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NRAD 201B > Exam 1 Flashcard CSV - ALL > Flashcards

Exam 1 Flashcard CSV - ALL

1
Q

What is subjective data in healthcare?

A

what pt tells you
- signs, symptoms
- reasons for seeking healthcare
- pain location
* pain intensity
* descriptions

ex: “I feel nauseated” or “I can’t see out of my left eye”.

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2
Q

How is subjective data typically documented?

A

quoting the actual words said by the client or family member

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3
Q

What does subjective data reveal?

A

perspective of the person giving the data
* thoughts
* feelings
* beliefs
* sensations

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4
Q

How can subjective data be used in relation to objective data?

A

used to clarify objective data
ex: asking “How did you get the scar?”

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5
Q

What is objective data in healthcare?

A

factual, measurable clinical findings

  • quality of breath sounds
  • vital signs
  • observed pain behaviors

what the nurse sees, hears, feels, and smells

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6
Q

How is objective data gathered?

A
  • physical assessment
  • laboratory results
  • diagnostic tests
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7
Q

How can objective data be used with subjective data?

A

validate or verify subjective data
ex: high pulse rate with description of pain

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8
Q

What is primary data in healthcare?

A

subjective or objective
obtained directly from the client
* their words: “I’m in pain”
* your own observations: vitals, body cues…

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9
Q

What is secondary data in healthcare?

A
  • obtained secondhand
  • the medical record: lab results
  • or from another caregiver
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10
Q

What are methods to obtain subjective data during a patient interview?

A
  • interviewing
  • open and closed questions
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11
Q

What are methods to obtain objective data during a physical exam?

6 types of assessing

A

Objective data can be obtained through
* inspection: sight
* palpation: touch
* percussion: tapping
* olfaction: smell
* direct auscultation (just ears)
* indirect auscultation (with a stethoscope)

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12
Q

What is the purpose of a comprehensive health assessment?

A

provides holistic information about the client’s overall health

  • physiological
  • psychological
  • socio-cultural
  • developmental
  • spirituality
  • chief complaint
  • current medications
  • health history: immunizations, conditions, surgeries
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13
Q

What does a comprehensive exam include?

A
  • observation
  • physical exam
  • interviewing
  • extensive health history
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14
Q

What and when is a focused assessment?

A
  • targets a specific issue
  • is performed when a particular problem is identified or suspected.
  • PRN
  • following up during treatment
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15
Q

What is a special needs assessment?

A

A focused assessment
in-depth information about a particular area

  • functional ability: PT, ST, RT
  • withdrawal (CIWA)
  • nutrition
  • pain
  • cultural/spiritual health
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16
Q

What is the Lawton Instrumental Activities of Daily Living (IADL) scale?

A

a person’s ability to perform sophisticated everyday tasks independently
* shopping
* meal preparation

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17
Q

What is the Katz Index of ADL scale used for?

A

patient’s independence in basic activities
* bathing
* dressing
* toileting
* transferring
* continence
* feeding

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18
Q

How should nursing assessments be individualized based on lifespan considerations?

4 points

A

consider
* developmental stages
* physical abilities
* cognitive abilities
* sensory changes

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19
Q

What are the five senses and their role in sensory perception across the lifespan?

A
  • sight
  • hearing
  • taste
  • smell
  • touch

all of which can decline with age, impacting
* balance
* communication
* safety.

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20
Q

How can sensory overload occur, and what are interventions for it?

A
  • too much sensory input (e.g., noise, light)

Interventions include
* reducing stimuli
* providing rest
* organizing care to limit disturbance

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21
Q

How can sensory deprivation occur, and what are interventions for it?

A

lack of stimulation (e.g., isolation)

Interventions include
* increasing stimuli
* engaging the patient
* providing meaningful interactions

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22
Q

What are common manifestations of altered mental sensory function, and what are their causes?

A

Manifestations include
* confusion
* disorientation
* hallucinations

often caused by
* sensory deficits
* medications
* environmental factors

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23
Q

What are the key components of cognition and communication?

A
  • perception
  • memory
  • reasoning
  • judgment
  • problem-solving abilities
  • clear thinking
  • awareness
  • effective communication skills
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24
Q

What influences cognitive function across the lifespan?

A
  • age
  • health status
  • education
  • environment
  • lifestyle factors: diet and exercise…
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25
Q

What factors can affect cognitive processes?

A
  • illness
  • medication side effects
  • age-related changes
  • stress
  • neurological disorders.
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26
Q

What are the normal functions of the musculoskeletal system?

3 points

A
  • supports movement
  • posture
  • protection of organs.
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27
Q

What are the characteristics of normal movement?

3 points

A
  • smooth, coordinated, voluntary movements
  • full ROM
  • muscle strength
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28
Q

What factors can affect or alter mobility?

A
  • age
  • injury
  • disease
  • medications
  • lifestyle habits: exercise and nutrition.
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29
Q

How does immobility impact physiological functioning?

A
  • muscle atrophy
  • joint stiffness
  • pressure ulcers
  • constipation
  • respiratory complications
  • decreased circulation: causing blood clots.
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30
Q

How does immobility impact psychological functioning?

A
  • depression
  • anxiety
  • social isolation
  • decreased self-esteem due to loss of independence.
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31
Q

What is the purpose of logrolling in nursing interventions?

A
  • Maintain spinal alignment
  • prevent injury
  • particularly for patients with spinal or back injuries.
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32
Q

How does ambulation support patient recovery?

A
  • Ambulation improves circulation, muscle strength
  • prevents complications such as blood clots and pneumonia.
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33
Q

Why is range of motion (ROM) important in patient care?

A
  • maintain joint flexibility
  • muscle strength
  • circulation
  • prevent contractures
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34
Q

What subjective data should be collected to assess mobility status?

A

includes the patient’s
* pain level
* ability to move
* past injuries
* current limitations

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35
Q

What objective data should be collected to assess mobility status?

A
  • range of motion
  • muscle strength
  • gait
  • posture
  • balance
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36
Q

What are the principles of correct body mechanics?

A
  • using legs instead of the back for lifting
  • keeping the spine aligned
  • maintaining a wide base of support
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37
Q

How does the HIPAA Privacy Rule protect health information?

A
  • regulating the use and disclosure of protected health information (PHI)
  • ensuring individuals’ privacy rights.
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38
Q

What are the methods for measuring body temperature?

