Basic Care and Comfort Flashcards
Clients with polycythemia vera are at risk of developing?
thrombosis
Dialysis disequilibrium syndrome (DDS ) is a potentially life-threatening condition associated with?
cerebral edema
Clients with dysphagia should receive what type of liquids?
thickened liquids and be monitored for coughing, gagging, and pocketing food
The nurse should position the client with the head of the bed for JVD at what angle?
30 - 45 degree angle
What is the measure for preventing aspiration pneumonia relating to the head-of-bed?
90 degrees during and 30 minutes after meals
What is the measure for preventing aspiration pneumonia relating to movements of the neck?
neck flexion while swallowing
having less than three bowel movements a week is considered
Constipation
The medical definition is three or more loose stools over a 24-hour period
Diarrhea
the best way to assess a patient’s mobility
direct visualization
can give valuable information about balance, motor strength, joint mobility, and muscle coordination
Gait
Decreased weight-bearing movement leads weakness and
muscle atrophy
Some examples of non-pharmacological comfort measures include
the use of music, warm blankets, and environmental controls such as low lighting and relaxation sounds (white noise, water, etc.)
BMI of 25 - 29.9
overweight
BMI of 30+
Obese
an ostomy for urine
Urostomy
The size of the catheter is referred to as the
French or Fr
Hyperressonance is an abnormal finding over
adult lung tissue
hyperresonance is a normal finding in
children’s lung tissue
an environment that is planned and maintained in a manner that eliminates all possible stressors so that psychiatric mental health clients with emotional and behavioral issues can concentrate their energies and thoughts on the things impacting them rather than external stressors
a milieu environment
a critical aspect and component of a milieu environment
Consistent boundaries
The American Nurses Association (ANA) advocates for pain management even if the
life-threatening side effects hasten death
Clients should be assessed for their bathing needs in preferences of their [. . .]
type of bathing
Note: Additionally, a bath once a week is acceptable as long as the client remains clean, without bodily odors, and is still hygienic. Pt refusing partial baths upon entry to hospital must be respected due to their cultural habits. So the appropiate response is to tell them → That is fine. At what time of the day do you prefer to bathe and do you prefer a shower or tub bath
theory of aging describes the aging process as one that results from cellular death that results from collagen
cross-linked theory
theory of aging describes the aging process as one that results from failure of the endocrine glands such as the pituitary gland and the hypothalamus gland
endocrine theory
theory of aging describes the aging process as one that results from cellular death that results from the breakdown of the person’s immune system
immunological theory
theory of aging describes the aging process as one that results from the collection and accumulation of free radicals in the body
free radical theory
which phase of the nursing process is the most foundational for delivery of care
assessment
Serotonin syndrome has S/S that go → Up or Down
↑ Up
eg. Muscle rigidity Restlessness and agitation Sinus tachycardia etc etc
The description of “nonverbal” in the context of pain assessment is the
inability to self-report pain
the failure to be adequately assessed using a numerical pain scale, and the inability to be adequately evaluated using a pictorial pain assessment scale
Inspection refers to
visual examination
what is the term that refers to visual examination in assessments
Inspection
is the first technique of the overall general survey and for each body part
Inspection
is a form of palpation and vibrations are felt in the abdomen or intestines
Tympany
Lungs are clearHeart rate and rhythm are regular
auscultation form of assessment
According to Dorothea Orem self-care theory, clients are in the educative and supportive mode when they can
care for their own self-care needs
in the self-care theory by Dorothea Orem, clients are in compensatory when they need
they need complete assistance from another to meet their self-care needs
Dorothea Orem developed the self-care theory that describes the degree to which our clients can fulfill their
self-care needs
Appetite decreases and the gastrointestinal system
slows with age
Pain is often called the
Fifth Vital Sign
first step in pain assessment is for the nurse to
Accept the client’s report of pain
If a patient does not immediately report pain, it is still the nurse’s responsibility to
question if he/she feels any pain
what 2 markers are significant (or should be monitored) if the client is taking warfarin
PT and INR
HEP goes with which blood marker (3 letters)
PTT
PT and INR
are significant if the client is taking warfarin
PTT and platelet count should be monitored closely when receiving what kind of infusion
heparin infusion
in therapeutic communications what does the phrase “what is causing you” mean when you tell this to a patient
focusing - you are focusing them on a topic or theme
I’ve noticed in therapeutic communication means
observation
What would you like to talk in therapeutic communication means
using a broad opening
The nurse should not ask about feelings of
dissatisfaction or anger
which are the risk factors that a patient most likely will be able to corrected by themselves
Lifestyle choices
Glaucoma, cataracts, and macular degeneration are all more common in the
elderly
is believed to be caused by the loss of elasticity of the crystalline lens
Presbyopia
CMP stands for
comprehensive metabolic panel
A patient with increased intracranial pressure should have the head of the bed elevated at
30 or 40 degrees
Note: Nurses should also be sure to avoid Trendelenburg and prevent the patient’s neck from flexing.
