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Fundamentals > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

critical thinking is the foundation for

A

effective communication

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2
Q

domains of nursing

A

nursing learning health individuals

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3
Q

7 core concepts

A

caring, professionalism, role competence, communication, cultural sensitivity, critical thinking, research and evidence based medicine

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4
Q

Caring

A

reflects valuing of others, nurses commitment to concern of self and others, theorist Jane Watson

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5
Q

professionalism

A

commitment to following core values, ethics, values and standards of nursing including advocacy, leadership, accountability, responsibility, and life long learning

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6
Q

Role Competence

A

application of specialized nursing knowledge, values, and skills necessary to provide safe care to people in different settings

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7
Q

Communication

A

exchange of facts, theorist Hildegard Peplau

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8
Q

Cultural Sensitivity

A

process of recognizing accepting and respecting different world views, informed interaction with others

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9
Q

Critical thinking

A

process that includes questioning, analysis, interpretation, inferences, and synthesis, that informs independent and interdependent nursing practices.

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10
Q

Research and evidence based practice

A

research- purpose to generate new knowledge

evidence based- existing knowledge utilized for nursing

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11
Q

nurse from the Latin word

A

nutrix meaning nourish

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12
Q

no longer true that ‘a nurse is a nurse’

A

area oriented can blindly go to a different floor

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13
Q

Virginia Henderson’s definition of nursing

A

assist sick or well, contributing or teaching about health or recovery (or peaceful death) that would be preformed unaided if they had the strength, will, or knowledge, and to help them regain independence as quickly as possible.

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14
Q

nursing is both a

A

science and an art

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15
Q

four broad aims for nursing practices

A

promote health, prevent illness, restore health, and facilitate coping

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16
Q

major goal for nursing is

A

client advocacy- speech for client when they are unable to for them self

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17
Q

nursing is now recognized as a

A

profession

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18
Q

criteria for a profession

A

according to Bixler: High intellectual level (critical thinking), high level of individual responsibility and accountability, authority, specialized knowledge, higher education, public service, code of ethics, have license

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19
Q

career

A

person’s major life work

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20
Q

job

A

group of positions that are similar in nature and skill, can be taught to anyone with similar skills

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21
Q

power

A

ability or capacity to exert influence over another person or group

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22
Q

sources of power

A

referent, expert, reward, coercive, legitimate, and collective

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23
Q

referent

A

power from close personal relationship with someone, parent or spouse

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24
Q

expert

A

power from knowledge, skills, or expertise…. professional such as doctor or manager

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25
Q

reward

A

power from the ability of one person to give another some type of reward for behaviors, job rewards

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26
Q

coercive

A

power from ability to punish or withhold reward, jobs

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27
Q

legitimate

A

power from legal act that gives them right to make decisions,, political

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28
Q

collective

A

power of a large group with similar beliefs, desires or needs… nursing is the largest group in healthcare

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29
Q

ways to increase powers in nursing

A

professional unity, political activities, accountability and professionalism, networking

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30
Q

5 vital signs

A

temperature(T), pulse (P), respirations (RR), blood pressure (BP)

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31
Q

baseline vital signs

A

tell us usually state of health for comparison

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32
Q

vital signs are a quick way to

A

monitor condition, identify problems, evaluate response to interventions

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33
Q

Alteration in vital signs indicates

A

change in condition

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34
Q

who can take vital signs?

A

nurse aide, medical assistants, family, pt, RN (responsible for the meaning and making sure its done)

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35
Q

How often should vitals be taken?

A

depends on pt condition, change in floor or meds, dr orders, nurse judgment but must at least follow Dr order

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36
Q

body temperature

A

heat produced- heat lost

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37
Q

core body temperature

A

in deep tissues, rectal tympanic esophagus pulmonary artery and urinary bladder

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38
Q

surface temperature

A

oral or axillary

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39
Q

normal range for temperature

A

36C-37.5C, 97F-99.5F, mean of 98.6F or 37C

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40
Q

temperature is regulated by

A

the hypothalamus

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41
Q

mechanism for heat production

A

metabolism, muscular activity, piloerection, hormones, fever, temperature

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42
Q

mechanism for losing heat

A

sweating

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43
Q

processes of losing heat

A

radiation, conduction, convection, evaporation

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44
Q

fever

A

pyrexia, rise in body temperature (100.4), can be from bacterial or viral, also from tissue injury

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45
Q

febrile

A

have fever

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46
Q

afebrile

A

without fever

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47
Q

FUO

A

fever of unknown origin

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48
Q

neurogenic fever

A

caused by damage to the hypothalamus

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49
Q

oral temperature

A

average 98.6F or 37C, need closed mouth, easy accurate comfortable, must wait 30 minutes from eating or drinking, can’t use on infants pt with o2 mask or face trauma