6 points

A
  • oral: 97.7-99.5 normal
  • rectal: 98.7-100.5 can cause injuries/complications/discomfort
  • axillary: lower than oral
  • tympanic: 98.2-100 normal
  • temporal: 98.7-100.5
  • dermal
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39
Q

what technique is used for tympanic temperatures?

A
  • Adults: pull top of ear up and back
  • Ped: pull bottom of ear down and back
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40
Q

what is the dermal route for temperature?

A
  • strip on forehead
  • used during surgery
  • not as accurate
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41
Q

When is oral temp contraindicated?

A
  • not useful is patient is eating/drinking
  • contraindicated in patients with mouth injuries
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42
Q

What can affect rectal temp?

A
  • presence of stool
  • not as accurate as oral
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43
Q

How to take a rectal temperature?

A
  • Sims position: left side, legs stacked
  • red probe
  • protective sheath and lube
  • adult: insert 1-1.5”
  • ped: 1”
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44
Q

how does axillary temp differ from oral reading?

A

axillary temp is lower than oral

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45
Q

What can affect a tympanic temp?

A
  • presence of earwax
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46
Q

What is the least accurate temp location?

A

tympanic

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47
Q

What affects body temperature?

A
  • exertion
  • bathing
  • location/route
  • eating/drinking
  • wait 10-15 minutes for body to settle
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48
Q

Define rigors

A
  • shaking
  • used to create fever
  • could be indication of sepsis
  • fever will present within an hour of onset.
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49
Q

febrile / afebrile

A

fever / no fever

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50
Q

hyperthermia / hypothermia

A

high body temp / low body temp

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51
Q

What is the radial pulse and where is it located?

A
  • wrist, below the thumb
  • routine pulse measurements
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52
Q

Where is the apical pulse and how is it measured?

A
  • fifth intercostal space near the left midclavicular line
  • measured using a stethoscope
  • must count for full minute
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53
Q

What characteristics are assessed in pulse and how long do you count?
RRS

A
  • rate, rhythm, and strength
  • even: 15 sec and multiply by 4 for minute
  • irregular: count whole minute
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54
Q

What is the difference between systolic and diastolic blood pressure?

A
  • Systolic pressure is the force during heart contraction
  • diastolic pressure is the force when the heart is at rest
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55
Q

How is orthostatic hypotension assessed?

A

Measure blood pressure in
* supine
* sitting
* standing positions
check for a drop in BP upon standing

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56
Q

What is the physiology and purpose of pulse oximetry?

A
  • measures arterial oxygen saturation (SaO2)
  • detecting light absorption differences
  • oxygenated vs. deoxygenated hemoglobin
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57
Q

Tips for obtaining accurate pulse oximetry readings

A
  • keep arm straight
  • keep extremities warm: vasoconstriction May limit circulation
  • can use the earlobe or nose for poor perfusion in extremities
  • dim lights or cover the probe with covers or a towel
  • May need to remove nail polish
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58
Q

What are the characteristics of pain used for assessment?

A
  • location
  • intensity
  • quality
  • duration
  • aggravating/relieving factors
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59
Q

What are the steps for inspecting the skin?

A

Inspect for
* color
* vascularity
* edema
* lesions

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60
Q

What are the steps for palpating the skin?

A

Palpate for
* temperature
* moisture
* texture
* thickness
* turgor

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61
Q

How are the eyes assessed during a physical exam?

A
  • pupil size
  • PERRLA

vision changes due to aging
* cataracts
* presbyopia: gradual loss of your eyes’ ability to focus on nearby objects

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62
Q

What is PERRLA

A

pupils are
equal
round and
reactive to
light and
accommodation

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63
Q

What is SBAR communication, and why is it important in healthcare?

A

SBAR
Situation
Background
Assessment
Recommendation

  • a standardized method for effective communication between healthcare professionals.
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64
Q

What factors can influence pain perception in adults and geriatrics?

A
  • age
  • cognitive function
  • medication use
  • underlying chronic illnesses: that may alter pain tolerance or expression
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65
Q

When is a rectal temperature measurement contraindicated?

A
  • rectal surgery
  • hemorrhoids
  • low white blood cell count: to avoid risk of infection or injury
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66
Q

What factors can influence vital signs?

A
  • age
  • activity level
  • emotions
  • medications
  • illness
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67
Q

What are normal vital signs for adults?

A

Temperature: 97.7-99.5°F - Oral
Pulse: 60-100 bpm, athletes 40-60
Respiration: 12-20 breaths per minute
BP: <120/80 mmHg
SpO2: 95-100%.

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68
Q

What is the significance of pulse oximetry readings?

A

less than 94% can indicate hypoxemia

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69
Q

What is orthostatic hypotension?

A
  • Orthostatic hypotension is a drop in blood pressure when moving from a lying to standing position
  • must assess before first time getting a new pt out of bed
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70
Q

What interventions prevent complications of immobility?

A
  • position changes
  • ROM exercises
  • compression devices
  • proper hydration
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71
Q

What are the safety precautions when assisting patients to ambulate?

A
  • proper footwear
  • use assistive devices: (walker, cane, gait belt)
  • assess for dizziness or weakness to prevent falls
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72
Q

What is the purpose of HIPAA?

A

HIPAA ensures
- continuity of healthcare coverage when changing jobs
- simplifies health insurance administration
- manages health information
- protects personal health information (PHI)

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73
Q

What rights does HIPAA give patients regarding their health information?

A

Patients have the right
- to access their health records
- to control over the use and disclosure of their protected health information (PHI)
- to keep their information private.

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74
Q

What is considered confidential information under HIPAA?

A
  • Any personally identifiable information (PII)
  • protected health information (PHI)
  • name
  • social security number
  • date of birth
  • medical records
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75
Q

What are the permitted uses of PHI under HIPAA?

A

can be used for
* healthcare treatment
* payment
* healthcare operations
* quality assessment
* legal cases
* compliance audits

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76
Q

What is the difference between privacy and confidentiality?

A
  • Privacy refers to the individual’s right to keep personal information private
  • confidentiality is the duty to protect that information from being disclosed.
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77
Q

What are some safeguards to maintain HIPAA privacy?

A

Safeguards include
* speaking quietly
* not using names
* not sharing passwords
* disposing of PHI properly
* avoid photocopying or faxing PHI

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78
Q

What are the penalties for violating HIPAA?

