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Core Concepts (Level 1 Nursing) > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

What are Ethical Principles?

A

Standards for what is right or wrong in regards to particular rights and norms

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2
Q

Basic Principles of Ethics

A
  • Advocacy
  • Confidentiality
  • Accountability
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3
Q

Advocacy

A

support of clients’ health, wellness, safety, and personal rights including privacy

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4
Q

Confidentiality

A

Protection of privacy without diminishing access to high quality care

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5
Q

Accountability

A

Ability to answer for one’s own actions

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6
Q

Ethical Principles

A 
Autonomy 
Justice
Veracity
Fidelity 
Beneficence 
Non-Maleficence 
Integrity
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7
Q

Autonomy

A

right to self determination

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8
Q

Justice

A

Treating people equally

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9
Q

Veracity

A

To tell the truth

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10
Q

Fidelity

A

To keep one’s promise

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11
Q

Beneficence

A

To do good

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12
Q

Non-Maleficence

A

To do no harm

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13
Q

Integrity

A

Do the right thing even when there is no one watching

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14
Q

What are ethical dilemmas?

A

Problems between people with different values and beliefs

you will never fully avoid ethical dilemmas but remember that you must ALWAYS self-reflect

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15
Q

Student Handbook

A
  • Phones and computers are a privilege
  • Classroom Dress Code
  • Standards of practice in nursing
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16
Q

ANA Code of Ethics

A
  • Largest nursing organization in the United States
  • Outline ethical obligations and duties of the nursing profession
  • 9 provisions that serve as the basic guidelines to the nursing profession
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17
Q

BON Guideline for Practice

A
  • Regulate the practice of nursing
  • Established a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advance practice licensure
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18
Q

What constitutes a therapeutic environment?

A

-Developing a trusting relationship where the patients feel comfortable sharing their story

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19
Q

4 things included in a therapeutic environment?

A
  1. Begin with the purpose of the interview
  2. Make sure the client is comfortable
  3. Gather information (General Survey)
  4. Conclude the interview by summarizing your findings
    * Remember to ALWAYS use open ended questions*
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20
Q

Health History Components

A
  1. Demographic Information
  2. Source History
  3. Chief Concern
  4. History of Present Illness
  5. Past history and current health status
  6. Family History
  7. Psychosocial History
  8. Health Promotion Behaviors
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21
Q

Demographic Information

A
  1. Name

2. D.O.B.

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22
Q

Source History

A
  1. Client/Patient

2. Family Members

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23
Q

Chief Concern

A

What is the main symptom being experienced

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24
Q

History of Present Illness

A
  1. Chronological description explaining why the clients seeks care
  2. P.Q.R.S.T.
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25
Q

Past history and current health status

A
  1. Illnesses
  2. Allergies
  3. Current Medications
  4. Lifestyle patterns (alcohol and tobacco use)
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26
Q

Family History

A

Family medical history

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27
Q

Psychosocial History

A
  1. Relationships
  2. Financial Status
  3. Spiritual Health
  4. Culture
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28
Q

Health Promotion Behaviors

A
  1. Exercise
  2. Activity
  3. Diet
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29
Q

Types of Data Collection

A

Subjective and Objective data

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30
Q

Subjective data

A

is information from the CLIENT/PATIENT

  • such as symptoms and chief complaint
  • Pain is always subjective (physical and emotional)
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31
Q

Objective data

A

Information that is measurable

  • such as info gathered in a physical exam and through diagnostic tests
  • use of senses (hearing, sight, touch, and smell)
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32
Q

Documentation

A

-standard for many accrediting agencies including the Joint Commission

33
Q

Joint Commission

A

Mandates the use of computerized databases to expedite the accreditation process

34
Q

Purposes for Medical Records

A
  1. Communication
  2. Legal Documentation
  3. Financial Billing
  4. Education
  5. Research
  6. Auditing
35
Q

Computerized Healthcare Should Contain

A
  1. Client Support
  2. Health Information and Data
  3. Administrative Processes
  4. Results Management
  5. Secure Electronic communication and connectivity
  6. Decision Support
36
Q

Elements of documentation

A 
Subjective Data (direct quotes from patient)
Objective Data (Should be descriptive and should include what the nurse sees, hears, feels, and smells)
*objective data should not contain any judgement)
37
Q

How do you conduct a Cardiac Assessment?

A

-measure heart rate and blood pressure
-examine the jugular veins
-auscultate the heart sounds (s1 and s2)
(diaphram=high pitch sounds)
(Bell=low pitch sounds)

38
Q

Equipment used in cardiac assessment

A
  • stethoscope
  • BP cuff
  • watch
39
Q

Cardiac Inspection and Palpation

A
  • JVD
  • Apical pulse
  • Lifts of chest
40
Q

Cardiac Auscultation

A

Turning to the left side allows for better auscultation

41
Q

Cardiac heart sounds

A

S1: LUB=closure of tricuspid and mitral valves
S2: DUB=closure of aortic and pulmonic valves

42
Q

Sites of the heart

A 
Aortic (right)
Pulmonic (left)
Erb's Point
Tricuspid
Apical/Mitral (5th intercostal space, mid-clavicular line)
43
Q

What is a General Survey?

A

A written summary/appraisal of overall health (1st interaction with the client)

44
Q

Components of a General Survey

A
  1. Physical Appearance
  2. Body Structure
  3. Mobility
  4. Behavior
  5. Vital Signs
45
Q

Components of Physical Appearance in a General Survey

A 
Age
Gender 
Race or Ethnicity
Color of skin
Level of consciousness (LOC)
Facial Features
46
Q

What is assess within the mobility segment of a general survey?