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50
Q

rectal temperature

A

average 99.5F and 37.5C, reliable core temp, cant be used on pt with diarrhea rectal surgery cardiac pt (can hit vegas never and decrease HR)

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51
Q

axillary temperature

A

average 97.7F or 36.5C, safe inexpensive, long measurement time and can be effected by position or environment

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52
Q

tympanic membrane temperature

A

average is 99.5F or 37.5C, easy provides core, not accurate in under 3 can also be inaccurate due to positioning

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53
Q

pulse caused by

A

contraction of the left ventricle

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54
Q

pulse is regulated by

A

SA node

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55
Q

parasympathetic NS

A

slows down HR

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56
Q

sympathetic NS

A

speeds up HR

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57
Q

normal pulse rate

A

60-100 bpm

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58
Q

tachycardia

A

HR >100 bpm

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59
Q

Bradycardia

A

HR < 60 bpm

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60
Q

pulse amplitude and quality

A

reflects volume of blood being ejected against the arterial wall 0-4(absent to bounding)

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61
Q

respiration

A

mechanism used to exchange o2 and co2 between the atmosphere and the blood and cells, regulated by the respiratory system in the brain stem

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62
Q

inspiration

A

act of breathing in (active)

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63
Q

expiration

A

act of breathing out (passive)

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64
Q

respirations average between

A

12-20 per minute in an adult

65
Q

tachypnea

A

increased RR (over 24/min)

66
Q

bradypnea

A

decreased RR (less than 10/min)

67
Q

Apnea

A

absence of breathing

68
Q

dyspnea

A

difficult or labored breathing

69
Q

characteristics of respirations

A

depth-deep normal or shallow, rhythm-labored irregular or regular

70
Q

blood pressure

A

force of blood against the arterial walls, provides tissue perfusion (pushes blood through the tissue)

71
Q

BP=

A

cardiac output x peripheral resistance (smaller lumen)

72
Q

arterial dilation

A

decreased BP

73
Q

arterial constriction

A

increased BP

74
Q

CO=

A

(cardiac output)= HR x stroke volume

75
Q

BP is determined by

A

Cardiac output, vascular resistance, volume of blood, viscosity, and elasticity of arterial walls

76
Q

systolic BP

A

peak of maximum pressure when ejection of blood from LV occurs, top #

77
Q

diastolic BP

A

minimum pressure exerted against the arterial walls, when the LV relaxes, bottom #

78
Q

measure of BP

A

in mm/Hg

79
Q

normal range of BP

A

<120/80

80
Q

prehypertension range

A

120-139/ 80-89

81
Q

stage 1 hypertension range

A

140-159/ 90-99

82
Q

stage 2 hypertension range

A

> 160/>100

83
Q

orthostatic hypotension

A

low blood pressure when rise position, SBP drops 20 points, caused by peripheral vasodilation w/o rise in CO, may be dizzy

84
Q

which vital signs are routinely measured?

A

pulse ox, BP, P, RR, T

85
Q

in clinical practice what sites can pulse be measured?

A

posterial tibial, radial, femoral, carotid

86
Q

BP can be measured using a cuff _____ and _____

A

stethoscope and sphygmomanometer

87
Q

normal arterial blood oxygen saturation is

A

95-100%

88
Q

purposes for infection control

A

reduce or eliminate source of infection and to protect client from disease

89
Q

client entering hospital are more at risk for infection bc

A

lower resistance, increased exposure to large number and type of disease organisms, they may have invasive procedures

90
Q

order in which infection occurs

A

infectious agent, reservoir, portal of exit, means of transmission, portal of entry, susceptible host

91
Q

standard precautions

A

used on all clients apply when in contact with blood, fluids secretions, nonintact skin, mucous membranes

92
Q

transmission based precautions

A

in addition to standard precautions for clients with suspected infection transmitted by airborne droplet or contact routes

93
Q

Airborne precautions

A

transmitted by airborne droplet nuclei, private room, monitor negative air pressure(6-12 exchanges per hour), door closed, fitted HEPA mask, for things like TB chicken pox and rubella

94
Q

droplet precautions

A

transmitted by large droplet, private room, door may be open, surgical mask within 3 ft, for things like rubella mumps diphtheria flu

95
Q

contact precautions

A

spread by direct or indirect, private room, gloves, gown, dedicated equipment, for things like MRSA

96
Q

types of healthcare associated infections (nosocomial)

A

exogenous, endogenous, and Iatrogenic

97
Q

exogenous

A

causative organism from other people

98
Q

endogenous

A

causative organism comes from germs person has

99
Q

Iatrogenic

A

occurs as a result of treatment or diagnostic procedure

100
Q

key factors in disinfection

A

time, concentration of chemical, temperature of chemical, type of organism

101
Q

major classes of chemical compounds

A

chlorine(effective against AIDS), iodine (bactericidal), ethyl/isopropyl alcohol (antiseptic, germicide)