A

Civil penalties
* range from $100-$50,000 per violation
* annual maximum of $1.5 million

Criminal penalties
* include fines up to $250,000 and imprisonment.

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79
Q

What are the social media restrictions under HIPAA?

A

must not
* post patient information
* take pictures of patients
* establish social relationships with patients
* make offensive comments about coworkers or employers online.

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80
Q

What should you do if there is a breach of PHI?

A

Report the breach immediately to the appropriate authorities, as required by the HITECH Act for breaches affecting more than 500 individuals.

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81
Q

What are the consequences of academic HIPAA violations?

A

Consequences include
* academic suspension
* course failure
* dismissal from nursing school
* disciplinary action by the Board of Registered Nursing.

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82
Q

How can language barriers be addressed in communication?

A

Use
* interpreters
* visual aids
* simple language

ensure patients understand their care.

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83
Q

How can you promote understanding in patient interactions?

A
  • clear language
  • explain carefully

check for understanding
* asking the patient to clarify or repeat

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84
Q

How do you assess coping and stress tolerance?

A

Listen for cues about
* recent stressors
* coping mechanisms
* thoughts of harming self or others: must report
* using open-ended questions.

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85
Q

How does being under the influence of substances affect communication?

A
  • impaired judgment
  • confusion
  • incoherence

requiring
* simple, direct, and nonjudgmental communication.

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86
Q

How does personal space affect communication?

A
  • ensures comfort
  • reduces feelings of vulnerability or threat during interactions
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87
Q

What are nonverbal cues in communication?

A
  • facial expressions
  • body language
  • eye contact
  • tone of voice
  • gestures

convey emotions or attitudes.

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88
Q

What are the key components of a physical assessment?

A
  • general appearance
  • vital signs
  • pain assessment
  • gathering subjective and objective data from the patient
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89
Q

What are the key elements to ensure during patient interaction?

A
  • privacy
  • sit at eye level
  • face the patient
  • reduce distractions
  • use therapeutic communication
  • ensure the patient understands
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90
Q

What aspects are assessed under cognition and perception?

A
  • Awareness
  • thought processes
  • memory
  • language
  • judgment
  • attention span
  • sensory impairments
  • trust: assess if they will physically strike out. be on guard.
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91
Q

What communication strategies are used with hostile or anxious patients?

A
  • remain calm
  • use non-confrontational language
  • provide reassurance to defuse tension and build trust.
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92
Q

What does it mean to facilitate communication?

A

ex: patient says they fell, you facilitate specificity.
what caused the fall? passing out? tripping? how often?

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93
Q

What effect does asking ‘Why’ questions have on communication?

A

Asking “Why” can
* make patients feel defensive or blamed, hindering open communication.
* seem confrontational

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94
Q

What is a physical assessment?

A
  • comprehensive head-to-toe or systems assessment
  • done each shift and as needed (PRN).
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95
Q

What is active listening in therapeutic communication?

A
  • giving full attention to the speaker
  • using verbal and nonverbal cues (e.g., nodding)

show understanding and encourage further sharing.

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96
Q

What is self-perception and self-concept?

A

Self-perception refers to how a person views themselves

self-concept includes their self-esteem and body image.

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97
Q

What is the difference between a physical assessment and a focused assessment?

A
  • A physical assessment is comprehensive and done head-to-toe or system-wide
  • a focused assessment is abbreviated and targets a specific system or issue.
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98
Q

What is the difference between closed and open-ended questions?

A

Closed-ended questions elicit short answers (e.g., yes/no)

open-ended questions encourage more detailed responses and discussion.

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99
Q

What is the difference between nursing history and medical history?

A

Medical history focuses on the patient’s diagnosis and condition

nursing history focuses on the patient’s responses to health problems.

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100
Q

What is the purpose of making observations during communication?

A
  • helps you note and reflect on the patient’s behavior or appearance
  • encouraging them to share more about their feelings or condition.
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101
Q

What is therapeutic communication?

8 points

A
  • Silence
  • Active empathetic listening
  • Restatement
  • Reflection
  • Summarizing
  • Clarifying
  • Validating
  • Touch
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102
Q

What role does silence play in therapeutic communication?

A

Silence allows patients time to process thoughts, reflect, and feel comfortable sharing more information.

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103
Q

What should you assess regarding a patient’s roles and relationships?

4 points

A
  • family roles
  • work status (e.g., employed, retired)
  • financial concerns
  • patient’s support system.
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104
Q

What should you avoid in patient communication?

A
  • using authority
  • creating distance
  • using medical jargon
  • interrupting
  • stereotyping
  • appearing rushed
  • asking “why” questions.
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105
Q

What types of history are collected during an admission assessment?

A
  • Health history
  • family health history
  • medical conditions
  • infectious diseases
  • childhood illnesses
  • immunization history
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106
Q

Why is it important not to appear rushed during patient interactions?

A

Appearing rushed can
* make patients feel unimportant or unheard
* affects trust and rapport.

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107
Q

Why is it important to assess a patient’s roles and relationships?

A
  • help guide care plans
  • address potential social or financial stressors
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108
Q

Why is it important to assess cognition and perception in healthcare?

A

Cognitive and perceptual functions affect a patient’s ability to
* communicate
* follow instructions
* participate in their care.

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109
Q

Why is it important to assess self-perception and self-concept?

A

It gives insight into the patient’s
* emotional health
* confidence
* concerns about their well-being and body image.

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110
Q

Why is it important to assess spirituality in patients?

A
  • Spirituality can affect the mind, body, and spirit
  • distress in one area can impact the patient’s overall health.
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111
Q

Why is it important to reduce distractions during patient interactions?

A
  • helps the patient feel heard
  • ensures effective communication.
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112
Q

Why should healthcare providers be aware of their own values and beliefs?

A
  • avoid letting personal biases affect patient care
  • focus on the patient’s beliefs
  • staying neutral on topics like politics or other sensitive matters
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113
Q

Why should medical jargon be avoided in patient communication?

A

Medical jargon can confuse patients, leading to misunderstandings and reduced comprehension of their condition.

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114
Q

What vital signs are included in a physical assessment?

7 points

A
  • Temperature
  • pulse
  • BP
  • respirations
  • pain
  • pulse oximetry
  • consciousness

“5 vitals”

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115
Q

What is the most cost-effective way to prevent infection?

