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Exam 1 Review Flashcards

1
Q

What launched the profession of nursing in the United States

A

Civil War

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2
Q

The war where Florence Nightingale first came up

A

Crimean War

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3
Q

Florence Nightingale’s Notes on Nursing

A

What it is and What it is Not

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4
Q

Where was the First professional nursing school established?

A

St. Thomas’ Hospital in London

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5
Q

Based on Florence Nightingale’s principles of nursing, where was the nation’s first nursing school opened?

A

Bellevue Hospital, New York City

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6
Q

What is first American nursing journal called?

A

The Nightingale

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7
Q

Where was the first board of nursing established?

A

North Carolina

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8
Q

Name the University that had the first bachelor’s degree in nursing.

A

University of Minnesota

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9
Q

Who is the founder of the modern nursing profession?

A

FLORENCE NIGHTINGALE

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10
Q

CLARA BARTON

A

Founder and first President of the American Red Cross

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11
Q

MARY ELIZABETH MAHONEY

A

First African American to study and work as a professionally trained nurse

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12
Q

SUSIE WALKING BEAR YELLOWTAIL

A

Broke barriers for Indigenous women and fought for culturally competent health care

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13
Q

LUTHER CHRISTMAN

A

Helped establish the National Male Nurse Association

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14
Q

Ildaura Murillo-Rohde

A

helped found the National Association of Hispanic Nurses

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15
Q

Anastacia Giron-Tupas

A

helped to develop the first baccalaureate nursing program offered in the Philippines

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16
Q

Bestowed with the title of Dame by Queen Elizabeth II for “services to Nursing and to International Humanitarian Aid.”

A

Dame Claire Bertschinger

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17
Q

How was nurses viewed before as?

A

Angel of Mercy, Battle-ax, Handmaiden

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18
Q

What is the most “trusted” profession?

A

Nurses

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19
Q

Nursing ranks low in what?

A

Desirability

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20
Q

How is Nursing Currently Defined? (PPFAA)

A
  1. Protection, promotion, and optimization of health and abilities
  2. Prevention of illness and injury
  3. Facilitation of healing
  4. Alleviation of suffering through the diagnosis & treatment of human response
  5. Advocacy in the care of individuals, families, groups, communities, and populations
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21
Q

Nursing is the _____ and _____ of human responses and advocacy in the care of individuals, families, groups, communities, and populations in recognition of the connection of all humanity.

A

diagnosis, treatment

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22
Q

Which nursing role “Address physical, emotional, social, and spiritual needs?”

A

Direct care provider

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23
Q

What does a Client/family educator role do?

A

Assess and diagnosis teaching needs

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24
Q

What does a Client advocate nursing role do?

A

Support rights and protecting from harm

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25
Q

What does a Change agent role do?

A

Advocate for change to enhance health

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26
Q

What is Manager nursing role function?

A

Coordinate and manage activities of health care team

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27
Q

Consumer of research nursing role function?

A

Apply evidence-based practice (EBP), identify clinical problems, and protect
rights of research subjects

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28
Q

What is SENC?

A

Safe, Effective Nursing Care

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29
Q

Nursing Today is based on what?

A

Safe, Effective Nursing Care (SENC)

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30
Q

Two types of SENC Competencies?

A
  1. Institute of Medicine (IOM) Core Competencies or National Academy of Medicine
  2. Quality and Safety Education for Nurses (QSEN) Competencies
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31
Q

What are the Institute of Medicine (IOM) Core Competencies?

A
  1. Provide patient-centered care
  2. Work in interdisciplinary teams
  3. Employ evidence-based practice (EBP)
  4. Apply quality improvement (QI)
  5. Utilize informatics
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32
Q

What does the Institute of Medicine (IOM) Core Competencies begin with?

A

including the patient on the health care team

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33
Q

What are the Quality and Safety Education for Nurses (QSEN) Competencies?

