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NCLEX Mark K > Crutches, Canes, Walkers & Psyh > Flashcards

Crutches, Canes, Walkers & Psyh Flashcards

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1
Q

Measuring crutches

Top

Bottom

Hand Grip

A

Top: measure 2 or 3 fingers widths between pad and axillary fold

Bottom: Tip 6” lateral and 6” in front of the foot

RULE OF LANDMARK OF AXILLA AND FOOt

Handgrip

Wrist level with handgrip
Elbow flexion 30°

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2
Q

2 point Gait

Move

What type of patient will use this

A

Crutch & Oppsite foot together

Together Right leg & Left crutche
Together Left leg & Right crutche

For: mild bilateral leg weakness

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3
Q

3 point Gait

Describe motion

Which type of patients use it

A

Move 2 crutches & bad leg together, follow3d by unaffected leg

Affected leg Not on ground

For: when 1 leg is affected

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4
Q

4 point Gait

Describe movement

For which type of patient

A

Move all 4 separately

Move one crutch -> opposite foot -> followed by opposite crutch -> followed by opposite foot

For: Severe bilateral leg problems

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5
Q

Swing through gait

Type of patient

A

Move both crutches & bad leg together. Followed by good leg

For: Amputee - Non weight bearing

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6
Q

Tip

Use even point Gait for even/ bilateral

2 for mild 4 for severe

Use odd point Gait when one leg is affected.

Use Swing through for amputation

A

Good advice

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7
Q

Which Crutches Gait

  1. Early stages RA
  2. Left above knee amputation
  3. 1st day post off right knee replacement- partial weight bearing allowed
  4. Advanced stages ALS
  5. Left hip replacement Non weight bearing
  6. Bilateral total knee replacement 1 day Post opp. Weight bearing allowed
  7. Bilateral knee replacement 3 weeks post opp
A
  1. 2 point
  2. Swing through
  3. 3 point
  4. 4 Point
  5. Swing through
  6. 4 Point
  7. 2 Point
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8
Q

Going up amd down stairs with crutches

How to explain

A

Up: Good foot, crutches, Bad

Down: Crutches, Bad, Good

Crutches move with Bad Leg

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9
Q

Canes

Hold on which side

A

Strong side

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10
Q

If belonging must be tied to walkers where should it be tied

A

Side not front

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11
Q

Tip: Psych Question

Decide if the patient is psychotic or non psychotic

A Non psychotic person has…

A

Insite (able to tell their own problem)

Reality Based

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12
Q

Which technique do you use with a Non-psychotic patient

A

Good therapeutic communication (Get them to talk more)
Reflection
Clarification
Amplification
Restatement

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13
Q

Psychotic person

2 defining characteristics

They don’t know they are sick

Which symptoms do they have unique to thier disease

A

No Insite Not reality bases

Symptom: Delusions & Hallucinations

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14
Q

A false fixed idea or belief
No sensory involvement

A

Delusion
(Paranoid, Grandeous, Somatic (involving body parts)

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15
Q

False fixed sensory experience

A

Hallucinations

In order of common place

Most common: Auditory; voices telling you to harm yourself

Visual:

Tactile:

Gustaory

Olfactory

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16
Q

A misinterpretation of reality
Sensory experience

With a referent in reality

A

Illusions

17
Q

Client Says

  1. I hear demon voices
  2. Client over hears chatter at nursing Station & states: I hear demon voices
  3. Client stares at wall and says I see a bomb
  4. Client stares at fire extinguisher on wall and says I see a bomb
A
  1. Hallucinations
  2. Illusion
  3. Hallucinations
  4. Illusion
18
Q

3 types of psychosis

Functional Psychosis: Function in everyday life.