A

Hand hygiene

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116
Q

By how much can handwashing reduce deaths from diarrheal disease?

A

Up to 50%

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117
Q

What are the two main methods of hand hygiene?

A

Soap and water or antiseptic hand rub

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118
Q

When should soap and water be used instead of hand rub?

A
  • hands are visibly soiled
  • before eating
  • after restroom use
  • at the beginning of the shift
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119
Q

How long should you wash your hands with soap and water?

A

For at least 20 seconds

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120
Q

What is the procedure for washing hands with soap and water?

A
  • Remove watch
  • clean under jewelry
  • keep clothing away from water
  • fingertips below wrists
  • use liquid soap
  • rub in circular motion
  • clean between fingers and under nails
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121
Q

When should hand hygiene be performed before an activity?

A
  • Before eating
  • before patient contact
  • before putting on gloves
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122
Q

When should hand hygiene be performed after an activity?

A
  • After using the restroom
  • removing gloves
  • contact with intact skin, body fluids
  • contact with objects in the patient’s room
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123
Q

Why should hand rub and soap not be used simultaneously?

A

It is ineffective to use both methods at the same time

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124
Q

What should be done if C. diff is confirmed or suspected?

A
  • Use soap and water
  • alcohol-based hand rubs are ineffective against C. diff
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125
Q

What is the recommended procedure for alcohol-based hand rubs?

A
  • Apply at least 3 mL
  • rub hands vigorously for 20 seconds
  • covering all surfaces until dry
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126
Q

What are some “Do Not” rules in hand hygiene?

A
  • Do not wash gloved hands
  • wear nail polish or artificial nails
  • have nails longer than ¼ inch
  • use hand rub and soap simultaneously
127
Q

What should you do if a gown doesn’t cover your back?

A

Wear a second gown in reverse

128
Q

What are the key differences in gloving between LTC and Acute Care?

A

LTC: One glove holds dirty items
Acute Care: Gloves must be removed in-room

129
Q

Where are linen and trash containers located in acute care settings?

A

In every patient room

130
Q

What is the procedure for removing gloves in acute care?

A
  • Strip off gloves inside the room
  • perform hand hygiene
  • then exit the room
131
Q

What does PPE stand for? Why? What agencies?

A
  • Personal Protective Equipment
  • worn for protection against infectious materials (OSHA)

OSHA regulates
CDC Recommends rules

132
Q

What types of PPE are used in healthcare?

A
  • Gloves
  • gowns
  • masks/respirators
  • goggles
  • face shields
133
Q

What are gloves used for in healthcare?

A
  • Protect hands from contact with infectious materials
  • can be sterile or non-sterile
  • Always change gloves after use
  • or if they are torn or heavily soiled
134
Q

What is the purpose of wearing a gown?

A
  • Protect skin and/or clothing
  • gowns can be reusable or disposable.
135
Q

How do masks and respirators differ?

A
  • Masks protect the mouth and nose from droplets
  • respirators protect the respiratory tract from airborne infectious agents
  • (Respirators are not used in nursing school)
136
Q

Why should goggles be used?

A
  • To protect the eyes
  • should fit snugly
  • regular glasses are not a substitute.
137
Q

What does a face shield protect?

A

Face, mouth, nose, and eyes

138
Q

What are standard precautions based on?

A
  • The assumption that any blood or bodily fluid could be infectious.
  • Hand hygiene and appropriate PPE are used to prevent infection.
139
Q

When should gloves be worn according to standard precautions?

A

When touching blood, bodily fluids, secretions, excretions, or non-intact skin.

140
Q

What should be worn during patient care activities that may generate splashes?

A
  • Mask and goggles or face shield to protect against splashes or sprays of blood, bodily fluids, secretions, or excretions.
141
Q

What PPE is required for contact precautions?

A

Gloves and gown for contact with patient or patient environment.

142
Q

What PPE is required for droplet precautions?

A

A surgical mask within 3 feet of the patient.

143
Q

What PPE is required for airborne infection isolation?

A

A particulate respirator and a negative pressure isolation room for the patient.

144
Q

What is the sequence for donning PPE?

A
  1. Gown
  2. Mask or respirator
  3. Goggles or face shield
  4. Gloves.
145
Q

What is the sequence for doffing PPE?

A
  1. Gown and gloves
  2. Goggles or face shield
  3. Mask or respirator
  4. Wash hands.
146
Q

What should you check before feeding a patient?

A

Ensure the patient is receiving the correct diet (e.g., regular, mechanical soft, clear liquid, diabetic, etc.).

147
Q

What is the recommended ratio of staff to patients in the dining room in LTC?

A
  • One staff for every 2-3 patients.
148
Q

How long should a meal take when feeding a patient?

A
  • 20-30 minutes
149
Q

What should be avoided during a patient’s meal?

A
  • Interrupting with medications
150
Q

What should you do before assisting a patient with their meal?

A
  • Assist to the bathroom and help with hand washing before and after the meal.
151
Q

What are important steps when feeding a patient with dementia?

A
  • Assess feeding ability
  • minimize distractions
  • remove inedible items
  • cue verbally (“take a bite, chew, swallow”)
  • avoid feeding too fast.
152
Q

What should be documented after a patient’s meal?

A
  • The amount of food and fluid consumed
  • any unusual feeding behaviors.
153
Q

what is dysphagia

A

difficulty swallowing

154
Q

What position should a patient be in for oral hygiene?

A
  • Semi-Fowler’s position
  • 15-45 degrees
155
Q

How should dentures be cleaned?

A
  • Remove from mouth
  • clean in the sink over a towel with cool water: hot can warp them
  • do not use hot water
  • store in a labeled denture cup.
156
Q

What is the most commonly lost article in hospitals?

A

(1) hearing aids, dentures

157
Q

How should you check the function of a hearing aid?

A
  • Listen for feedback after turning it on.
158
Q

What are clues that a patient might have hearing loss?

A
  • Inappropriate answers to questions or confabulation (making up answers).
159
Q

How should you communicate with a patient who has hearing loss?

A
  • Make eye contact
  • speak directly and clearly
  • check for understanding
  • write it down if necessary.
160
Q

How do you brush a patient’s teeth?

A
  • Use a 45-degree angle
  • gently brush all surfaces and the tongue
  • rinse and spit.
161
Q

What should be done before removing hearing aids?

