Both VN 15 Test 1 Study Guide

Question 1

harm that results because a person did not act reasonably

Answer 1

Negligence

Question 2

What are the four necessary components that must be proved in negligence?

Answer 2

• duty
• breach of duty
• causation
• injury

Question 3

Do nurses need personal liability insurance? Is it mandatory?

Answer 3

Although many agencies have liability insurance with an umbrella clause that includes its employees, nurses should obtain their own personal liability insurance.

Question 4

means being faithful to work-related commitments and obligations.

Answer 4

Fidelity

Question 5

means the duty to be honest and avoid deceiving or misleading a client

Answer 5

Veracity

Question 6

refers to a competent person’s right to make his or her own choices without intimidation or influence

Answer 6

Autonomy

Question 7

means “doing good” or acting for another’s benefit. To do good, an ethical person prevents or removes any potentially harmful factor.

Answer 7

Beneficence

Question 8

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

Answer 8

Fidelity

Question 9

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

Answer 9

Veracity

Question 10

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.

Answer 10

Autonomy

Question 11

if the patient has cancer, the beneficent act is to eliminate the cancer with surgery, drugs, or radiation.

Answer 11

Beneficence

Question 12

When can restraints be used?

Answer 12

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.

Question 13

List complications of immobility x 6

Answer 13

*Acute pain
*Compartment syndrome
*Peripheral neurovascular dysfunction
*Impaired bed mobility
*Impaired skin integrity
*Ineffective tissue perfusion
*Bathing self-care deficit

Question 14

List the client instructions for cane use

Answer 14

*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.

Question 15

List the steps for a four-point alternate gait with crutches

Answer 15

*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.

Question 16

List nursing interventions when caring for a client in a skeletal traction from a fracture

Answer 16

*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

Question 17

15. List signs of infection at the pin site of traction

Answer 17

*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

Question 18

List abnormal findings the VN might find when assessing the integumentary system

Answer 18

*Note any changes in color as cyanosis, erythema, jaundice, or pallor.
*Variations in skin temperature, texture, and perspiration or dehydration may indicate underlying conditions.

Question 19

Describe the heart sounds s1, s2, s3, s4

Answer 19

*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

Question 20

What is the rationale for checking pupils in a head-to-toe assessment? What is it looking for?

Answer 20

*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

Question 21

What are nursing interventions when caring for a client with a Thomas Splint?

Answer 21

*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

Question 22

What are nursing actions following the application of a plaster cast?

Answer 22

*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

Question 23

What are some recommendations for client complaining of itching after cast application?

Answer 23

Client can take oral medications or blow cool air down the cast.

Question 24

List client education for walker use

Answer 24

• 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.

Question 25

List client education for crutch use

Answer 25

• 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.

Question 26

List client education for prosthesis use

Answer 26

• 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

Question 27

How do you measure for knee-high anti-embolic stockings?

Answer 27

• 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.

Question 28

damaged skin or soft tissue

Answer 28

Wound

Question 29

an open sore caused by poor blood flow

Answer 29

Ulcer

Question 30

a wound in which the surface layers of skin are scraped away

Answer 30

Abrasion

Question 31

a separation of skin and tissue in which the edges are torn and irregular

Answer 31

Laceration

Question 32

a crack in the skin, especially in or near mucous membranes.

Answer 32

Fissure

Question 33

replacement of damaged cells with fibrous tissue

Answer 33

Scar

Question 34

(pale, regardless of race) - anemia, blood loss

Answer 34

Pallor

Question 35

superficial burns, local inflammation, carbon monoxide poisoning

Answer 35

Erythema

Question 36

fever, hypertension

Answer 36

Flushed

Question 37

trauma to soft tissue

Answer 37

Ecchymosis

Question 38

low tissue oxygenation

Answer 38

Cyanosis

Question 39

liver or kidney disease, destruction of red blood cells

Answer 39

Jaundice

Question 40

ethnic variation, sun exposure, pregnancy, Addison disease

Answer 40

Tan

Question 41

small clicking, bubbling, or rattling sounds in the lungs. They are heard when a person breathes in (inhale)

Answer 41

Rales

Question 42

sounds that resemble snoring.

Answer 42

Rhonchi

Question 43

wheeze-like sounds heard when a person breathes

Answer 43

Stridor

Question 44

high pitched sounds produced by narrow airways

Answer 44

Wheezing

Question 45

List steps to taking a tympanic temperature

Answer 45

• 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

Question 46

How and why does the VN assess muscles and muscle strength on their head to toe?

