Both VN 15 Test 1 Study Guide Flashcards
harm that results because a person did not act reasonably
Negligence
What are the four necessary components that must be proved in negligence?
• duty
• breach of duty
• causation
• injury
Do nurses need personal liability insurance? Is it mandatory?
Although many agencies have liability insurance with an umbrella clause that includes its employees, nurses should obtain their own personal liability insurance.
means being faithful to work-related commitments and obligations.
Fidelity
means the duty to be honest and avoid deceiving or misleading a client
Veracity
refers to a competent person’s right to make his or her own choices without intimidation or influence
Autonomy
means “doing good” or acting for another’s benefit. To do good, an ethical person prevents or removes any potentially harmful factor.
Beneficence
nurses are obligated to be competent in performing skills and services required for safe and appropriate care. This implies that nurses pursue continuing education and maintain current certification for CPR
Fidelity
If a patient was starting chemotherapy and asked about the side effects, a nurse practicing veracity would be honest about the side effects they could expect with chemotherapy
Veracity
a young woman who seeks the removal of both breasts because she fears breast cancer though there is no evidence she is at a high risk for it. In such case, the duty to respect the client’s wishes may be nullified.
Autonomy
if the patient has cancer, the beneficent act is to eliminate the cancer with surgery, drugs, or radiation.
Beneficence
When can restraints be used?
They are used with the intention to subdue a client’s activity, Use must be justified and accompanied by informed consent from the client or a responsible relative.
List complications of immobility x 6
*Acute pain
*Compartment syndrome
*Peripheral neurovascular dysfunction
*Impaired bed mobility
*Impaired skin integrity
*Ineffective tissue perfusion
*Bathing self-care deficit
List the client instructions for cane use
*Maintain two points of support on the ground at all times
*Keep the cane on the stronger side of the body
*Support body weight on both legs
*Move the cane forward 6-10 inches or 15 cm
*Then move the weaker leg forward toward the cane
*Next, advance the stronger leg past the cane
*Per ATI: Another method of cane walking includes having the client move the “bad” affected extremity and the cane at the same time.
List the steps for a four-point alternate gait with crutches
*Do not alter the crutches after the proper fitting
*Follow the prescribed crutch gait
*Support body weight at the hand grips with elbows flexed at 30 degrees
*Position the crutches on the unaffected “good” side when sitting or rising from a chair.
List nursing interventions when caring for a client in a skeletal traction from a fracture
*Have clients exercise the toes of the foot in the cast every 15 minutes while awake
*Keep traction on continuously unless there are orders to remove
*Keep the height of the bed elevated to ensure weights hang from bed
*Provide for client’s hygiene and oral needs.
*Make sure to report any symptoms that may be worsening to the charge or health care provider
*Use pressure relieving devices if patient is confined to bed
*Encourage isometric, isotonic, and active range of motion exercise
- List signs of infection at the pin site of traction
*Skin redness
*Skin on is warm to touch
*Swelling or hardening of the skin at pain site
*Drainage that is yellow, green, thick, or smelly
* A fever
*Numbness or tingly at pin site
*Increased pain at pain site
*Pins at site are loose or have movement
List abnormal findings the VN might find when assessing the integumentary system
*Note any changes in color as cyanosis, erythema, jaundice, or pallor.
*Variations in skin temperature, texture, and perspiration or dehydration may indicate underlying conditions.
Describe the heart sounds s1, s2, s3, s4
*The two normal heart sounds are s1 and s2
*s3 is normal in children but abnormal in most adults, appears after s2
*s3, s4: heart murmurs
What is the rationale for checking pupils in a head-to-toe assessment? What is it looking for?
*The nurse assesses the pupils for accommodation(the ability to constrict when looking at a near object and dilate when looking at an object in the distance)
*Regular eye examinations are important because having your vision corrected can improve the quality of day-to day life.
*They help detect certain eye conditions such as cataracts, glaucoma, and age-related macular degeneration, which could lead to sight loss. Poor vision could be a risk for falls
What are nursing interventions when caring for a client with a Thomas Splint?
*Avoid changing the position of the injured part even if it appears grossly deformed
*Leave a high-top show or a ski boot in place if the injury involves an ankle
*Cover any open wounds with clean material
*Select a rigid splinting material such as a flat board, broom handle, or rolled up newspaper
*Pad bony prominences with soft material
*Apply the splinting devices so that it spans the injured area from the joint about to the joint below the injury
*Use an uninjured area of the body adjacent to the injured part as a splint if no other sturdy material is available
*Use wide tape or wide strips of fabric to confine the injury part to the splint
*Loosen the splint orr the material used to attach it, if the fingers or toes are pale, blue, or cold
What are nursing actions following the application of a plaster cast?
*Explain how the cast will be applied. If using plaster of pairs, be sure to tell the client that it will feel warm as it dries.
*Wash your hands or use an alcohol- based hand rub
*Wash the client’s skin with soap and water, and dry well
*Cover the skin with a stockinette and protective padding as directed
*If applying plaster cast, open rolls, and strips of plaster gauze material. Briefly dip the one at a time in water and wringing out the excess moisture
*If using fiberglass material, open the foil packets one at a time
What are some recommendations for client complaining of itching after cast application?
Client can take oral medications or blow cool air down the cast.
List client education for walker use
• Stand within the waker, hold the walker at the padded handgrips, pick up the walker and advance 6 to 8 inches, are a step forward, support the body weight on the handgrips when demoting the weaker leg.