A
  • Turn off the hearing aid before removing.
162
Q

How do you clean hearing aids?

A
  • Wipe with a damp cloth
  • check for cracks or loose tubing
  • clean the outer ear for wax buildup.
163
Q

What is the first step in washing a patient during a bed bath?

A
  • Wash the eyes with a wet, soap-free washcloth, one eye at a time.
164
Q

How should the perineum of a female patient be cleaned?

A
  • Wash from front to back
  • avoiding contact with the anus to prevent infection
  • Rinse and dry well, without using powder.
165
Q

How should the perineum of a male patient be cleaned?

A
  • Gently retract the foreskin (if applicable)
  • wash the penis and scrotum with a soapy washcloth
  • rinse, and dry.
166
Q

How should the anus be washed during a bed bath?

A
  • Turn the patient onto their side
  • raise the top leg
  • wash, rinse, and dry the anal area.
167
Q

When should the RN be notified during a bed bath?

A
  • If redness or skin breakdown is observed.
168
Q

What additional care can be offered after a bed bath?

A
  • Oral care
  • shaving
  • air care.
169
Q

What are CHG baths?

A

Chlorhexidine gluconate (CHG) baths are used to reduce the risk of infection in patients
* especially before surgery

170
Q

What should you monitor before assisting a patient with toileting?

A
  • check for intake/output (I/O) orders
  • be aware of any stool or urine sample needed
171
Q

What should be considered before assisting with toileting?

A
  • Activity level
  • mobility restrictions
  • personal, cultural, and religious concerns: patient may prefer a same-sex caregiver.
172
Q

What supplies should be gathered before toileting?

A
  • Wipes
  • toilet paper
  • gloves
  • barrier cream
173
Q

Why is perineal care important?

A
  • The perineum is dark, warm, and moist, which supports bacterial growth.

Peri care prevents
* infection
* maceration
* excoriation

and promotes comfort.

174
Q

what is maceration

A
  • A softening and breaking down of skin resulting from prolonged exposure to moisture
175
Q

What is excoriation?

A
  • redness and removal of the topmost surface of the skin
176
Q

What is the PureWick system used for?

A
  • It is used for female urinary incontinence and immobility.
  • do not use in combo with a brief
177
Q

What are the contraindications for using PureWick?

A
  • Confused patients: can’t vocalize discomfort
  • bowel incontinence: causes UTI
  • skin irritation or breakdown: will worsen with suction
178
Q

When should a bedpan be used?

A
  • When the patient has no bed mobility restrictions and can sit upright in bed.
179
Q

When should a fractured bedpan be used?

A
  • When the patient has mobility restrictions (e.g., joint or back surgeries) and must lie flat in bed.
180
Q

How often should incontinent patients be checked?

A
  • Hourly to prevent skin breakdown.
181
Q

What to do every time you leave a patient?

A
  • bed locked and lowered
  • call light in reach
  • belongings are within reach
182
Q

What is the proper technique for lifting?

A
  • Lift with your legs/arms
  • keep the curve in your back
  • avoid twisting while lifting.
183
Q

Why is it important to obtain vital signs on patients?

A
  • To establish a baseline
  • monitor effects of surgery/disease
  • recognize changes
  • watch trends.
184
Q

What is the normal temperature range for adults and geriatrics?

A

Adults: 97.7-99.5°F
Geriatrics: 95-96.8°F

185
Q

What is the normal pulse rate for adults?

A
  • 60-100 beats per minute
  • Average: 80 bpm
  • athletes 40-60
186
Q

What affects pulse rate?

A
  • Age
  • sympathetic/autonomic nervous system
  • and medications.
187
Q

What are the main sites for pulse assessment?

A
  • Radial artery: thumb side of wrist
  • apical (PMI): point of maximum impulse
  • brachial: elbow. site for BP

Emergency sites include
* femoral: in groin
* carotid: caution. can dislodge plaques in older pts.

188
Q

How is pulse quality rated in EHR?

A
  • 0 = Absent
  • 1+ = Thready
  • 2+ = Normal
  • 3+ = Bounding

too strong = hypertension, extra hydration

189
Q

What is the normal respiratory rate for adults?

A
  • 12-20 breaths per minute
  • geriatric may be faster
190
Q

What factors increase respiratory rate?

A
  • age = less efficient lungs = higher resp rate
  • Activity
  • pain
  • fever
  • anxiety
  • anemia: low O2
  • chronic disease.
191
Q

What factors decrease respiratory rate?

A
  • sleep
  • some medications (opiates)
  • dying process
192
Q

what are respiratory characteristics

A
  • rate
  • depth
  • rhythm
  • effort
193
Q

What are the terms for abnormal respiratory patterns?

4 terms

A
  • Tachypnea (fast)
  • dyspnea (difficulty)
  • exertional dyspnea (with activity)
  • apnea (no breathing)
194
Q

What is the normal blood pressure range for adults and elderly?

A
  • Adults: 120/80 mmHg
  • Geriatrics: up to 160/95 mmHg
195
Q

What can cause inaccurate blood pressure readings?

A
  • Wrong cuff size
  • incorrect placement
  • auscultatory gap
  • irregular heart rate
  • using an electronic BP machine.
196
Q

what is auscultatory gap?

A
  • interval of absolute or relative silence occasionally found on listening over an artery during deflation of the blood pressure cuff
  • may underestimate systolic (didn’t pump high enough)
  • may overestimate diastolic (sound may disappear and come back)
197
Q

What are orthostatic abnormal findings?

A

HR and BP taken lying down, sitting, then standing.
* pulse increases by 20+ BPM
* systolic decreases 20+ mmHg
* diastolic decreases 10+ mmHg
* pt becomes dizzy

  • allow 1-3 min between readings
198
Q

Significance of orthostatic hypotension

A
  • dehydration
  • blood loss
  • risk for loss of consciousness/falls
199
Q

What is pulse oximetry used for?

A
  • A non-invasive procedure to measure the amount of hemoglobin bound with oxygen
  • normal value is 95% or greater.
  • in healthy patient less than 94% is clinically significant
200
Q

How is pain intensity assessed and treated?

A
  • Using the 0-10 scale
  • goal is to get pt to a 2 or less
  • don’t risk respiratory depression
  • vitals should support claim: high bp, hr, rr
201
Q

What does PAIN stand for?