  1. Name 4 diseases associated with this
  2. Psychosis of Dementia
    What is the cause of their Dementia
  3. Psychotic Delirium
A
  1. Skizo, Skizo, Major, Manics
    Schizophrenia, Schizoaffective disorder, Major Depression, Manic
  2. Brain Damage from Dementia
  3. Temporary, 2ndary (underlying cause), Sudden
19
Q

Functional Psychotic has brain damage (No / Yes)

Can they learn reality

How to teach reality to them (4) Steps

A

No

Yes

  1. Acknowledge Feelings
  2. Present Reality
  3. Set Limit
  4. Enforcement Limit
20
Q

Teaching Step to bring functional Psychotics into reality.

  1. I see your angry, you seem upset, tell me more about how your feeling
  2. I know you see that demon but I don’t.
    I understand you believe the mafia wants to kill you but in reality this isn’t going to happen.
  3. That topic is off limits in our conversation

Stop talking about certain subject

  1. I see your too ill to stay reality based and end the conversation
A
  1. Acknowledge Feelings
  2. Present Reality
  3. Set a limit
  4. Enforce limit
21
Q

Tip

If in between 2 choices chose the more positive option

A

38$ p/h to start

22
Q

Psychosis of Dementia

To handle them during situations do 2 steps

Why?

A
  1. Acknowledge Feelings
  2. Redirect them

Why? They can’t learn reality.

23
Q

Is reality orientation appropriate with dementia patients.

Ie. Orientation them to Person, Place, Time

Can you do presentation of reality to dementia patients

A

Yes.

However, don’t do presentation of reality.

Don’t orientate them out of their Hallucinations.

Ie. Presenting them with the reality that there not King Arthur

24
Q

How to handle a patient with a Psychosis Delirium

(2) Steps

A
  1. Acknowledge Feelings
  2. Reassure about safety & temporariness of their condition
25
Q

Patient with Schizoaffective disorder who points at 2 people talking at table across the room.

“Those people are plotting to kill me.”

What do you do.

A
  1. Acknowledge. I hear you and that must be frightening
  2. Orientate to reality. Those people aren’t plotting to kill you
  3. Establish limits: Were not going to talk about this anymore
  4. Enforce limits: (they keep talking about it) I see your too ill now to converse
26
Q

Patient with AD during conversation points to two people and says

“Those people are trying to kill me”

How do you respond

A
  1. Acknowledge. You seem scared, that seems frightening
  2. Redirect. Let’s go somewhere you can be safe.

Don’t switch subject but direct what they are saying

27
Q

A patient with delirium tremors says: “ See those two people over there, they are plotting to kill me”

What would a RN do

A
  1. Acknowledge statement: This must be terrifying
  2. Reassure them of their safety. You are safe that symptom of your illness will go away when you get better
28
Q

Which personality disorders would you consider treating as a Functional Psychotic

A

Antisocial
Borderline
Narcissistic

29
Q

Multi Actual Assessment Axis

1.
2.
3.
4.
5.

A
  1. Prima4y psych disease
  2. Retarded/ Personality disorder
  3. Medical Conditions
  4. Psychosocial (unemployed/ divorce)
    5 Score 0 - 100 of ability to function. 100 is highest
30
Q

Flight of ideas

Word Salad

Neologism

(Can’t make a phase that is coherente)

(Each phrase is coherente but put together the phrases don’t make sense)

(Making up imaginary words)

A

Neologism

Flight of ideas

Word Salad

(Making up imaginary words)

(Each phrase is coherente but put together the phrases don’t make sense)

(Can’t make a phase that is coherente)

31
Q

Narrowed Self Concept

When a functional Psychotic refuses to leave room and change clothes

Define themselves as where they are and change their clothes

Do you make them change clothes and leave room.

What do you tell them

A

No.

Dangerous Situation

Steps in functional psychosis

32
Q

Mrs Jones is depressed since her child went to college. Lost her job. Hates way she feels

Refuses to leave room to do ADL

What do you do?

A

Use good therapeutic communication skills

I see your depressed
It’s time for your shower “ tell them”
Be directive

33
Q

Ideas of reference…

A

When you think everyone is talking about you

NCLEX Mark K (9 decks)

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