Answer 46

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

Question 47

How long does the VN count the apical pulse for in their head to toe?

Answer 47

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.

Question 48

What is the order to assess bowel sounds in the head to toe?

Answer 48

*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

Question 49

How and why does the VN check for skin turgor in their head to toe?

Answer 49

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.

Question 50

1st stage in the Nursing Process!!

Answer 50

Physical assessment

Question 51

four techniques of a physical assessment include

Answer 51

1 Inspection 2 Percussion 3 Palpation 4 Auscultation

Question 52

What is some general data that you can obtain just from observing and interacting with your client?

Answer 52

• 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

Question 53

Head-to-Toe approach of data collection.

Answer 53

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

Question 54

Body systems

Answer 54

asssessing the client according to the functional systems of the body it involves examining the structures in each system seperately.

Question 55

What is included in a mental status assessment?

Answer 55

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

Question 56

What is examined during an eye assessment?

Answer 56

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.

Question 57

an assessment technique for determining equality or disparity of bone-conducted sound

Answer 57

Weber Test

Question 58

an assessment technique for comparing air versus bone conduction of sound

Answer 58

Rinne Test

Question 59

pink, intact, and kept moist by salivary glands located below the tongue

Answer 59

Normal oral Mucous Membranes

Question 60

is a break in the skin

Answer 60

Wound

Question 61

is an open, crater- like area

Answer 61

Ulcer

Question 62

is an area that has been rubbed away by friction

Answer 62

Abrasion

Question 63

is a torn, jagged wound

Answer 63

Laceration

Question 64

is a crack in the skin, especially in or near mucous membranes

Answer 64

Fissure

Question 65

is a mark by the healing of a wound or lesion

Answer 65

Scar

Question 66

(pale, regardless of race) - anemia, blood loss

Answer 66

Pallor

Question 67

(red) - superficial burns, local inflammation, carbon monoxide poisoning

Answer 67

Erythema

Question 68

(pink) - fever, hypertension

Answer 68

Flushed

Question 69

(purple) - trauma to soft tissue

Answer 69

Ecchymosis

Question 70

(blue) - low tissue oxygenation

Answer 70

Cyanosis

Question 71

(yellow): liver or kidney disease, destruction of red blood cells

Answer 71

Jaundice

Question 72

(brown) - ethnic variation, sun exposure, pregnancy, Addison disease

Answer 72

Tan

Question 73

(flat, round, colored, non palpable area) - freckles

Answer 73

Macule

Question 74

(elevated, palpable, solid) - wart

Answer 74

Papule

Question 75

(elevated, round, filed with serum) - blister

Answer 75

Vesicle

Question 76

(elevated, irregular border, no free fluid)- hives

Answer 76

Wheel

Question 77

(elevated, raised border, filled with pus) - boil

Answer 77

Pustule

Question 78

(elevated, solid mass, deeper and firmer than papule) - enlarged lymph node

Answer 78

Nodule

Question 79

(encapsulated round, fluid- filled or solid mass beneath the skin) - tissue growth

Answer 79

Cyst

Question 80

preferred site to assess skin turgor?

Answer 80

The area over the chest is a good assessment location because the skin in other areas tends to loosen with age

Question 81

How do you assess skin turgor?

Answer 81

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

Question 82

What does poor skin turgor possibly indicate?

Answer 82

Prolonged "tenting" indicates dehydration

Question 83

exaggerated natural curve of the spine

Answer 83

Lordosis

Question 84

an increased thoracic curve

Answer 84

Kyphosis

Question 85

pronounced lateral curvature of the spine

Answer 85

Scoliosis

Question 86

correlates with the "lub" sound and is louder at the apex or mitral area when using the diaphragm of a stethoscope

Answer 86

S1

Question 87

"dub" sound can be heard in the mitral area. It is louder over the aortic area

Answer 87

S2

Question 88

normal in children, but abnormal in most adults. Sounds like "lub-dub-dub." It is much more pronounced than a split second sound. Heart murmurs

Answer 88

S3

Question 89

heart murmurs. Clicks and rubs

Answer 89

S4

Question 90

(loud and coarse) They are equal in length during inspiration and expiration and are separated by a brief pause

Answer 90

Tracheal sounds

Question 91

(harsh and loud) They are shorter on inspiration than expiration with a pause between them. They are heard over the upper sternum anteriorly and between the scapulae posteriorly

Answer 91

Bronchial sounds

Question 92

These medium-range sounds that are equal in length during inspiration and expiration have no noticeable pause. They are heard on either side of the central chest or back.

