Exam 2

Question 1

What is MS?

Answer 1

An autoimmune disorder that affect nerve cells in the brain and spinal cord, characterized by plaque build up on the CNS, which damages the myelin sheath and interferes with impulse transmission. Includes relapses and remission, but most cases don’t affect lifespan.

Question 2

What are some risk factors and triggers for MS?

Answer 2

Risks: Between 20 and 40 years old, female, Northern European descent, family history.
Triggers: viruses, infections, cold climate, physical injury, emotional stress, pregnancy, fatigue.

Question 3

What are some physical assessments and lab tests that may detect MS?

Answer 3

Physical: fatigue, pain, changes in vision especially when exposed to heat, tinnitus, vertigo, decreased hearing, dysphasia, slurred speech, muscle spasticity, weakness, bowel/bladder dysfunction, memory loss, sexual dysfunction.
Lab tests: MRI (reveals plaques) and spinal tap (reveals elevated protein level & increase in WBC)

Question 4

What are some nursing care interventions a nurse will implement for a patient with MS?

Answer 4

Monitor for symptoms, activity tolerance & skin integrity, discuss coping mechanisms, offer support, encourage intake, assist with bladder elimination when experiencing dysfunction, monitor cognitive function, exercise muscles, grouping care tasks, rest periods, safety precautions

Question 5

What are some things the nurse may want to educate their patient with MS on?

Answer 5

Create a plan for disease progression, community resources, respite services, PT/OT, home health, use of assistive devices, speech therapist, avoid triggers,

Question 6

What are some complications patients can experience because of fractures that the nurse should be aware of?

Answer 6

Acute compartment syndrome, hemorrhage, hypovolemic shock, fat embolism syndrome, venous thromboembolism, infection, chronic complications

Question 7

What are some signs a patient may have acute compartment syndrome that the nurse should be watching for?

Answer 7

Build up of pressure from swelling of fascia, most common in thigh & forearm, swelling, extreme pain, redness, decreased cap refill, edema, cyanotic color

Question 8

What are some assessments the nurse should include for her patient with a fracture?

Answer 8

Type of injury, events leading up to, drug/alcohol involvement, medical history, assess for complications, check urine for blood, assess for swelling, perfusion, & skin integrity, coping ability, labs and imaging

Question 9

What are the goals for patients with fractures?

Answer 9

Managing acute pain, increasing mobility, preventing/monitoring for neuro vascular compromise, & preventing infection

Question 10

What are some assessments the nurse should include for a patient with a spinal cord injury?

Answer 10

ABC, indications of internal bleeding, LOC, level of injury, cardiovascular & respiratory status, imaging results

Question 11

What are some potential complications patients with a spinal cord injury might encounter?

Answer 11

Respiratory distress, cardiovascular instability, secondary spinal cord injury, decreased mobility and sensation.

Question 12

What are the types of errors nurses should be aware of?

Answer 12

Commission: doing the wrong thing
Omission: did not do anything
Execution: did the right thing incorrectly

Question 13

What are the levels of errors?

Answer 13

Adverse event: unintended harm by an act of commission or omission rather than a result of a disease process
Near miss: error that could have harmed the patient, but did not in a result of chance
Sentinel event: unexpected occurrence involving death or serious injury

Question 14

What is a culture of safety?

Answer 14

Focusing on what went wrong and why rather than blaming one person followed by disciplinary measures. This allows for measures to be implemented to reduce errors by changing the failing system.

Question 15

What are some human factors that affect the likelihood of an error occurring?

Answer 15

Inability to multitask, lack of knowledge of technology, aides conversing with nurse during med pass, phone calls, computer system not working, visitors, personal issues on mind

Question 16

What are some characteristics of high reliability organizations?

Answer 16

Sensitivity to operations, focused on predicting and preventing rather than reacting to errors, reluctance to simplify, deference to expertise, explicit value of safety

Question 17

What is just culture?

Answer 17

The value of reporting errors without punishment; seeks to find balance between the need to learn from mistakes and need for discipline; doesn’t mean nurses aren’t responsible for their errors, but does mean they aren’t punished for a flawed system.