102
Q

asepsis

A

absence of disease producing microorganisms

103
Q

pathogen

A

disease producing microorganism

104
Q

medical asepsis

A

practice to prevent spread of pathogens, clean technique

105
Q

isolation technique

A

practice to prevent transmission of microorganisms

106
Q

assessment process

A

collection, validation, organization, and recording data

107
Q

database assessment

A

comprehensive (all aspects of health)

108
Q

focus assessment

A

determine state of specific condition

109
Q

maslow’s hierarchy of needs high priority

A

at the bottom 1)physiological needs 2)safety and security 3) love and belonging 4)self esteem 5) self actualization

110
Q

physiological needs

A

activity and exercise, normal temp, food balance, sexuality, cleanliness, no pain, water-salt balance, o2 and circulation, sleep

111
Q

safety and security

A

dependence, stability, protection from harm

112
Q

love and belonging

A

love and affection, acceptance, approval from others, unity with loved ones

113
Q

self esteem needs

A

usefulness, self reliance, goal achievement, independence, endurence

114
Q

esteem from others

A

dignity, attention, importance

115
Q

self actualization needs

A

personal growth, awareness, increased learning, religious satisfaction

116
Q

parts of a rapid assessment

A

ABC, what’s going into/out of the pt, pain, and safety

117
Q

nursing goal in wound care

A

promote tissue repair

118
Q

intentional wound

A

planned therapy or treatment, risk of infection is low, surgery IV lumbar puncture

119
Q

unintentional wound

A

unexpected trauma, high risk of infection, accidents burns forceful injury

120
Q

open wound

A

can be intentional or unintentional, skin surface is broken

121
Q

closed wound

A

result of blow, skin surface not broken but soft tissue is damaged

122
Q

acute wound

A

recent injury, less than 30 days old

123
Q

chronic wound

A

persist beyond healing time, can require serial debridements

124
Q

abrasion

A

friction of skin

125
Q

puncture

A

penetrating trauma

126
Q

laceration

A

open wound or cut, ragged edges with torn tissues

127
Q

contusion

A

bruise

128
Q

avulsion

A

catching leg on door, skin completely torn away from the body

129
Q

staging pressure ulcers

A

1) red nonblanchable 2)actual break in skin, blister 3) beyond dermis into subcutaneous tissue 4) extends to muscle or bone

130
Q

red wound

A

needs protection

131
Q

yellow wound

A

infection, needs cleaning

132
Q

black wound

A

eschar, needs debridement

133
Q

serous wound drainage

A

clear and watery

134
Q

sanguineous

A

looks like blood

135
Q

serosanguineous

A

combination of clear and blood

136
Q

purulent

A

yellow/green foul smell

137
Q

non-stick dressing

A

prevent dressing from stick to wound, petrolatum or telfa

138
Q

gauze

A

most common, also for packing

139
Q

transparent dressing

A

applied over small wound protect skin from shearing, Op site

140
Q

hydrocolloids

A

absorb drainage, occlusive and adhesive, provides cushioning, Duoderm

141
Q

hydrogels

A

o2 permeable, non-adhesive maintains moisture, Aquasorb

142
Q

hemorrhage

A

excessive bleeding after first 48 hours of surgery, internal swelling, apply additional dressing and watch VS, DO NOT REMOVE ORIGINAL DRESSING

143
Q

hematoma

A

bruise, localized collection of blood

144
Q

infection

A

usually 2-11 days, increased drainage (purulent), increased WBC in labs

145
Q

dehiscence

A

serious, something gave way, increase serosanguineous post op 4-5 day

146
Q

Evisceration

A

organ comes out

147
Q

fistula

A

tube like passage way that forms between 2 organs

148
Q

fight or flight response

A

arousal of sympathetic NS, prepares body for action

149
Q

medulla oblongata

A

controls HR BP and RR

150
Q

reticular formation

A

continuously monitors the physiological status of the body through connection with sensory and motor tracts

151
Q

pituitary gland

A

produces hormones that adapt to stress, regulates other hormones, feedback mechanism

152
Q

three stage reaction to stress

A

1) Alarm stage 2) resistance stage 3) exhaustion stage

153
Q

GAS

A

general adaptive syndrome

154
Q

alarm reaction

A

can last one minute to several hours, increase pupil dilation HR hormone level blood volume blood glucose levels blood flow to muscles o2 intake and mental alertness

155
Q

resistance stage

A

body stabilizes and returns to normal

156
Q

exhaustion stage

A

body can no longer resist effects of stress, may result in death

157
Q

Lazarus theory

A

transactional stress theory- cognitive affect coping response

158
Q

psychological indicators of stress

A

anxiety, anger, depression

159
Q

cognitive indications of stress

A

problem solving, self control, suppression, day dreaming

Fundamentals (4 decks)

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