Answer 92

Bronchovesicular sounds

Question 93

Their soft, rustling quality is longer on inspiration than expiration with no pause between. Sounds are located in the periphery of all the lung fields.

Answer 93

Vesicular sounds

Question 94

(also called rales) - intermittent, high- pitched, popping, and heard in distant areas of the lungs, primarily during inspiration.

Answer 94

Crackles

Question 95

(also called rhonchi) - low pitched, continuous, bubbling, and heard in larger airways.

Answer 95

Gurgles (Rhonchi)

Question 96

Whistling or squeaking sounds caused by air moving through a narrowed passage.

Answer 96

Wheezes

Question 97

Pleural friction rubs are grating, leathery sounds caused by two dry pleural surfaces moving over each other.

Answer 97

Rubs

Question 98

How do you assess muscle strength?

Answer 98

The nurse assess all four extremities separately to determine muscle strength He/She asks the client to grasp, squeeze, and release the nurse's fingers. As the nurse pulls on the forearm and upper arm, he/she instructs the client to resist To test strength in the lower extremities, the nurse has the client push and pull against resistance.

Question 99

Excessive fluid within tissue and signifies abnormal fluid distribution

Answer 99

Edema

Question 100

Which clients are prone to edema?

Answer 100

Clients with cardiovascular, liver, and kidney dysfunction are prone to edema

Question 101

Slight indention (2 mm), normal contours, associated with interstitial fluid volume 30% above normal

Answer 101

1+ Edema

Question 102

Deeper pit after pressing (4 mm), lasts longer than 1+, fairly normal contour

Answer 102

2+ edema

Question 103

Deep pit (6 mm), remains several seconds after pressing, skin swelling by general inspection

Answer 103

3+ Edema

Question 104

Deep pit (8 mm), remains for a prolonged time after pressing, possibly minutes, frank swelling

Answer 104

4+ Edema

Question 105

Fluid can no longer be displaced secondary to excessive interstitial fluid accumulation, no pitting, tissue palpates as firm or hard, skin surface shiny, warm moist

Answer 105

5+ (brawny) Edema

Question 106

IAPP Abdomen

Answer 106

Inspected Auscultated Palpation Percussion

Question 107

Why IAPP in Order

Answer 107

Touching or manipulating the abdomen can alter bowel sounds, thus producing invalid findings

Question 108

What do fissures indicate?

Answer 108

An anal fissure is a small tear in the thin, moist tissue that lines the anus. The anus is the muscular opening at the end of the digestive tract where stool exits the body. Common causes of an anal fissure include constipation and straining or passing hard or large stools during a bowel movement.

Question 109

What are the purposes of mechanical immobilization?

Answer 109

● Relieves pain and muscle spasms ● Supports and aligns skeletal injuries ● Restricts movements while injuries heal ● Maintains a functional position until healing is complete ● Allows activity while restricting movements of an injured area ● Prevents further structural damage and deformity

Question 110

identify 6 steps when applying an emergency splint.

Answer 110

● Avoid Changing the position of the injured part even if it appears grossly deformed. ● Leave a high top shoe or a ski boot in place if the injury involves an ankle. ● Cover any open wounds with soft material. ● Select 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 above to the joint below the injury.

Question 111

What should you check for after applying an inflatable splint?

Answer 111

● Indents

Question 112

When would a cervical collar be used?

Answer 112

● To treat athletic neck injuries and other trauma that results in neck sprain or strain.

Question 113

When should cervical collars be worn?

Answer 113

● Clients wear them continuously, even while sleeping for 10 days to 2 weeks.

Question 114

What is the purpose of a sling?

Answer 114

● Used to elevate, cradle and support parts of the body.

Question 115

Be able to identify the 3 different types of braces & their uses:

Answer 115

● PROPHYLACTIC ● REHABILITATIVE BRACES ● FUNCTIONAL BRACES

Question 116

List the different materials that casts are made from.

Answer 116

● They are formed using either wetted rolls of plaster of paris or pre moistened rolls of fiberglass.

Question 117

What are the advantages and disadvantages of each?

Answer 117

● inexpensive, easy to apply, low incidence of allergic reactions.