A
  • pattern: how it changes with circumstance
  • area: location
  • intensity: 1-10
  • nature: throbbing, stabbing, etc…
202
Q

Non-numeric pain scale

A
  • Wong-Baker Faces scale
203
Q

Duration pain terms

A
  • acute: short term
  • chronic: long term. 3+ mo.
  • intracatable: constant
  • intermittent: comes and goes
204
Q

What nursing tools can cool a febrile patient?

A
  • Radiation (uncover patient)
  • convection (fan)
  • evaporation (cool cloth)
  • conduction (ice pack to reduce inflammation).
205
Q

What nursing tools can warm a patient?

A
  • Radiation (cover patient)
  • convection (close doors)
  • evaporation (keep patient dry)
  • conduction (warm packs to help healing. increase blood flow 2-3 days after injury).
206
Q

What are some signs to assess for violence?

A
  • # 1 history of violence
  • Altered LOC
  • psychiatric history
  • substance abuse
  • verbal/non-verbal signs of aggression
  • awareness of surroundings (pt and nurse safety): leave yourself an exit
  • potential weapons: no steth on neck
207
Q

What are the abnormal skin color changes?

A
  • Pallor: paleness
  • erythema: redness
  • cyanosis: blueness of lips, mucous membranes
  • jaundice: yellow
  • ecchymosis: abnormal bruising
208
Q

What causes ecchymosis?

A
  • anticoagulant or antiplatelet meds
209
Q

what does cyanosis indicate?

A
  • hypoxia
210
Q

What is skin turgor, and what is abnormal?

A
  • Pinching the skin should result in it snapping back
  • if it “tents” or stays up, it is abnormal.
  • best to pinch near collar bone on geriatric
211
Q

What is clubbing in nails a sign of?

A
  • Chronic hypoxia
  • lung disease
212
Q

What are common skin variations in the elderly?

A
  • Dry skin
  • skin tags
  • lentigines: sun spots
  • thinning hair
  • senile purpura: like ecchymosis (easy brusing)
213
Q

Why perform neurological assessments?

A
  • To determine baseline: iteracting/talking…
  • recognize changes in neuro status throughout the day
  • identify the need for tests or interventions
  • safety: impulsivity/lowered awareness
  • see if they can retain info from morning to afternoon
214
Q

What are the main points to document in a neurological assessment?

A
  • Level of consciousness (LOC): aware, alert, awake
  • orientation/mental status: ask specific questions. pt’s may try to hide/play off if they are disoriented.
  • pupillary response: should constrict with light
  • motor response and strength
  • sensory function: can they feel you
  • reflexes
215
Q

What should you ask to determine if a pt is oriented?

A
  • full name
  • time of day
  • what city
  • what season
  • note changes from baseline
216
Q

What is pronator drift?

A
  • A test where a patient holds arms out with eyes closed, and if one arm drifts downward.
  • can indicate opposite hemisphere issue
217
Q

What are common terms used in heart rate assessment?

4 points

A
  • Bradycardia: less than 60 bpm
  • tachycardia: greater than 100 bpm
  • pulse deficit: diff between apical and peripheral pulse
  • dysrhythmia: irregular rhythm
218
Q

How do you assess sensation?

A

Test for response to stimulus
* normal
* numbness/tingling
* lack of sensation, or pain

219
Q

What are the main components of a musculoskeletal assessment?

A
  • Symmetry
  • strength
  • range of motion (ROM)
  • pain

used to prep to ambulate

220
Q

How do you assess musculoskeletal system?

A

Arms
* hand grips: give on finger in each hand to squeeze
* push pull: palm to palm, have them push you away and pull against you

Legs
* push/pull: they bend knee to meet your hand

Feet
* flex/point: against hand pressure

221
Q

What factors should be included in a
neurological health history (subjective)?

A

Ask open ended questions

  • Headache
  • Head injury
  • Dizziness/Vertigo: inner ear
  • Seizures
  • Tremors
  • Weakness
  • Deficits
  • Lack of coordination
  • Numbness or tingling
  • Difficulty swallowing (dysphagia)
  • Difficulty speaking (aphasia)
  • Significant history: stroke, brain injury
  • Environmental/occupational hazards
222
Q

What is expressive aphasia?

A
  • Difficulty speaking after a stroke (CVA)
  • patient can understand others.
223
Q

What is receptive aphasia?

A
  • individuals have difficulty understanding written and spoken language
224
Q

What are the abnormal changes in pupil function for geriatric patients?

A
  • Cataracts: pupils develop irregular shape.
  • changes due to eye surgery
225
Q

How can illness affect a person’s ability to perform self-care?

A

Illness can limit mobility, cause pain, and affect sensory perception, cognitive abilities, or mental health, making it difficult to perform daily hygiene tasks.

226
Q

How does pain affect the ability to perform self-care?

A

Pain can reduce mobility and motivation, while pain medications may cause drowsiness, limiting a person’s ability to perform self-care.

227
Q

What is the impact of sensory deficits on patient safety and hygiene?

A

Patients with sensory deficits may not be aware of hazards and are at increased risk of injuries or infections due to impaired vision, hearing, or touch.

228
Q

How can cognitive impairment affect hygiene?

A

Cognitive impairment may prevent patients from recognizing the need for hygiene or knowing how to perform related tasks, compromising their overall health.

229
Q

What are the types of baths?

A

Types include
- prepackaged
- towel bath
- bag bath
- basin and water bath
- shower
- tub bath
- therapeutic bath

230
Q

What are prepackaged bathing products used for?

A
  • ensure consistent technique
  • prevent skin damage
  • reduce the risk of infections from rough washcloths or basins.
231
Q

When is a towel bath recommended?

A

for patients with
* mild to moderate skin integrity impairment
* activity intolerance
* dementia.

232
Q

What are guidelines for assisting patients with meals and feeding?

A
  • checking for diet restrictions
  • ensuring safe swallowing
  • positioning the patient upright
  • offering assistance without rushing.
233
Q

What does the term accomodation mean?

A
  • Healthy pupils dilate when looking at something far away
  • constrict when looking at something close.
234
Q

Which patients are at high risk for falls?

A
  • Patients with mobility impairments
  • sensory deficits
  • cognitive impairments
  • those on medications affecting balance
235
Q

What are safety measures to prevent falls?