A

1.Patient-centered care
2. Teamwork and collaboration
3. Evidence-based practice (EBP)
4. Quality improvement (QI)
5. Informatics
6. Safety

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34
Q

Which nursing theorist described the process by which a nurse acquires clinical skills and judgment via 5 categories

A

Patricia Benner

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35
Q

What model is the most useful framework for assessing nurses’ needs at different stages of professional growth?

A

Benner’s Model

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36
Q

What are the 5 categories from Benner’s Model? (List from lowest to highest)

A
  1. Novice
  2. Advanced Beginner
  3. Competent
  4. Proficient
  5. Expert
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37
Q

What category of Benner’s Model is this: Beginners with no experience; rigid adherence to rules; minimal judgement

A

Novice

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38
Q

What category of Benner’s Model is this: Provides care drawing from some practical experience; can perform tasks but has difficulty improvising and prioritizing.

A

Advanced Beginner

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39
Q

What category of Benner’s Model is this: Enacts intentional short-term and longer term planning for care; efficient and organized

A

Competent

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40
Q

What category of Benner’s Model is this: Decision-making and prioritizing come more easily; practice with holistic perspective rather than in steps or parts.

A

Proficient

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41
Q

What category of Benner’s Model is this: Has intuitive grasp of broader situations; able to analyze and think critically for creative solutions.

A

Expert

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42
Q

What is defined as the mental process of actively and skillfully perception, analysis, synthesis and evaluation of collected information through observation, experience and communication that leads to a decision for action.

A

Critical thinking

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43
Q

Nursing is more than performing tasks; it requires what?

A

great critical thinking skills

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44
Q

The National Council of State Boards of Nursing integrates what?

A

critical thinking & decision making

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45
Q

What are the Complex Critical-Thinking Processes?

A
  1. Problem-solving
  2. Clinical judgement
  3. Clinical reasoning
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46
Q

Process of synthesizing knowledge and information from numerous sources & incorporating experiences to develop a plan of care for a particular client or case scenario

A

Clinical reasoning

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47
Q

What is the MODEL FOR CRITICAL THINKING called?

A

Star

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48
Q

Star Model

A
  • Contextual awareness
  • Using credible sources
  • Analyzing assumptions
  • Exploring alternatives
  • Reflecting & deciding
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49
Q

Bloom’s Taxonomy

A
  1. create
  2. evaluate
  3. analyze
  4. apply
  5. understand
  6. remember
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50
Q

Types of Nursing Knowledge

A
  1. Theoretical
  2. Practical
  3. Self-knowledge
  4. Ethical
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51
Q

Theoretical Nursing Knowledge

A

knowing why

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52
Q

Practical Nursing Knowledge

A

Knowing what do and how to do it

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53
Q

Self-knowledge Nursing Knowledge

A

to think critically, you must be aware of your beliefs, values, and cultural and religious biases

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54
Q

Ethical Nursing Knowledge

A

knowing your obligation to patients and colleagues is key; you know right versus wrong

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55
Q

A systematic, patient-centered, goal-oriented method of caring that provides a framework for nursing practice

A

Nursing Process

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56
Q

What is ADPIE in Nursing Process?

A
  1. Assess
  2. Diagnose
  3. Plan
  4. Implement
  5. Evaluation
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56
Q

Step in ADPIE that:

  • Systematic gathering of information
  • uses collecting, validating, and communicating data
  • relates to thorough patient evaluation
A

Assessment/Assess

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57
Q

Step in ADPIE that:

  • response to health/illness issue
  • Form a nursing diagnosis based on the collected data
  • instructs the nursing care that the patient shall receive
A

Diagnosis

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58
Q

Step in ADPIE that:

  • develop a care plan drawing on information from the nursing diagnosis
  • be measurable and goal-oriented
  • specifying goals/outcomes and interventions
A

Planning outcomes

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59
Q

Step in ADPIE that:

  • measuring extent that goal achieved
  • determine if goals met and outcomes achieved
A

Evaluation

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60
Q

Step in ADPIE that:

  • the care plan is put into action
  • Perform the nursing actions identified in planning
A

Implementation

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61
Q

What are some Data Sources?