List client education for crutch use
• Four Point: one crutch, opposite foot, other crutch remaining foot
• Two point: one crutch and opposite foot move in unison followed by the remaining pair
• Three point: non weight bearing both crutches move forward followed by the weight bearing leg
• Three point partial weight bearing: both crutch are advanced with the weaker leg; the stronger leg is placed parallel to the weaker leg
• Swing through: both crutches are moved forward: one or both legs are advanced beyond the crutches.
List client education for prosthesis use
• Passive Prosthetic: is designed to look like a natural limb, these prostheses are lightweight, they do not have active movement but a person function
• Powered prosthetics are operated by system cables, harness and manual control
• Electrical Powered prosthesis- include motor and batteries that provide movement and power
• Hybrid prosthesis- combines body powered and electrically powered components in one prosthesis
• Activity specify prosthesis- designed for an activity with a residual limb with no prosthesis or passive body powered or electrically powered damaged or simply will not work as needed for specific activities
How do you measure for knee-high anti-embolic stockings?
• Some brands of knee high socks also require a calf length and an ankle measurement. Take the ankle measurement above the ankle bone at the narrowest part of the ankle. The calf length is measurement from the floor near your heel to the start of the knee on the backside of your leg.
damaged skin or soft tissue
Wound
an open sore caused by poor blood flow
Ulcer
a wound in which the surface layers of skin are scraped away
Abrasion
a separation of skin and tissue in which the edges are torn and irregular
Laceration
a crack in the skin, especially in or near mucous membranes.
Fissure
replacement of damaged cells with fibrous tissue
Scar
(pale, regardless of race) - anemia, blood loss
Pallor
superficial burns, local inflammation, carbon monoxide poisoning
Erythema
fever, hypertension
Flushed
trauma to soft tissue
Ecchymosis
low tissue oxygenation
Cyanosis
liver or kidney disease, destruction of red blood cells
Jaundice
ethnic variation, sun exposure, pregnancy, Addison disease
Tan
small clicking, bubbling, or rattling sounds in the lungs. They are heard when a person breathes in (inhale)
Rales
sounds that resemble snoring.
Rhonchi
wheeze-like sounds heard when a person breathes
Stridor
high pitched sounds produced by narrow airways
Wheezing
List steps to taking a tympanic temperature
• Use a clean probe tip each time, follow manufacture’s instructions carefully
• Gently tug on the ear, pulling it back
• Gently insert the thermometer until the ear canal is fully sealed off
• Squeeze and hold the button for 1 second
• Remove the thermometer and read the temperature
How and why does the VN assess muscles and muscle strength on their head to toe?
The VN asks the client to grasp, squeeze, and release the nurse’s fingers. As the nurse pulls and pushes on the forearm and upper arm, he or she instructs the client to resist. To test strength in the lower extremities, the nurse has the client push and pull against resistance
How long does the VN count the apical pulse for in their head to toe?
The apical heart rate is counted by listening at the chest with a stethoscope or by feeling the pulsations in the chest for 1 full minute at an area called the “point of maximum impulse.
What is the order to assess bowel sounds in the head to toe?
*Have the client recline. This position provides access to the abdomen.
*Reduce noise. A quiet environment facilitates an accurate assessment.
*Warm the diaphragm of the stethoscope. Warmth promotes comfort.
*Place the diaphragm lightly in the right lower quadrant (RLQ) and listen for clicks or gurgles. *Move the chest piece over all four quadrants in a clockwise pattern from the RLQ to the right upper quadrant (RUQ) to the left upper quadrant (LUQ), and ending at the left lower quadrant (LLQ). If no sounds are audible initially, listen for 2 to 5 minutes. This sequence follows the anatomic areas of the upper to lower bowel.
*Document the frequency and character of the bowel sounds. Doing so provides data for problem identification and future comparisons.
*Once you have finished the auscultation, note the softness or firmness of the abdomen and feel for palpable masse
How and why does the VN check for skin turgor in their head to toe?
To assess skin turgor, the nurse gently pinches the client’s skin over the sternum or below the clavicle in an attempt to lift it from the underlying tissue. The area over the chest is a good assessment location because the skin in other areas tends to loosen with age. When the nurse releases the tissue, it should return quickly to its original position. Prolonged “tenting” indicates dehydration. When documenting skin turgor, it could be described as elastic if it resumes its previous position when the fold of skin is released or nonelastic if the fold of skin remains longer than 3 seconds.
1st stage in the Nursing Process!!
Physical assessment
four techniques of a physical assessment include
1 Inspection
2 Percussion
3 Palpation
4 Auscultation
What is some general data that you can obtain just from observing and interacting with your client?
• Physical appearance with regard to clothing and hygiene
• Level of consciousness
• Body size
• Posture
• Gait and coordinated movement (or lack of it)
• Use of ambulatory aids
• Mood and emotional tone
Head-to-Toe approach of data collection.
Prevents overlooking some aspect of data collection
Reduces the number of position changes required of the client
Generally takes less time because the nurse is not constanly moving around the clinet in what may appear to be haphazard manner
Body systems
asssessing the client according to the functional systems of the body it involves examining the structures in each system seperately.
What is included in a mental status assessment?
provides information about a client’s attention, concentration, memory, and ability to think abstractly.
for most clients, documenting that they are alert and oriented to person, place, time, and circumstances is all that is necessary
What is examined during an eye assessment?
appearance of the eyes, iris, sclera, corneas, eyelashes,
More advanced practitioners use an instrument called an ophthalmoscope to examine structures within the eye. After gross inspection, the nurse assesses functions such as visual acuity, pupil size and response, and ocular movements.