A
  • uncluttered environment
  • tab alarms
  • grippy footwear
  • call lights in reach
  • pads on floor
  • lowering bed
  • 2 bed rails (4=restraint)
236
Q

What is a bag bath?

A

A bath using 8 to 10 washcloths instead of a towel and bath blanket, where each section of the body is cleansed with a fresh cloth.

237
Q

When is a basin and water bath used?

A
  • When a patient refuses a prepackaged bath
  • or if the patient is grossly soiled.
238
Q

What is a risk of using reusable basins for bathing?

A

Reusable basins can become a reservoir for microorganisms and may lead to healthcare-associated infections.

239
Q

what kind of water should be used for bathing?

A

Use distilled, sterile, or filtered water to prevent skin contamination from bacteria biofilm.

240
Q

What is recommended if tap water is used for bathing?

A

Bathe the patient with a solution of chlorhexidine (CHD) and water to combat bacteria that may be present.

241
Q

When is a shower appropriate for patients?

A

Showers are suitable for ambulatory patients who can safely stand and move.

242
Q

What are the benefits of a tub/therapeutic bath?

A

Soaks crusty or scaly areas, and relaxes stiff, sore muscles and joints.

243
Q

What are examples of therapeutic baths?

A

Oatmeal or coal tar baths for skin conditions like psoriasis, or a warm sitz bath for cleansing and soothing inflammation.

244
Q

slow heart rate < 60 bpm

A

bradycardia

245
Q

fast heart rate, > 100 BPM

A

tachycardia

246
Q

pulse deficit

A
  • variance between apical/Peripheral pulses
  • contractions not making it to extremities
  • premature ventricular contractions
247
Q

abnormal rhythm, irregular

A

dysrhythmia
atrial fibrilations

248
Q

What is external respiration?

A
  • Oxygen enters the lungs, and carbon dioxide exits during ventilation.
249
Q

What is internal respiration?

A
  • The exchange of gases between blood and cells through diffusion (O2 and CO2).
250
Q

What is perfusion?

A
  • The distribution of RBCs/oxyhemoglobin to cells in the body.
251
Q

What muscles are involved in the mechanics of breathing?

A
  • The thoracic muscles and the diaphragm.
252
Q

What is normal blood pressure?

A

Less than 120/80 mmHg.

253
Q

What is considered Stage 2 hypertension?

A

140+ systolic
90+ diastolic.

254
Q

What is a hypertensive crisis?

A

Blood pressure higher than 180/120 mmHg; consult a doctor immediately.

255
Q

What is the direct method of measuring blood pressure?

A

A catheter is inserted into an artery.

256
Q

What is the indirect method of measuring blood pressure?

A
  • A blood pressure cuff is used; also known as blood pressure by auscultation.
  • stethescope and sphygmomanometer
257
Q

What factors affect blood pressure?

A
  • Sympathetic & parasympathetic nervous systems
  • blood volume
  • medications
  • peripheral vascular resistance.
  • sleep, activity, stress, exercise
258
Q

How does the size of the blood pressure cuff affect readings?

A
  • A cuff that is too small may give high readings
  • a cuff that is too large may give low readings.

inverse relationship

259
Q

How is systolic blood pressure detected?

A
  • The first sound heard during auscultation.
  • inflate to 30 points above expected systolic, and begin to deflate
  • ask pt what their norm is and use as guideling for inflation
260
Q

How is diastolic blood pressure detected?

A

The absence of sound after the final beat heard.

261
Q

What are reasons to avoid using certain limbs for blood pressure measurement?

A
  • Mastectomy or lymph issues: could trap lymph fluid = lymphedema
  • hemodialysis grafts or fistulas: could clot device: can make them unusable
  • PICC lines
  • IVs in the arms: if IV in both arms, use the lower flow rate option
  • Do not use the arm that is paralyzed or on the same side of previous breast or shoulder surgery
262
Q

What are blood pressure locations?

4 points

A
  • Radial artery (at wrist)
  • posterior tibial artery (inner ankle)
  • brachial artery (at elbow)
  • popliteal artery (behind inner knee)

systolic pressure may be 20 to 30 mm Hg higher in the lower extremities

263
Q

What are normal findings in a skin assessment?

A
  • Warm, mostly dry
  • moist with activity
  • smooth and firm texture
  • absence of injury (intact skin).
264
Q

What are abnormal skin changes?

A
  • Cool, cold, hot
  • localized changes: cellulitis
  • diaphoretic: sweating heavily
  • clammy: damp and sticky
  • dry, and flaky skin

temp changes can indicate low blood sugar

265
Q

What are normal skin variations in adults?

A
  • Cherry angiomas: raised vessel bumps
  • seborrheic keratoses: bumpy, scaly moles
266
Q

What should be assessed during a hair examination?

A
  • Hygiene
  • condition: well groomed?
  • infestation: lice, scabies…
267
Q

What should be assessed during a nail examination?

A
  • Hygiene
  • color
  • shape
  • capillary refill: hands and feet

abnormal
* clubbing or spoon-shaped nails koilonychia

268
Q

What cultural considerations should be made for dark-skinned patients during a skin exam?

A
  • Check lighter pigmented areas or mucus membranes for color changes
  • jaundice in the sclera of the eyes
  • cyanosis in nail beds or lips.
  • paleness = yellow/brown to ashen
  • erythema = dark purple
269
Q

What is the continuum of consciousness from alert to coma?

A
  • Alert
  • lethargic: sleepy
  • obtunded: can be roused with verbal stimuli
  • stuporous: responds to painful stimuli (sternal rub, pen on nail bed)
  • comatose: unresponsive to stimuli
270
Q

What should be inspected during an eye assessment?

A
  • Check for asymmetry: lazy eye
  • pupil size before light (3 mm normal)
  • ability to track
  • incomplete closure
  • ptosis: dropping lid after stroke
  • response to light reflex (PERRL)
271
Q

Types of PERRL findings

A

Light reflex
* Brisk (Normal)
* Sluggish (Slow)
* Unresponsive (Fixed)

Unilateral or Bilateral

272
Q

What are common causes of abnormal pupil response?

A
  • Drug use or brain injury
  • lead to sluggish, unresponsive, or pinprick pupils.
273
Q

What should be assessed during an ear exam?

A
  • Check for tenderness
  • pain
  • hearing loss: general hearing acuity
  • hearing aids
  • document any abnormal findings: lacerations, etc…
274
Q

What are common speech abnormalities?