A
  • Patient and patient’s behavior
  • Physical assessment
  • Family and significant other
  • Patient record
  • Findings of the provider – Physician, APRN, or Physician Assistant/Associate (PA)
  • Consultations
  • Laboratory & Diagnostic study results
  • Other health care professional results
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62
Q

What are the 2 types of Data Collection?

A
  1. Subjective data
  2. Objective data
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63
Q

Subjective data

A

Information perceived only by the affected person: “I have pain in my left shoulder.

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64
Q

Objective data

A
  • Observable (e.g., inability to move a limb)
  • Measurable (e.g., vital signs)
  • Usually occurs during the physical assessment period
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65
Q
  • A clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes.
  • provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable
A

Nursing Diagnosis

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66
Q

NOT a medical diagnosis

A

Nursing Diagnosis

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67
Q

A medical diagnosis is:

A
  • is made by a doctor or advanced health care practitioner
  • focuses on the patient’s disease, medical condition, or pathologic state – determining which falls into the expertise of advanced medical practitioners
  • Does not usually change. Remains in medical history
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68
Q

A statement of client health status that nurses can identify, prevent, or treat independently

A

Nursing Diagnosis

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69
Q

What are the Steps to Writing a NANDA Diagnosis?

A
  1. Pick the diagnostic label
  2. Read the definition
  3. Identify the related factor(s) or “related to” (r/t)
  4. Identify the defining characteristics or “as evidenced by” (AEB)
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70
Q

What are the 2 types of Nursing Diagnosis?

A
  1. Risk
  2. Actual
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71
Q

Only 2 parts:
1.Patient’s problem
2.“related to” (r/t) – related factors

example: Risk for falls related to acute illness

A

Risk

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72
Q

3 parts
1. Patient’s problem
2. “related to” – related factors
3. “as evidence by (AEB)” – defining characteristic(s)

example: Excess Fluid volume r/t excess sodium intake AEB edema (2+ lower extremities)

A

Actual

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73
Q

What model do we use to prioritize patient problem?

A

Maslow’s Hierarchy of Human Needs

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74
Q

What are the 5 parts of Maslow’s Hierarchy of Human Needs? (list from bottom up)

A
  1. Physiological
  2. Safety
  3. Need for love, affection, belonging
  4. Need for Esteem
  5. Need for Self-actualization
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75
Q

Maslow’s Hierarchy of Human Needs: Physiological examples

A
  • breathing
  • food
  • water
    -sex
  • sleep
  • homeostasis
    -excretion
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76
Q

Maslow’s Hierarchy of Human Needs: Safety examples

A

security of the following:
- body
- employment
- resources
- morality
- family
- health
- property

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77
Q

2 types of Planning Outcomes

A
  1. Short-term goals
  2. Long-term goals
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78
Q

Long-term goals

A

weeks or months

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79
Q

Short-term goals

A

hours or a day or so

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80
Q

SMART Goals

A

S- Specific
M- Measurable
A- Attainable
R-Relevant
T- Timely

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81
Q

Always evidence-based

A

Interventions

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82
Q

2 types of Planning Interventions

A
  1. Direct-care interventions
  2. Indirect-care interventions
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83
Q

Type of Planning intervention that is performed through interaction with the client(s)

A

Direct-care interventions

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84
Q

Types of Nursing Interventions

A
  1. Independent intervention
  2. Dependent intervention
  3. Collaborative/interdependent intervention
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84
Q

Type of Planning intervention that is performed away from the client but on behalf of a client or group of clients (e.g., advocacy)

A

Indirect-care interventions

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85
Q

the authorization for the performance of selected nursing interventions from a licensed nurse to an unlicensed assistive person (UAP)

A

Delegation

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86
Q

Five Rights of Delegating: TCPDS

A
  1. Task (Can I delegate it?)
  2. Circumstance (Should I delegate it?)
  3. Person (Who is best prepared to do it?)
  4. Direction/Communication (What does the UAP need to know?)
  5. Supervision/Evaluation (How will I follow up?)
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87
Q

conscious internal dialogue, sometimes known as self-talk

A

Intra-personal Communication

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88
Q

communication occurs between two or more people

A

Inter-personal Communication

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89
Q

Nurses use ______ to gather information during assessment, to teach about health issues, to explain care, and to provide comfort and support

A

interpersonal communication

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90
Q

2 Methods of Communication

A
  1. verbal
  2. non-verbal
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91
Q

Active Listening

A

SOLER

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92
Q

What is SOLER?