Question 18

What are the three behaviors that factor into just culture decisions?

Answer 18

Human error: accident
At-risk behavior: a choice that increases risks but nurse does not recognize it as a risk or believes it is justified
Reckless behavior: making choices when knowing the consequences and disregarding anyways

Question 19

What are seven aspects that go into a culture of safety?

Answer 19

Leadership, teamwork, evidence base, communication, learning, just culture, and patient centered care

Question 20

What are some risk factors the nurse should be aware of that can affect the safety of the patient and cause errors?

Answer 20

Patient: skin integrity, age, inadequate lighting, diseases, work hazards, hazards at home
Nurse: rushed, distracted, multitasking, fatigue, staffing issues, poor communication, poor documentation, lack of knowledge, short cuts

Question 21

What are some sources of ethics that may influence how a nurse forms their ethical beliefs?

Answer 21

Family, culture, geographic area, socioeconomic status, faith, peers, education, workplace

Question 22

What are the ethical principles a nurse should have and what do they mean?

Answer 22

Veracity: respect for persons; telling the truth
Nonmaleficence: do no harm
Beneficence: doing good actions
Justice: treating all equally
Fidelity: being loyal; doing what you say you’ll do

Question 23

What are some ethical issues in nursing that a nurse may encounter?

Answer 23

Protecting pt’s rights/dignity
Respecting/not respecting informed consent treatment
Providing care with risk to the health of the nurse
Using or not using chemical or physical restraints
Understaffing that limits pt care
Prolonging the dying process
Not considering/policies threatening pt’s quality of life
Working with unethical/impaired coworkers

Question 24

What are some obstacles a nurse may encounter when needing to report a medical error?

Answer 24

Time it takes to report, tedious and nonfriendly report forms, not wanting to tell on someone, not perceiving the error as serious

Question 25

What are some risk factors for developing asthma?

Answer 25

Older adults, family history, smoking, second hand smoke, environmental allergies, exposure to chemical irritants or dust, GERD

Question 26

What are some assessments the nurse might make that may indicate a patient has asthma?

Answer 26

Dyspnea, tight chest, anxiety, coughing, wheezing, mucus production, prolonged exhalation, poor oxygen saturation, barrel chest

Question 27

What are some nursing care interventions a nurse might implement for a patient with asthma?

Answer 27

Positioning in high fowlers, administer oxygen, monitor HR and rhythm, maintain IV access, reassure pt, rest periods, administer medications

Question 28

What are some things the nurse may need to educate a patient with asthma who is taking medications to treat it?

Answer 28

Report black, tarry stools, drink lots of fluids, take prednisone with food, avoid people with respiratory infections, use good mouth care, do not stop abruptly, practice proper use of MDI, rinse mouth and gargle after inhaled glucocorticoids

Question 29

What are some diagnostic procedures used to diagnose asthma and what is the criteria required for a diagnosis?

Answer 29

Total lung capacity, tidal volume, functional residual capacity, residual volume, forced vital capacity, forced expiratory volume, peak expiratory flow.
An increase in these values by 12% following administering bronchodilators is diagnostic for asthma.

Question 30

What are some causes and symptoms of iron deficiency anemia?

Answer 30

Causes: blood loss, poor GI absorption, inadequate diet
Symptoms: weakness, pallor, reduced exercise tolerance, fissures at corner of mouth

Question 31

What are some causes and symptoms of vitamin B-12 deficiency anemia?

Answer 31

Causes: vegan diets, small bowel resection, chronic diarrhea, diverticula, tapeworm, overgrowth of intestinal bacteria
Symptoms: pallor, jaundice, smooth beefy red tongue, fatigue, weight loss, abnormal sensations in hands/feet, poor balance

Question 32

What are some causes and symptoms of folic acid deficiency anemia?

Answer 32

Causes: poor nutrition, chrons disease, anticonvulsants, oral contraceptives
Symptoms: pallor, jaundice, smooth beefy red tongue, fatigue, weight loss

Question 33

How can a patient get aplastic anemia and what are some symptoms of it?

