
After surgery patients lungs
may have reduced volume and may require greater effort to cough and deep breathe; inadequate lung expansion can lead to atelectasis and pneumonia. Purposely utilizing diaphragmatic breathing can decrease this risk.
Sentinel event
may result in death of the client and are cause by a severe variation in the standard of care. These events are analyzed using the root cause analysis tool
Infants of age 8-10 months
may show hand preference
Adverse hospital event
medical error that may result in causing harm to the client, however the harm is not too severe or life-threatening to the client. Adverse events are caused by human errors made by health care professionals or error in the hospital system. These events are analyzed using the failure mode effective analysis tool
Intractable pain
neuropathic pain; severe, constant, and is not curable
Bronchial breath sounds
normal and consist of a full inspiration and expiratory phase with the expiratory phase being louder -heard over the trachea and large bronchi of the lungs
To comply with patient centered care
nurse should understand that the client is the source of control when providing healthcare. ex. asking patient if prefers artificial limbs or crutches
To improve quality of care
nurse uses data from previous cases to improve the quality of care provided to the client. This nursing action adheres to the QSEN competency called quality improvement.
To comply with teamwork and collaboration
nurse works with a physical therapist to enhance the remaining limb function of the client ex.
Nurse-managed clinics
nursing services with a focus on health promotion and education as well as on chronic disease.
Primary care
nutrition counseling to the the client qualifies as primary care
Dehydration in older adults
older adults are sensitive to changes in fluid and electrolyte levels; sodium, potassium, and chloride. Will manifest in mental status and confusion. It is difficult to assess for dehydration in older adults based on sunken eyes, dry skin, and decreased bowel sounds because these can be prominent as general normal findings in the elderly client
Analyticity
one of the concepts of a critical thinker and involves the use of EB knowledge for clinical decision-making. This skill may also help in anticipating possible results or consequences of a procedure or given situation.
Visceral pain
organ pain
Feedback component
outcome that is reflected by the client's responses to nursing interventions. This component also includes responses from family members and consultation from other health care professionals.
Community Health centers
outpatient clinics that provide primary care to a specific population such as clients with young children or clients with diabetes
Diaphragmatic breathing does not influence
pain, healing time, or thrombus formation
Papule
palpable, circumscribed, and has a solid elevation and a size smaller than 1cm
Stages of Health Behavior Change
precontemplation (not intending to make a change), contemplation (considering a change), preparation (making small change), action (actively engaged in change), maintenance (sustained change)
Community health centers
primary care to specific client population living in a specific community
The AMIA (American Medical Informatics Association)
professional organization that is developing nursing informatics competencies - does not provide codes for entering client's data in the EHR
Clients with disabling stroke, alzheimer disease, and frailty disease
prolonged dwindling disease trajectory
Turning the client to the side (postoperative client)
promotes drainage of secretions and prevents aspiration, especially when the gag reflex is not intact. This position also bring the tongue forward, preventing it from occluding the airway when it is in the relaxed state. Risk for aspiration is increased when the supine position is assumed by a semi-alert client. High fowlers position may cause the neck to flex in a client who is not alert, interfering with respirations. Trendelenburg position is not used for a postoperative client because it interferes with breathing
illness prevention
protects people from actual or potential threats to health ex. immunization
When ascultating blood pressure
readings between the arms can vary as much as 10 mm Hg and are often higher in the right arm. Readings that differ by 15 mm Hg or more suggest atherosclerosis or disease of the aorta.
Knee-chest position and sims position
rectal examinations
Infection of IV site
redness, heat, swelling at entry point and possible purulent drainage
Self-regulation
reflecting on the nurse's experience
Quality and Safety Education for Nurses (QSEN) quality improvement
requires nurses to integrate the best current evidence with clinical expertise and client's needs and preferences. The nurse complies with this competency by reading medical textbooks to understand the implications of the client's condition on psychological health.
Three important attributes of health care quality
safety (good clinical decisions), effectiveness (curative and preventive interventions) , and efficient care (cost-effective interventions, reducing duration of hospital stay)
Assisted living
services like laundry, assistance with meals and personal care, 24-hour oversight, and housekeeping. -group of residents live together, but each resident has his or her own room and shares dining and social activity areas
Occupational health services
services that aim to increase worker productivity, decrease absenteeism, and reduce the use of expensive medical care
Block and parish nursing
services to older clines who are unable to leave their homes
Biot's respirations
shallow breaths interrupted (2-3 breaths) then followed by irregular periods of apnea
Symptoms of ascites
shiny and taut appearance of the abdominal skin
Eczema
skin condition that can be worsened with excessive drying
Assessing skin turgor in aging adult
skin over the sternum should be used instead of skin on the arm for checking turgor.
Alcohol, stimulants physical findings of the skin
spider angiomas
Omaha System
standardized technology to support nurse practices. It includes codes for entering the data obtained from a problem rating scale in the EHR use omaha system to enter the client's score
The WHO defines health as a
state of complete physical, mental, and social well-being, not merely the absence of disease or imfirmity
Resolution of an ethical dilemma
step 1: is this an ethical dilemma? step 2: gather information related to case step 3: clarify values; distinguish facts step 4: verbalize problem step 5: identify possible course of action step 6: Negotiate a plan step 7: evaluate the plan over time
Cross eyes is a result of
strabismus, neuromuscular injury or congenital anomaly
lymphedema
swelling in one or more extremities that is the result of impaired flow of the lymphatic system
wellness education
teaches people how to care for themselves
Progressive atrophy of the convolutions of the brain with a decrease in its blood supply, during the aging process produces
tendency to become more forgetful, a reduction in short-term memory, and susceptibility to personality changes
The American Nurses Association recognizes
the International Classification of Nursing Practice (ICNP) as standardized terminology for nursing. It provides vocabulary to include nursing data in computerized information systems, such as the EHR. ICNP is not a drug guide, so it does not provide information about medications and their side effects; it does not give information on cultural practices and beliefs; unlike public health informatics ICNP does not help develop new tools and methodologies for conducting biosurveillance
Self-confidence
trusting one's own reasoning process
Education
using criteria to determine results of nursing actions
Utilitarianism
value of something is decided by its usefulness; also called consequentialism since the primary emphasis is on the outcome of consequence of the action. The right action is based on the greatest good for the greatest number of people
Cocaine skin findings physical findings of the skin
vasculitis
Thirst reflex diminishes
with age; leads to a decline in fluid intake
Women at most risk for breast cancer
women over 40 years of age, family history, late-age menopause (after 50), who have not had children or who conceived after the age of 30 years, women with excessive oral contraceptives, and early-start menarche