A

S- Sit Straight
O- Open Posture
L- Lean forward
E- Eye contact is maintained
R- Relax

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93
Q
  • If something doesn’t seem right to you, it’s important to raise your concerns, especially when it comes to patient safety
  • You can feel empowered using this tool to point out a problem or a conflict of information without challenging the other person’s authority or coming off as a personal attack
A

CUS Tool

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94
Q

CUS Tool

A

I am Concerned …
I am Uncomfortable …
This is a Safety Issue

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95
Q

a communication tool that helps provide essential, concise information, usually during a crucial situation

A

SBAR

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96
Q

SBAR

A

S- Situation
B- Background
A- Assessment
R- Recommendation

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97
Q

a developmental process in which one achieves increasing levels of awareness, knowledge, and skills along a continuum, improving one’s capacity to work and communicate effectively in cross-cultural situations

A

Cultural competency

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98
Q

often seen as an alternative approach to cultural “competence”

A

Cultural Humility

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99
Q

Cultural Humility

A

a reflective process of understanding one’s biases and privileges, managing power imbalances, and maintaining a stance that is open to others in relation to aspects of their cultural identity that are most important to them

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100
Q

self-awareness, examining personal attitudes to identify bias

A

Cultural Awareness

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101
Q
  • Knowledgeable about culture prevalent in their area of practice
  • Has more to do with personal attitudes and being careful not to say or do something that might be offensive to someone from a different culture
A

Cultural sensitivity

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102
Q

apply knowledge of client’s culture to their care delivery

A

Cultural appropriateness

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103
Q

impose rules of your own culture onto another person

A

Cultural imposition

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104
Q

we’re all influenced by them whether we like it or not

A

Bias

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105
Q

subconscious tendency to seek & interpret information in ways that affirm our existing beliefs, ideas, expectations

A

Confirmation Bias

105
Q

refers to negative attitudes toward other people based on faulty and rigid stereotypes about race, gender, sexual orientation, and so on

106
Q

refers to the behavioral manifestations of that prejudice

A

Discrimination

107
Q

the tendency to think that your own group (cultural, professional, ethnic, or social) is superior to others and to view behaviors and beliefs that differ greatly from your own as somehow wrong, strange, or unenlightened

A

Ethnocentrism

108
Q

the unsubstantiated belief that all people of a certain racial or ethnic group are alike in certain respects

A

Cultural stereotyping

109
Q
  • a social construct
  • a form of prejudice and discrimination based on the belief that race is the principal determining factor of human traits and capabilities and that racial differences produce an inherent superiority (or inferiority)
110
Q

the assumption that members of one sex are superior to those of the other sex

111
Q

can involve foreign languages, dialects, regionalisms

A

Language barriers

112
Q

words or expressions used by a subculture, including medicine

A

Healthcare Jargon

113
Q

This theory helps distinguish nursing as a separate discipline from medicine and related sciences, and assists nurses in understanding their patients and their needs

A

Nursing Theory

114
Q

Organized set of related ideas & concepts​

115
Q

Broader & more philosophical than theories​

116
Q

Symbolic representation of framework​
Conceptual model – model expressed in language​

117
Q

Worldview or ideology​

118
Q

Created an environmental adaptation theory

A

Florence Nightingale

119
Q

Was ahead of her time in recognizing the importance of hygiene and cleanliness in the environment

A

Florence Nightingale

120
Q

Known as the “mother of psychiatric nursing”

A

Hildegard Peplau

121
Q

Believed that interpersonal relationships and communication can improve mental health