Question 118

Disadvantages

Answer 118

● Takes 24-48 hours to dry : large cast may take up to 72 hours of dry ● weight bearing must be delayed until thoroughly dried. ● Heavy ● Prone to cracking or crumbling, especially at the edges ● softens when wet.

Question 119

Of Paris

Answer 119

Plaster

Question 120

Fiberglass

Answer 120

● Light weight ● Porous ● Dries in 5-15 minutes ● Allows immediate weight bearing ● Durable

Question 121

One that is cut into two pieces lengthwise from either a cy body or cylinder cast.

Answer 121

Bivalved cast

Question 122

What should you educate your client before their cast is going to be removed?

Answer 122

● The joint may have a limited range of motion. ● the skin appears pale and waxy and may contain scaled of patches of dead skin ● Skin is washed as usual with soapy warm water, areas of the skin are left in place they are not forcibly removed. ● Apply lotion to the skin add moisture

Question 123

purpose of Traction?

Answer 123

● Reduce muscle spasms ● Realign Bones ● Relieve pain ● Prevent Deformities

Question 124

3 different types of traction

Answer 124

MANUAL TRACTION Skin TRACTION (AKA)- WIRES and PINS SKELETAL TRACTION

Question 125

What do you need to do to maintain effective traction?

Answer 125

● Traction must produce a pulling effect on the body ● Countertraction (Counterpull) must be maintained ● The pull of traction and the counterpull must be in exactly opposite directions. ● Splints and slings must be suspended without interference ● Ropes must move freely through each pulley ● The prescribed amount of weight must be applied ● the weight must hang free

Question 126

What is the purpose of an External Fixator?

Answer 126

is a metal device inserted into and through one or more broken bones to stabilize fragments during healing.

Question 127

What are quadriceps setting and gluteal setting good for?

Answer 127

Promote tone and strength in weight-bearing muscles

Question 128

two exercises done and what are the muscles used for?

Answer 128

Both types are easily performed in bed or in a chair. To stand and support their body weight

Question 129

Why would you have a client dangle their feet on the side of the bed?

Answer 129

Helps normalize blood pressure, which may drop when the client rises from a reclini

Question 130

What would a tilt table be used for?

Answer 130

Raises the client from a supine to a standing position. Helps clients adjust to being upright and bearing weight on their feet.

Question 131

Why would a walking belt be used?

Answer 131

For walking assistance in case client loses balance, the nurse can support him or her and prevent injuries.

Question 132

What should the nurse observe for when a client is walking?

Answer 132

* Pallor * Weakness * Dizziness

Question 133

What should you do if a client looks like they are not tolerating the walk or going to faint?

Answer 133

The nurse supports the client by sliding an arm under the axilla and placing a foot to the side, forming a wide base for support. With the client ents weight braced, the nurse balances the client on a hip until help arrives or slides the client down the length of the nurse’s leg to the floor.

Question 134

A cane is used for a client who has weakness on ____________ of the body

Answer 134

ONE SIDE

Question 135

Which side does the cane go on?

Answer 135

The Stronger side of the body

Question 136

clients who need brief, temporary assistance with ambulation are likely to use axillary crutches

Answer 136

Axilla Crutches

Question 137

forearm crutches are generally used by experienced clients who need permanent assistance walking

Answer 137

Forearm Crutches

Question 138

are used by clients who cannot bear weight with their hands and wrists.

Answer 138

platform crutches

Question 139

Below the knee amputation

Answer 139

BKA

Question 140

Above the knee amputation

Answer 140

AKA

Question 141

Permanent prosthetic device be fitted and hy

Answer 141

Should be fitted several weeks to months until the wound heals and the stump size is stable. The prosthesis is custom made to conform to the stump and meet clients needs.

Question 142

What considerations should we consider with our older clients? Gerontologic considerations

Answer 142

-having an elevated toilet and grab bars might be needed to improve the ability to transfer and maintain independence in the older client. -if the client seems to have an unusual gait, assess feet for corns, calluses, bunions and or ingrown toenails. -encourage a smooth, progressive cadence if older client seems to have a “step-stop” pattern when ambulating. -clients tend to build a habit of picking up the can or walker instead of making sure it makes contact with the floor, instead encourage client to use a walker with 4 wheels -using a ramp with handrails can help an older client enter and leave their residence safely -if a client is having a hard time going up and down the stairs of their own home, might be a good idea to rearrange their home to use just the first level of the home.