A
  • Slurred: slow, strained, alcohol…
  • garbled: word soup
  • dysarthria (difficulty speaking). stroke, broca area of brain
275
Q

What are abnormal gait patterns?

A
  • Slow
  • unsteady
  • leaning to one side
  • shuffling
  • wide gait (duck walk) - geriatric
276
Q

What movements are involved in range of motion (ROM) assessments?

4 points

A
  • Flexion
  • extension
  • abduction
  • adduction
277
Q

What is flexion?

A

Movement that decreases the angle between two body parts (e.g., bending the elbow).

278
Q

What is extension?

A

Movement that increases the angle between two body parts (e.g., straightening the elbow).

279
Q

What is abduction?

A

Movement of a limb away from the midline of the body (e.g., raising the arm sideways).

280
Q

What is adduction?

A

Movement of a limb toward the midline of the body (e.g., lowering the arm to the side).

281
Q

What is included in neurosensory (CMS) checks?

A

CMS = circulation/motion/sensation
check 3 diff areas of body

  • cap refill
  • ROM
  • response to stimulus
    • normal, numb/tingling, lack of sensation, pain

establish baseline and assess for changes

282
Q

What is the CIWA protocol used for?

Clinical Institute Withdrawal Assessment

A

Assessing alcohol withdrawal symptoms
* Nausea and vomiting
* Tremors
* Paroxysmal sweats: sudden recurrence or intensification
* Anxiety
* Agitation
* Tactile disturbances: false feeling of something touching you, either on the surface of your skin or inside your body
* Auditory disturbances: hear voices or noises that aren’t there
* Visual disturbances: short spell of flashing or shimmering of light in your sight
* Headache
* Disorientation
* clouded sensorium: the inability to think clearly or concentrate

Scored with points system to assess risk

283
Q

What is included in the “Situation” section of SBAR?

A
  • Identify yourself
  • patient details
  • admitting diagnosis
  • current problem or situation
284
Q

What is included in the “Background” section of SBAR?

A
  • Pertinent medical history: pertinent comorbidities
  • code status
  • allergies
  • vital signs/trends
  • pain status
  • recent meds
  • labs/diagnostics
  • what circumstances led to this event?
285
Q

What is the purpose of the “Assessment” section in SBAR?

A

your assessment of the situation
* the problem
* condition change
* interventions taken

286
Q

What should be addressed in the “Recommendation” section of SBAR?

A
  • State what action you recommend to correct the problem
  • ex: meds, O2, activity changes, or consults.
287
Q

What are the key factors assessed in the Morse Fall Scale?

A
  • History of falling
  • secondary diagnosis: HT, DM…
  • ambulatory aids
  • IV/heparin lock: cords are trip hazard
  • gait
  • mental status
288
Q

What is considered a high fall risk on the Morse Fall Scale?

A

A score of 45 or higher.

289
Q

What score range indicates a moderate fall risk?

A

25-44 points.

290
Q

What score indicates a low fall risk?

A

0-24 points.

291
Q

What tones come from stethoscope diaphragm?

A

high frequency
most used

292
Q

What tones come from stethoscope bell?

A

low frequency sounds

293
Q

How is capillary refill tested?

A
  • Press on the nail bed or skin for a few seconds until it blanches (turns white), then release and observe.
294
Q

What is a normal capillary refill time?

A

Less than 2 seconds.

295
Q

What does prolonged capillary refill (more than 2 seconds) indicate?

A
  • poor circulation
  • shock
  • dehydration
296
Q

Abnormal findings in capillaries?

A
  • darkness
  • blackness
  • cyanosis
297
Q

What is the Glasgow Coma Scale (GCS) used for?

A
  • To assess a patient’s LOC following a head injury or neurological impairment.
298
Q

What are the three components of the Glasgow Coma Scale GCS?

A
  • Eye-opening response
  • verbal response
  • motor response.
299
Q

How is eye-opening scored in the GCS?

A

Spontaneous = 4
to sound = 3
to pressure = 2
no response = 1.

300
Q

How is the verbal response scored in the GCS?

A

Oriented = 5
confused = 4
inappropriate words = 3
incomprehensible sounds = 2
no response = 1

301
Q

How is the motor response scored in the GCS?

A

Obeys commands = 6
localizes pain = 5
withdraws from pain = 4
abnormal flexion (decorticate) = 3
abnormal extension (decerebrate) = 2
no response = 1

302
Q

GCS Score breakdowns

A

15: indicating full consciousness.
13-15: mild brain injury
9-12: moderate brain injury
8 or less: severe brain injury
3: indicating deep coma or unresponsiveness.

303
Q

What is decorticate posturing?

A
  • patient’s arms are flexed towards the body
  • legs extended
  • indicating severe brain damage
304
Q

What is decerebrate posturing?

A

patient’s arms and legs are extended and rotated outward, with the head arched back.

305
Q

Which posturing is considered more severe, decorticate or decerebrate?

A

Decerebrate posturing is considered more severe, as it indicates deeper brain damage

306
Q

If you plan is to recheck vitals, how long is normally a reasonable amount of time to see a significant change with most patients?

A

10 minutes

307
Q

Abnormal BP findings
3 broad terms and values

A

hypotension: below 90/60
hypertension: above 140/90
systolic hypertension: 130+/80- (common in elderly)

308
Q

What is vasodilation?

A
  • The increase in the diameter of blood vessels, which diverts core-warmed blood to the body surface for heat transfer.
  • cools the body
309
Q

What is vasoconstriction?

A

The narrowing of blood vessels that conserves heat by shunting blood from the periphery to the body’s core.

310
Q

What is the correct size for a blood pressure cuff for adults?

A
  • The bladder width should cover two-thirds of the upper arm length
  • 40% of arm circumference with the bladder encircling 80% of the arm.
311
Q

What should you do if using an improperly sized cuff?

A

If necessary, use a cuff that is too large rather than too small, and document the cuff size with the BP reading.

312
Q

What should always be documented when taking blood pressure?

A

Always document the site used for the measurement.

313
Q

farenheit to celsius

A
  • subtract 32
  • multiply by 5
  • divide by 9
314
Q

celsius to farenheit

A
  • multiply by 9
  • divde by 5
  • add 32

NRAD 201B (5 decks)

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