A

Hildegard Peplau

122
Q

Her theory was focused on therapeutic relationship using communication and collaboration

A

Hildegard Peplau

123
Q

The founder of transcultural nursing

A

Madeleine Leininger

124
Q

According to her theory, the nurse must make cultural accommodations for the health benefit of the client

A

Madeleine Leininger

125
Q

Called nurses to see the whole of the patterns of people’s lives in relationship to their environment and to respond to what is meaningful

A

Margaret Newman

126
Q

Her theory asserts finding greater meaning in life

A

Margaret Newman

127
Q

Maintaining an environment free of negative energy is important

A

Martha Rogers

128
Q

Proposed noninvasive modalities for nursing. Ex. therapeutic touch, humor, music, meditation and guided imagery, and even the use of color

A

Martha Rogers

129
Q

Her theory states that a patient is not simply the illness or injury being treated, but an entire person

A

Betty Neuman

130
Q

Her theory wants patients to be cared for from a holistic perspective in order to ensure they are cared for as people and not simply ailments

A

Betty Neuman

131
Q

Orem’s Self-Care Deficit Nursing Theory explains what nursing care is required when people are not able to care for themselves

A

Dorothea Orem

132
Q

Goal is to help client attain total self-care

A

Orem’s Self-Care Deficit Nursing Theory

133
Q

She created the adaptation model theory

A

Sister Callista Roy

134
Q

This theory where Nurses assist clients with adaptation

A

Roy’s adaptation model theory

135
Q

Her theory states Caring promotes health and individual/family growth

A

Jean Watson

136
Q

What theory states that “Caring promotes health and individual/family growth?”

A

Science of Human Caring

137
Q

Developed the nursing theory known as the “Science of Human Caring”

A

Jean Watson

138
Q

SDOH

A

Social Determinants of Health

139
Q

What are the Social Determinants of Health (SDOH)?

A
  1. Economic Stability
  2. Education (Access and Quality)
  3. Health Care (Access and Quality)
  4. Neighborhood and Built Environment
  5. Social and Community Context
140
Q

What are the Ethical Principles?

A
  1. Autonomy
  2. Nonmaleficence
  3. Beneficence
  4. Fidelity
  5. Veracity
  6. Justice
141
Q

Nurses are Ethical Agents

A
  • Knows the difference between right and wrong
  • Apply ethical principles in decision making
  • Value neutrality
142
Q

What are the factors in Ethical Decision Making?

A
  1. Values
  2. Attitudes
  3. Beliefs
143
Q

What is the key point in Ethical Decision Making?

A

Important to clarify the influence of your values each time you enter a situation in which you are called on to be objective in decision making

144
Q

-Right to choose and ability to act on that choice

-Informed consent

145
Q

To do no harm

A

Nonmaleficence

146
Q

Promote good

A

Beneficence

147
Q

Keep promises

148
Q

Tell the truth

149
Q

Obligation to be fair

150
Q

Not legally binding; however, often exceed legal obligation

A

Nursing code of ethics

151
Q

Nursing code of ethics

A

Formal statement of group’s expectations & standards for professional behavior

152
Q

Processes for Ethical Practice: MORAL

A

M- Massage the dilemma
O- Outline the options.
R- Resolve the dilemma.
A- Act by applying the chosen option.
L- Look back and evaluate.

153
Q

Nursing practice is guided by what?

A

legal principles

154
Q

What is the purpose of laws?

A
  1. Protect clients/society
  2. Define scope of nursing practice
  3. Identify the minimum level of care to be provided
155
Q
  • Failure to care
  • Professional held liable
A

Malpractice

156
Q
  • Financially or legally responsible for something
  • Nurses are legally responsible for their own actions
157
Q
  • Principal or standard for decision making
  • Belief about the worth of something
158
Q

Mental dispositions or feelings

159
Q

Accepts as true

160
Q

Board of Nursing

A

Govern the activities of administrative agencies
(Administrative Law)

