Exam 1 Flashcards

1
Q

Direct care providers address…

A

physical, emotional, social, and spiritual needs

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2
Q

What are 3 things therapeutic communication can be used for?

A

I- healthcare team
II- patients and family
III- community and community wellness (ex.social media)

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3
Q

When it comes to client/family education, what should you implement and evaluate?

A

teaching plans; effectiveness of those teaching plans

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4
Q

For client advocacy, you should support their decision while…

A

protecting them from harm when they cannot use their voice and support their decision despite differing from family and healthcare opinions

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5
Q

Provide an example of counseling a patient

A

medication options for treatment, like birth control; changing behaviors and habits

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6
Q

Being a counselor to a patient requires…

A

• good communication skills
• the ability to advise clients to support healthcare issues

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7
Q

What’s the purpose of a change agent? Provide examples

A

helping individuals, families, groups and communities change as needed

ex. post-partum depression and medicaid legislation

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8
Q

How do nurse leaders inspire others? (4)

A

• willingness to improve and grow
• assertive communication
• personal positive health practices (exercise, rest, etc.)
• staying up to date with practices

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9
Q

What does a nurse manager do?

A

coordinates team activities, balancing staff activities

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10
Q

What does a nurse case manager do?

A

coordinates care delivered to the client in the community

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11
Q

What does a research consumer do?

A

uses evidence based practices to identify problems needing research and protects research subjects (patients)

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12
Q

The 3 necessities of PCC are..

A

• respect patient differences, values, expressed needs, etc.
• relieve pain and suffering
• patient education for wellness and coordination of continuous care

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13
Q

Around how many deaths per year are caused due to neglect and malpractice?

A

250,000

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14
Q

What are some ways to utilize informatic technology? (4)

A

• communicate
• manage knowledge
• mitigate errors (make less severe)
• support decision making

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15
Q

Name the 5 core competencies of nursing

A

I- Provide PCC
II- Work in interprofessional teams
III- employ evidence based practice (EBP)
IV- apply quality improvement
V- utilize informatics

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16
Q

What are the 9 roles and functions of a nurse?

A

I- direct care provider
II- communicator
III- client/family educator
IV- client advocate
V- counselor
VI- change agent
VII- leader
VIII- manager/case manager
IX- research consumer

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17
Q

Tier 1 (Standard) Precautions are also called…

A

universal precautions, because every patient receives it

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18
Q

What is the goal of Tier 1 precautions?

A

protect workers and patients by stopping the spread of infection

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19
Q

What are Tier 1 precautions used for?

A

contact with blood, bodily fluids (except sweat), excretions, sputum (mucus)

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20
Q

What are some components of Tier 1 precautions?

A

WASHING YOUR HANDS
needlestick
cough etiquette
eyewear, gowns, gloves (PPE)

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21
Q

What precautions are included in Tier 2?

A

contact
droplet
airborne

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22
Q

What does contact precautions mean, and what are some examples?

A

direct contact with the patient can lead to spread of pathogens

ex. wound infections with MRSA, UTIs, C.Diff

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23
Q

What do you need regarding contact precautions?

A

• private room
• PPE (GOWN AND GLOVES)
• dispose of materials in patients room

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24
Q

What does droplet precautions mean, and what are some examples?

A

organism spreads through large droplets with mucous membranes when sneezing, coughing, spitting, TALKING

ex. flu, COVID, RSV (respiratory syncytial virus)

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25
Q

What are the necessary equipment for droplet precautions?

A

• mask needed within 3 to 6 feet
• MASK, GOWN, GLOVES, FACE SHIELD

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26
Q

What does airborne precautions mean, and what are some examples?

A

spreads through air currents (STUDENTS CANT TAKE CARE OF THEM)

ex. Ebola, TB, measles

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27
Q

What to do for airborne precautions?

A

• patient needs negative pressure room, might transfer patient if no room available
• N-95 MASK, GOWN, GLOVES

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28
Q

What is protective isolation used for?