Subjective data is information that is perceived only by
the person affected
Note: This data cannot be seen or verified by another person
Objective data are
observable and measurable data
Note: that can be heard, seen, or felt by someone other than the person who is experiencing them. Examples of actual data include edema, vomiting, or having an elevated body temperature.
Therapeutic play should be - unstructured or structured
unstructured - meaning let the kid do his play
with children, once therapeutic play is initiated it should be done how often
regularly
the cane should be held with the hand on which side
opposite side of the injury
as the patient advances the cane forward they need to move their
affected leg forward too
which patient “status” should always be given priority in any assessment
Respiratory status
Trendelenburg position increases the venous blood return to the
heartNote: when a client is affected by hypotension, hypovolemia, or shock
position used to increase oxygenation in patients with respiratory distress
Prone position
What are some procedures which use the Sim’s position
usually used for rectal exams, treatments, and enemas
position usually used for rectal exams, treatments, and enemas
Sim’s position (lateral recumbent position)
describe lateral recumbent position
prone with one knee sort of up, also called Sim’s position
This is when a patient is seated in a “semi-sitting” position when the head of the bed is elevated at a 45 to 60 degrees angle
Fowler’s position
position used to promote relaxation of abdominal muscles
Fowler’s
position use to promote or improve uterine drainage in post-partum women
Fowler’s
the position aids Peristalsis and swallowing by the effect of gravitational pull
Fowler’s
Subjective data is information from the
client’s point of view (“symptoms”)
including feelings, perceptions, and concerns obtained through interviews
Objective data is
observable and measurable data (“signs”)
obtained through observation, physical examination, and laboratory/diagnostic testing
General appearance and behavior represent which kind of data
objective data
In stage 3 and 4 of wounds, the nurse should ensure that the client has been given pain medication for changing the dressing at least how many minutes before
30 minutes
when it comes wound care always use non-sterile gloves to remove the
old dressing
the extrinsic factor that most greatly and most frequently hurts and interferes with our clients’ physical and emotional recovery from a disease or disorder
Family dynamics
tympany is the percussion sound heard over the
abdomen
Restraints should be released one at a time every
2 hours per day to allow for a range of motion exercises
Pain in terms of the client’s sensory description can include subjective comments such as
crushing and sharp
Each sleep cycle lasts
90 to 120 minutes and repeats throughout the night
characterized by a brief period of light sleep. This is a transition period from wakefulness to sleep and lasts about 5 to 10 mins
NREM Stage 1
During this period, both heart rate and body temperature drop. The brain produces bursts of rapid, rhythmic brain wave activity known as “sleep spindles” – most people spend about 50% of the total sleep in this stage
Stage 2
characterized by difficulty in terms of awakening (Deep Sleep). During this period, muscles relax, blood pressure, and breathing rate decrease
Stage 3
It is also referred to as delta sleep because it is characterized by deep, slow brain waves (low frequency, high amplitude) known as delta waves, what stage is this?