161
Q

HIPAA

A

Health Insurance Portability and Accountability Act

162
Q
  • Protects health insurance benefits for workers
  • Standards to protect privacy of health information
163
Q

EMTALA

A

Emergency Medical Treatment and Active Labor Act

164
Q

Requires health care facilities to provide emergency medical treatment, regardless of ability to pay, legal status, or citizenship status

165
Q
  • Right for clients to make decisions regarding his/her/their own health care
  • Legal written advance directives
A

Patient Self-Determination Act (PSDA)

166
Q

2 types of Legal written advance directives (PSDA)

A
  1. Living will
  2. Durable power of attorney for health care
167
Q

Provides instructions to the medical team about care choices

A

Living will

168
Q

Names one or more people to make decisions if that person becomes mentally incapacitated

A

Durable power of attorney for health care

169
Q

Protection against discrimination of individuals with disabilities

A

Americans with Disabilities Act (ADA)

170
Q

A law that protects people from legal repercussions when they believe another person is injured and decide to help them out.

A

Good Samaritan laws

171
Q

What are the State Laws Guiding Nursing Practice?

A
  1. Mandatory reporting laws
  2. Good Samaritan Law
  3. Nurse practice Acts
172
Q

What is included in the Mandatory reporting laws?

A
  1. Abuse
  2. Communicable disease/Infection
173
Q

What are the types of Criminal Law?

A
  1. Misdemeanor
  2. Felony
174
Q

Misdemeanor

A
  • Minor crime – relative to felony
  • Less than a year in jail
  • May lose professional license.

Example: assault, battery, and petty theft.

175
Q

Felony

A
  • More than 1 year in jail
  • Lose the right to vote, hold public office, serve on a jury, and possess firearms.
  • May also lose any professional licenses.
  • Examples: murder, assisted suicide, rape/sexual assault, or stealing drugs and equipment.
176
Q

Dispute between individuals or entities

177
Q
  • Written or oral agreements between two parties
  • Explicit or implicit
A

Contract Law

178
Q
  • Wrongs done to one individual to another not involving contracts
  • Involves claims for damages
179
Q
  • Defamation of character
  • Slander
  • Libel
A

Quasi-intentional torts

180
Q

Three types of Tort Law

A
  1. Quasi-intentional torts
  2. Intentional torts
  3. Non/unintentional torts
181
Q
  • Assault and battery
  • False imprisonment
  • Invasion of privacy
  • Fraud
A

Intentional torts

182
Q
  • Negligence
  • Malpractice
A

Unintentional tort

183
Q

Negligence

A
  • Failure to perform as a reasonable, prudent person would
  • Failure to follow standards of practice
  • No intent to harm is present
184
Q

Malpractice

A

–Four elements necessary
a. Existence of a duty
b. Breach of a duty
c. Causation
d. Damages

185
Q

promote comfort, improve self-image, and decrease infection and disease

A

Activities of daily living (ADLs)

186
Q

What are the ADLs?

A
  1. Personal grooming
  2. Bathing
  3. Dressing
  4. Feeding
  5. Toileting
  6. Transferring
  7. Walking/Ambulating
187
Q

What are the Nursing Roles?

A
  • Assess self-care abilities
  • Provide assistance with ADLs
  • Promote self-care in ADLs
  • Delegate appropriate parts of hygiene care
188
Q

What are the Factors That Influence Hygiene and Self-Care Practices?

A
  • Personal preferences
  • Culture and religion/spirituality
  • Economic status
  • Developmental level
  • Knowledge level
189
Q

What are Types of Scheduled Hygiene Care?

A
  1. A.M. care
  2. P.M. Care
  3. H.S. Care (Hours of Sleep)
190
Q

comfort rounds or safety rounds frequency

A

Hourly rounds

191
Q

After breakfast: bathing, toileting, oral care, hair, skin, bed making

192
Q

Afternoon: toileting, handwashing, oral care, readying for visitors

193
Q

Prior to sleep: relaxation activities, readying environment to facilitate sleep

194
Q

When you think about prioritizing who should get a bath, think about what?

A

“what can cause more harm if I don’t bathe this patient first?”