A

patients who are immunocompromised (higher risk of sepsis), oncology patients, and those with transplants (ex. cystic fibrosis)

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29
Q

What to do when patients feel lonely and isolated?

A

socialize with them, setting up call with family, telling family to use PPE

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30
Q

What does the nursing process include? (6)

ADPIE

A

• Assessment
• Analysis (Diagnosis)
• Planning (Outcome)
• Planning (Intervention)
• Implementation
• Evaluation

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31
Q

What is the main purpose of Assessment?

A

recognizing cues

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32
Q

What is entailed in the Assessment process?

A

• data collected to determine abnormal info
• subjective, objective, primary (from patient), and secondary (obtained secondhand) information
• use info to reach a conclusion

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33
Q

What is the main purpose of Diagnosis?

A

analyzing cues and prioritizing hypothesis

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34
Q

What is entailed in the Diagnosis process?

A

• PES= problem, etiologys and symptoms
• NDA- NURSING DIAGNOSIS ASSOCIATION

MASLOWS HIERARCHY OF NEEDS!

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35
Q

What is the main purpose of Planning (Outcome)?

A

prioritizing hypothesis

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36
Q

What is entailed in the Planning (Outcome) process?

A

patient focused, short term (by end of shift) and long term goals, SMART goals

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37
Q

What does SMART goals stand for?

A

S- Specific
M- Measurable
A- Achievable
R- Reasonable
T- Timely

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38
Q

What is the purpose of Planning (Intervention)?

A

generating solutions

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39
Q

What is entailed in the Planning (Intervention) process?

A

• things done to fix the problem
• independent (nurse-initiated) and collaborative (orders from providers) interventions

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40
Q

What is the purpose of Implementation?

A

taking action and document; overlaps with all steps

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41
Q

What is entailed in the Implementation process?

A

ACTION PHASE OF THE NP (so is assessment and evaluation)

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42
Q

What is entailed in the Evaluation process?

A

• constantly checking to see if interventions are working, REASSESS!!
• if not working, reconsider and make changes

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43
Q

What are the 4 spatial zones of personal space?

A

Intimate (less than 18 inches)
Personal (18 in. to 4 ft)
Social (4–12 ft)
Public (>12 ft)

44
Q

Body language

A

gestures have different meanings in different cultures, like thumbs up, beckoning motion, smiling

BE MINDFUL OF FACIAL EXPRESSIONS

45
Q

What are some things you should know when it comes to cultural social organization? (3)

A

• know the family leader and decision maker
• know about expected death rituals
• know holiday dates

46
Q

What are some differences in cultural and ethnic practices? (8)

A

• health wellness practices
• end of life care
• language
• family patterns
• religious
• dietary restrictions
• gender for caring
• values, beliefs and behaviors

ALWAYS ASK, NEVER ASSUME!!!!!

47
Q

What are 6 things to consider regarding cultural PCC?

A

• verbal/nonverbal communication
• personal space
• body language
• time orientation
• social organization
• self awareness

48
Q

What are 3 barriers regarding culture PCC?

A

• lack of knowledge
• language
• sexism

49
Q

What are 9 complications of immobility?

A
  • orthostatic hypotension
  • venous thromboembolism (VTE)
  • atelectasis and pneumonia
  • constipation
  • pressure ulcers
  • contractures
  • renal calculi
  • osteoporosis
  • psychological effects like depression, sleep disturbances
50
Q

What is the drop in BP when relating to orthostatic hypotension?

A

20 mmHg systolic, 10 mmHg diastolic

51
Q

What are some things a nurse can do to help with orthostatic hypotension?

A

• move slowly with time to dangle extremities before standing
• education for family and patient is VERY important to prevent injury

52
Q

What is the most common source of VTE and what to look out for?