47
Q

Components of behavior in a general survey

A

Dress
Hygiene
Grooming
Odors

48
Q

Components of Vital signs in a general survey?

A 
Temperature
Pulse
Respirations
Blood Pressure
Oxygen Saturation
49
Q

Steps of Assessment

A

Inspect, palpate, percuss, auscultate

*Abdomen: Inspect, auscultate, percuss, palpate

50
Q

Pain Assessment

A 
P-Provoke
Q-Quality
R-Region/Radiation
S-Severity/Setting(Origination)
T-Timing
*use face scale if <7 yrs of age
51
Q

Vital Signs and Pain

A

Vital signs may be elevated when experiencing pain

52
Q

Non-Pharmalogical Comfort Measures for pain

A
  1. Relaxation
  2. Imagery
  3. Distraction
  4. Acupuncture
  5. Music Therapy
  6. TENS Unit (Heat/Cold therapy touch)
  7. Humor
  8. Meditation
  9. Breath-work
53
Q

Types of Pain

A 
Acute
Chronic
Central
Breakthrough
Phantom
Psychogenic
Nociceptive
54
Q

Acute pain

A
  • Temporary

- < 6 months

55
Q

Chronic pain

A
  • Ongoing and reocurring

- > 6 months

56
Q

Central Pain

A

Nerve pain

57
Q

Breakthrough Pain

A
  • Not managing pain well/not staying on top of surgery

- Hard to control if you do not control pain well

58
Q

Phantom Pain

A

Pain in limb after amputation

59
Q

Psychogenic

A

Pain associated with psychological factors (fear, anxiety, and depression)

60
Q

Nociceptive Pain

A
  • Damage to tissue or inflammation of tissue
    1. Somatic: bones, joints, muscles
    2. Visceral: internal organs
    3. Cutaneous: ski or subcutaneous tissue
    4. Referred: sensed in a region other than the site of origin
61
Q

Clinical Manifestations of pain

A
  1. Facial Expressions
  2. Exhaustion
  3. Tears
  4. Decreased Attention Span
62
Q

Pain Threshold

A

the point at which a patient feels pain

63
Q

Pain Tolerance

A

the amount of pain the person is willing to bear

64
Q

Transduction

A

painful stimuli to an electrical impulse

65
Q

Acute pain and anxiety

A

Acute pain can lead to increased anxiety

66
Q

Chronic pain and depression

A

Chronic pain can lead to increased depression

67
Q

Factors that affect pain experience

A

Age
Fatigue
Culture

68
Q

Holistic Assessment includes

A
  1. AIDET
  2. Gain trust/rapport
  3. Complete health history
  4. Cultural Assessment
  5. Comprehensive physical assessment
  6. Comprehensive psychosocial assessment
    * Infants and children require a different assessment approach*
    * Assessment for Older adults requires a comprehensive understanding of the factors aging plays in physical, social, mental, and emotional health.
69
Q

Techniques of physical assessment

A

inspect
palpate
percuss
auscultate

70
Q

Quality and Safety Education for Nurses (Q.S.E.N.)

A
  1. Patient centered care
  2. Quality improvement
  3. Evidence based practice
  4. Teamwork and collaboration
  5. Safety
  6. Informatics
71
Q

What are the national patient safety goals per the Joint Commission?

A
  1. Correctly identify the patient (Name/D.O.B.)
  2. Improve Staff Communication
  3. Use medicines safely
  4. Use alarms safely
  5. Prevent infection
  6. Identify patient safety risks
  7. Prevent mistakes in surgery
72
Q

Accident/Error/Injury Prevention (Falls)

A
  • Perform fall risk assessment
  • Appropriate number of side rails raised
  • Personal items close by/bed side table
  • Call light within reach and patient knows how to use it
  • Use fall risk alerts/ ID bands
  • Hourly rounds
  • Gait belts/safety equipment
  • High risk patients near the nursing station
  • Bed in lowest position/wheels are locked
73
Q

Why are restraints used?

A

To protect a patient and other patients or staff

  • Never use for punishment or convenience
  • provider must prescribe seclusion or restraints in writing after a face to face assessment of the client
74
Q

What are the two types of restraints?

A

Physical and Chemical

75
Q

What is R.A.C.E.

A 
Used in fire emergency
R-Rescue
A-Alarm
C-Contain
E-Extinguish
76
Q

What is P.A.S.S.

A 
How to use fire extinguisher
P-Pull the pin
A-Aim at the base of the fire
S-Squeeze the lever
S-Sweep side to side
77
Q

Home Safety

A
  1. Basic First Aid
  2. CPR
  3. Keep emergency numbers near phone
  4. Fire Extinguisher
  5. Smoke Detectors
  6. Safety plans for fires (practice regularly)
  7. Watch for carbon monoxide
78
Q

Standard Safety Precautions

A
  • Always exercise hand hygiene
  • Needle sticks (never recap; properly dispose of sharps)
  • Exposure to blood borne paths (P.P.E.-glove gown masks)
  • Latex allergy (limit exposure and hand hygiene)
  • Musculoskeletal Injuries (practice good ergonomics and use mechanical lift devices)
  • Workplace violence (know how to call for help, policies and procedures, harsh punishment for violators)
  • Emergency Codes

Core Concepts (Level 1 Nursing) (2 decks)

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