Stage 3
This stage represents 10 to 20 percent of the total sleep time in young to middle-aged adults but decreases with age
NREM Stage 3
the stage that follows NREM deep sleep and is characterized by vivid dreams
REM Sleep
In this sleep stage, the brain becomes more active, the body becomes relaxed and immobilized, and eyes rush
REM sleep
on an average, begins 90-minutes after falling asleep
REM Sleep
Most parasomnias such as sleepwalking (somnambulism) occur during this stage
Stage 3
When REM sleep is complete, the cycle returns to
stage 2 sleep
nonverbal communication of pain may include
stooped gait, facial grimacing, and gasping sounds
A patient who presents with nonverbal communication of a stooped gait, facial grimacing, and gasping sounds is most likely experiencing
pain
The transmission of information without the use of words is termed
nonverbal communication
what is also known as body language
nonverbal communication
Nonverbal signs associated with fluid-deficit
may include slowed responses and agitation
may include head and lips in the downwards expression, adaptive hand gestures, social withdrawal, frowning, crying, and decreased levels of eye contact and smiling
Nonverbal signs associated with depression
these are nonverbal signs that include tenseness, difficulty sleeping, and stomach problems that can be associated with
generalized anxiety
an independent nursing intervention to promote sleep, is a hot beverage, but the nurse must be aware of that
it doesn’t have caffeine
A soothing back massage and encouraging exercise/activity during the daytime hours are [. . .]
sleep promotion interventions that can and should be done without a doctor’s
Although hot beverages can promote sleep, the client’s beverage of choice should not have [. . .]
caffeine as it may deprive the person of sleep
A health assessment is a method by which nurses gather both [. . .]
subjective and objective data
A health assessment includes both a [. . .]
health history and physical evaluation
the health assessment is used to gather the data necessary to create [. . .]
the plan of care
When instructing a patient to ambulate with a cane, the nurse should apply what type of device to get the pt off the chair/bed [. . .]
gait belt to the patient’s waist
The patient should have the cane in [. . .]
stronger side or opposite site of injury
height of the cane should be measured from the patient’s [. . .]
wrist crease
The patient should have the cane on what hand [. . .]
unaffected/stronger side
when instructing a client to walk with a cane tell them to look [. . .]
ahead as they ambulate – not down at the ground
The cane should be placed on the patient’s [. . .]
stronger side of their body
the nurse should instruct the patient to advance the cane and then the [. . .]
weaker side forward
The patient should have the tip of the cane approximately how many inches from their shoe [. . .]
4 inches
The neurological complication can occur when a vest restraint is too tight around the client’s body causing [. . .]
numbness and tingling
An infant of 6 six weeks who presents with a fever must be worked up for [. . .]
infectious causes
nurse should first assess the patient’s pain to determine the cause before administering [. . .]
pain medication
Objective data is [. . .]
observable and measurable
When performing an assessment, the nurse will collect [. . .]
subjective and objective data
observable and measurable data is also called [. . .]
Objective data
Dumping syndrome is characterized by [. . .]
rapid peristalsis
Patients with Dumping Syndrome should avoid [. . .]
simple carbohydrates (refined sugars)
a common complication following gastric bypass surgery [. . .]
Dumping syndrome
Patients often present with colicky abdominal pain, diarrhea, nausea, and tachycardia [. . .]
Dumping syndrome
Signs and symptoms of dumping syndrome generally occur right after [. . .]
eating
an example of a dopamine antagonist is [. . .]
haloperidol
Spiritual distress should be treated with [. . .]
a referral to the clergy and psychosocial support of the client
drug that is also used to treat psychotic disorders such as schizophrenia and bipolar disease [. . .]
dopamine antagonist
antipsychotic drug that is also used to treat psychotic disorders [. . .]
dopamine antagonist like haloperidol