A

Deep vein thrombosis (DVT); EDEMA, REDNESS IN CALVES/LEGS

53
Q

What are some things a nurse can do to help with VTE?

A

• early mobility exercises after surgery can reduce risk of VTE
• thrombus embolic (antiembolism) stockings (TED)
• sequential compression devices (SCD)

54
Q

What is atelectasis?

A

alveoli collapse

55
Q

What can a nurse do to help with atelectasis and pneumonia?

A

• based on lung sounds, check vitals and patient report, then x-ray tests
• early mobilization/turning, coughing, deep breathing after surgery

56
Q

What can a nurse do to alleviate constipation?

A

• patient report of last BM (3 days or more) and abdominal sounds and distention
• mobility,fluids and meds used for treatment to increase motility and BM
• treatment especially important for those on NARCOTICS/OPIOIDS

57
Q

What can a nurse to do help with pressure ulcers?

A

• turn every 2 hours
• use pressure relieving mattresses

58
Q

What are contractures?

A

irreversible atrophy to muscle with stiffness and loss of movement; common areas are hands, feet, and knees

59
Q

What can a nurse do to help with contractures?

A

• ROM exercises used to prevent
• use braces and splints to reduce risk

60
Q

List the components of the spread of infection (6)

A

• infectious agents (pathogens)
• reservoir (living/nonliving, where they live and multiply)
• portal of exit (bodily fluids, coughing, sneezing, etc.)
• mode of transmission (direct/indirect contact, droplet, airborne)
• portal of entry (orifices, IV sites, vector bite)
• susceptible host

61
Q

What is a latent infection?

A

infection with no discernible symptoms like AIDS

62
Q

What is comprehensive assessment?

A

holistic data, observation, physical assessment, interview

63
Q

What is focused assessment?

A

data about an actual problem that has been identified or suspected

64
Q

Syndrome

A

several related problems are present

65
Q

Cognitive outcome

A

describes increase in patient knowledge and intellectual behaviors

ex. repeat info or apply knowledge

66
Q

Psychomotor outcome

A

patients achievement of new skills using physical assessment

67
Q

Affective outcome

A

describes changes in patient values, beliefs, and attitudes

ex. observing patient behavior and conversation

68
Q

Cultural imposition

A

applies the majority cultural view to people (opposite of cultural sensitivity)

69
Q

Socialization

A

learning to become a member of a society

70
Q

Assimilation

A

new members gradually take on essential values and beliefs of dominant culture

71
Q

ETHNIC Cultural Competency Tool

A

E-Explanation
T-Treatments
H-Healers
N-Negotiate
I-Intervention
C-Collaboration

72
Q

ASKED Model of Care

A

A-Awareness
S-Skills (ability to conduct cultural assessment with sensitivity)
K-Knowledge
E-Encounters (take practice to become competent)
D-Desire

73
Q

What does a nurse change agent do?

A

helps clients, families, groups, etc. facilitate and adjust to change

74
Q

Name 8 things a nurse can do to mitigate falls

A
  1. GAIT BELT
  2. Monitor client walking
  3. Clutter-free environment
  4. Orient client to situation
  5. Non-skid footwear
  6. Call light in reach
  7. Keep bed in LOWEST position
  8. Educate client about hazards and safety
75
Q

What does SPLATT stand for regarding falls?

A

S- Symptoms at time of fall
P- Prior history of falls
L- Location of fall
A- Activity at time of fall
T- Time of fall
T- Trauma post fall

76
Q

What is the PICOT acronym for?

A

how to use EBP’s, effectively search nursing literature

77
Q

What does PICOT stand for?

A

P- Patient, Population to be tested (ex. elderly)
I- Intervention, treatment to be provided (ex. dehydration)
C- Comparison, Control group (ex. elderly community dwellers)
O- Outcome, result to be measured (ex. symptoms of dehydration)
T- Time, duration (ex. hospitalization length)

78
Q

What is the 1st level of the Hierarchy of Needs (HON)?