195
Q

Factors That Influence Hygiene and Self-Care Practices (Physical Status)

A
  1. Pain
  2. Limited mobility
  3. Sensory deficits
  4. Cognitive impairments
  5. Emotional disturbances
196
Q

What are the 3 purposes of Bathing?

A
  1. Health Promotion
  2. Pleasure or relaxation
  3. Social interaction
197
Q

What are the Types of Baths?

A
  1. Assist Bath
  2. Complete Bath
  3. Partial Bath
198
Q

Bathe areas hard to reach

A

Assist Bath

199
Q

Bathe the client from head to toe, cleanest areas first

A

Complete Bath

200
Q

Bathe only those areas absolutely necessary, including perineum

A

Partial bath

201
Q
  • Tends to become agitated when told it is time to bathe
  • Provide care in short intervals, but don’t rush
A

Client who has dementia

202
Q
  • A thorough skin assessment is essential, but it is difficult
  • Lift folds
A

Client who is obese

203
Q

Nursing Process: Nail Care

A
  • Trim Nails straight across with a nail trimmer
  • just file for patients with diabetes or circulatory problems
204
Q

These patients should seek nail care from a podiatrist

A

patients with Diabetes

205
Q

What happens if oral care is not implemented well?

A

The bacteria can travel down to the lungs

206
Q

an inflammation of the oral mucosa

A

Stomatitis

207
Q

inflammation of the tongue

208
Q

Always use electric razors for which patients?

A

patients taking anticoagulant

209
Q

Eye care for the unconscious client

A

comatose or critically ill clients need more frequent eye care

  • lost the blink (corneal) reflex
210
Q

What to do to prevent cross-contamination if there is drainage or crusting?

A

a different wipe should be used for each eye

211
Q

are expensive and often essential to the client, so handle and store them properly; never place in water

A

Hearing aid care

212
Q

a wax

213
Q

visible portion of the external ear

214
Q

Usually the nose requires no special care
(true or false)

A

True, except for an unconscious client or patient with NG tube

215
Q

NG tube

A

Nasogastric tube

216
Q

provide special skin care and a lubricant at the point where the tube touches the nares

A

Caring for a client with NG tube

217
Q

Nursing Process: Nose - need to provide care for which clients?

A
  1. unconscious patients
  2. patients with NG tube
218
Q

Each time you enter a client’s room, you should what?

A

Scan/Assess the environment

219
Q

Each time you leave the room, ask what?

A

“What else can I do for you?” This ensures that you have not overlooked anything.

220
Q

What should you Instruct unlicensed assistive personnel (UAP) regarding from?

A
  1. Client’s limitations
  2. Amount of assistance needed
  3. Use of assistive devices
  4. Presence and care of tubes
  5. Observations to make during hygiene care
221
Q

Including brushing teeth, combing hair, and/or shaving

A

Personal grooming

222
Q

Wash face and body in the tub or shower

223
Q

Put on clothes and manage one’s appearance

224
Q

Consuming meals from plate to mouth using proper utensils.

225
Q

Going to and from the toilet to clean oneself

226
Q

Moving the body from one position to another (not necessarily just walking)

A

Transferring

227
Q

Move from one place to another using their legs; also called “ambulating.”

228
Q

A Factor that influence Hygiene and Self-Care Practices: When to bathe, what products to use

A

Personal preferences

229
Q

A Factor that influence Hygiene and Self-Care Practices: Beliefs about hygiene and cleanliness

A

Culture and religion/spirituality

230
Q

A Factor that influence Hygiene and Self-Care Practices: Inadequate bathing facilities and
Monetary constraints

A

Economic status

231
Q

A Factor that influence Hygiene and Self-Care Practices: influenced by:
Parents, media, peers, age

A

Developmental level

232
Q

A Factor that influence Hygiene and Self-Care Practices: Client teaching is an important part of your hygiene care because most people will, eventually, take care of their own personal hygiene

A

Knowledge level

233
Q
  • Bathing removes perspiration and bacteria from the skin surface, helping to prevent body odor
  • The warmth from the bath solution and the friction of bathing dilates the blood vessels near the surface of the skin, increasing the circulation
  • Bathing stimulates depth of respirations and provides sensory input
A

Health promotion

234
Q

bathing can be a time to strengthen the nurse-client relationship

A

Social interaction

235
Q

Patient cannot tolerate activity; movement is not a good idea.