A

physiological (food, water, shelter, sex, sleep, etc.)

79
Q

What is the 2nd level of the HON?

A

safety (employment, resources, health, etc.)

80
Q

What is the 3rd level of the HON?

A

love and belonging (friendship, family, sexual intimacy)

81
Q

What is the 4th level of the HON?

A

self esteem (confidence, achievement)

82
Q

What is the 5th level of the HON?

A

self actualization (creativity, purpose, morality…)

83
Q

What is the American Nurses Association (ANA)?

A

legal aspects of nursing, creates standards of practice for competent care

84
Q

What is the National Student Nurses Association (NSNA)?

A

student counterpart of ANA, advocates on behalf of student nurses

85
Q

What is the National League for Nursing (NLN)?

A

establishes and maintains universal standards of education for nurses

86
Q

What is the Joint Commission?

A

ensure quality and safety of hospital, hospital specific

87
Q

What is the International Council of Nurses?

A

ensures quality nursing across the globe

88
Q

Positioning patients

A

PROPER ALIGNMENT OF BED
USE OF ROM
DRAW SHEETS, PILLOWS, WEDGES, SIDE RAILS, OVERHEAD TRAPEZE, FOOTBOARD, SANDBAGS/TROCHANTER ROLLS, SPLINTS

89
Q

Sims bed position

A

semi-prone; enema

90
Q

Supine bed position

A

opposite of prone; dorsal-recumbent, head and shoulders on pillow

91
Q

Transferring patients out of bed

A

MECHANICAL LIFT
TRANSFER BOARDS
TRANSFER BELT

92
Q

Canes

A

hold the cane on the strong side, 4 inches to the side of the foot with elbow flexed 30 degrees at top of hip joint; move cane AND WEAK LEG, then strong leg

93
Q

The crutch pad for crutches should be…

A

3 fingers below the axilla

94
Q

How to move using crutches

A

MOVE 6 IN. WHEN WALKING
MOVE INJURED LEG FORWARD WITH CRUTCHES THEN STEP PAST WITH STRONGER LEG
30 DEGREE ELBOW FLEXION
GO UP STAIRS WITH GOOD LEG, GO DOWN STAIRS WITH BAD LEG

95
Q

Incubation (Stages of Infection)

A

initial infection, before symptoms appear

96
Q

Prodromal (Stages of Infection)

A

vague symptoms, most infectious

97
Q

Convalescence (Stages of Infection)

A

returns to normal health after illness and illness decline

98
Q

Layer 4 of the CJMM

A

all factors that affect care; context/setting

99
Q

Layer 3 of the CJMM

A

nursing process (ADPIE)

100
Q

Layer 2 of the CJMM

A

cycle of forming, refining, and evaluating hypothesis

101
Q

Layer 1 of the CJMM

A

clinical judgement

102
Q

Layer 0 of the CJMM

A

client goals/needs are met (THIS IS THE GOAL!)

103
Q

What does the BALI acronym stand for regarding cultural competency?

A

B- Be aware of your own cultural beliefs
A- Appreciate that the client is unique and is influenced by culture, not defined
L- Learn about clients cultural group
I- Incorporate clients cultural values in care plan

104
Q

Name the 8 Assistive Devices

A
  1. canes
  2. walkers
  3. braces
  4. crutches
  5. gait belts
  6. patient lifts
  7. transfer board
  8. scoot sheet
105
Q

Moving clients in bed

A

MOVING UP IN BED
TURNING
LOGROLLING
FRICTION REDUCING DEVICES LIKE SCOOT SHEETS AND TRANSFER

106
Q

Walker

A

stand between the back legs of the walker, DO NOT SLIDE WALKER UNLESS THERES WHEELS, move weaker leg forward as walker goes forward

107
Q

What are extrinsic risk factors?

A

environmental factors and activities that increase the risk of falling; ex. inappropriate cane size, clutter, no grab bars