A

Decreased Activity Intolerance

236
Q

Teach foot care, especially what?

237
Q

(True or false): Remove hangnails by carefully removing them with cuticle clipper.

238
Q

(True or False): Clean under the nails with an orangewood stick or other blunt instrument.

239
Q

bathing dilates the blood vessels near the surface of the skin, increasing what?

A

circulation

240
Q
  • Removal of food particles and secretions
  • Improved appetite
  • Reduction of the incidence of pneumonia, especially on a ventilator (want to avoid ventilator assisted pneumonia – VAP)
A

Oral Care Importance

241
Q

VAP or ventilator assisted pneumonia can happen with improper oral care (True or False)

242
Q

To prevent cross-contamination if there is drainage or crusting, what should you do?

A

a different wipe should be used for each eye

243
Q

use dressing self-care deficit or bathing self-care deficit

A

when the difficulty with hair care lies with self-care ability

244
Q

NG tube is used to supply what?

245
Q

Nursing Process: Environment Assessment

A

-Temperature(comfortable?)
- Side rails
- Bed position (not high)
- Wheels locked on bed
- Clean linen
- Call light within reach
- Over-bed table clean and clear
- Uncluttered walking spaces
- No foul odors; remove food tray after meal

246
Q

The pain itself, limited mobility caused by the pain, and drowsiness from analgesics used to manage the pain may all contribute to a self-care deficit

247
Q

(e.g., from joint and muscle problems, casts or traction, injury, weakness, fatigue, surgery, prescribed bedrest, or pain) makes it difficult to perform hygiene activities.

A

Limited Mobility

248
Q

diminish a person’s ability to perform hygiene measures safely and independently

A

Sensory Deficit

249
Q

Cannot determine the need for hygiene
Cannot problem-solve ADL processes
Forgets when last performed hygiene and ADLs

A

Cognitive impairments

250
Q

Profound lack of energy for ADLs
Altered reality does not include hygiene

A

Emotional disturbances

251
Q

prior to delegating what should you do?

252
Q

Infants have fragile, easily injured skin
As a child matures, the skin becomes more resistant to injury and infection, but children need adults to provide or supervise the cleanliness of their skin

A

Developmental level: Factor Affecting the Skin

253
Q
  • Health status
  • Dampness
  • Dehydration
  • Nutritional status
  • Insufficient circulation
  • Skin diseases
  • Jaundice
  • Lifestyle and personal choices
    -Developmental level
A

Factors affecting the skin

254
Q
  • Prepackaged bathing products
  • Basin and water
  • Shower
  • Tub bath
  • Therapeutic bath
A

Other Types of Baths

255
Q
  • Oatmeal bath for specific skin conditions
  • Warm sitz to cleanse perineal area
A

Therapeutic bath

256
Q

The reason for agitation for client who has dementia

A

usually that the client experiences pain, cold, fear, and loss of control

257
Q

significantly reduce aggressive behaviors of a client with dementia by doing what?

A

giving a towel bath or bag bath instead

258
Q
  • Corn
  • Calluses
  • Tinea pedis/athlete’s foot
  • Ingrown toenail
  • Foot odor
  • Plantar warts
  • Pressure injuries
  • Bunion
A

Common Foot Problems

259
Q

assess the appearance and care of the nails

A

Assessment: Nursing Process for Nail Care

260
Q

Analysis/Nursing Diagnosis for Nail Care

A

there are no nursing diagnoses specific for nail care

261
Q

outcomes are more appropriate for circulation

A

Planning Outcomes/Evaluation: Nursing Process for Nail Care

262
Q

What is the Planning Intervention/Implementation for Nail Care?

A

teach nail care

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