Answer 33

RBC deficient because of impaired cellular regulation of the bone marrow which then fails to produce RBC; usually occurs w/ leukopenia & thrombocytopenia.
Symptoms: severe signs of anemia, severely low CBC counts, & infection is common

Question 34

What are some risk factors for developing anemia?

Answer 34

Acute/chronic blood loss, chemical/radiation exposure, increased hemolysis, inadequate dietary intake or malabsorption, bone marrow suppression, age

Question 35

What are some physical assessments the nurse may find for a patient with anemia?

Answer 35

Pallor, fatigue, irritability, numbness/tingling, dyspnea on exertion, sensitivity to cold, tachycardia, palpitations, dizziness, pale nail beds & mucus membranes, spoon shaped nails

Question 36

What are some risk factors for developing a pulmonary embolism?

Answer 36

Immobility, oral contraceptives, estrogen therapy, pregnancy, tobacco use, elevated platelet count, obesity, surgery, central IV, heart failure, chronic a fib, sickle cell anemia, long bone fractures, cancer, trauma, old age

Question 37

What are some physical assessments the nurse may find when a patient is experiencing a PE?

Answer 37

Anxiety, feelings of doom, pressure in chest, pain upon inspiration, chest wall tenderness, dyspnea, cough, pleurisy, tachycardia, hypotension, tachypnea, crackles in lungs, heart murmur, sweating, low grade fever, decrease O2 sats, cyanosis, distended neck veins, syncope

Question 38

What is coronary artery disease?

Answer 38

Most common type of heart disease/ #1 cause of death
Includes stable angina, unstable angina, & MI
Main causes are atherosclerosis & inflammation

Question 39

What is a stable angina?

Answer 39

“Strangling of the chest”
Temporary imbalance between artery’s ability to supply oxygen & cardiac muscle’s demand for oxygen
Does not cause permanent damage to tissue
Occurs with exercise or stress & is relieved by rest or nitroglycerin

Question 40

What is the difference between the two types of acute coronary syndrome, unstable angina and myocardial infarction?

Answer 40

Unstable angina: partial blockage, occurs with exercise/stress, increases in occurrence/severity over time
MI: most serious, complete blockage, severe depletion of O2, hypoxia, occlusion of blood flow

Question 41

What is the difference between the two types of MI’s: STEMI and NSTEMI?

Answer 41

NSTEMI: less damaging, partial/temporary blockage, depression of ST wave
STEMI: more common, abrupt/prolonged blockage, elevated ST wave

Question 42

What are some factors that put patients at risk for CAD?

Answer 42

Hyperlipidemia, diabetes, hypertension, smoking, obesity,inactivity, diet,stress, old age, male, African American, menopause

Question 43

What are some assessments a nurse may find for a patient with CAD?

Answer 43

Pain, BP, HR, SOB, heart sounds, weak/unpalpable peripheral pulses, dizziness, fatigue, n/v, cold/clammy skin, denial, fear, anxiety

Question 44

What are some nursing care interventions the nurse should implement for a patient with CAD?

Answer 44

1-2 large IVs, telemetry, bed rest, promote rest, continuous ECG, administer O2, no caffeine, slowly increase activity, cardiac diet, MONA (morphine, oxygen, nitroglycerin, aspirin)

Question 45

What are some lab tests that may indicate CAD?

Answer 45

CRP, creatine kinase, CK-MB, troponin, myoglobin, CBC, ECG, stress test, echocardiogram
All the labs will be elevated if there’s been damage to the heart muscles or surrounding muscles

Question 46

What are some factors that put patients at risk for dysrhythmias?

Answer 46

Age, cardiovascular disease, MI, acid base imbalance, electrolyte imbalance, heart failure, metabolic disorders, drug/alcohol use, hypovolemia, shock

Question 47

What are some physical assessments the nurse may find for a patient with a dysrhythmia?

Answer 47

Poor perfusion, anxiety, chest pain/tightness, dizziness, palpitations, pounding of chest, SOB, weakness, fatigue, abnormal ECG

Question 48

What are patients with dysrhythmias at risk for?

Answer 48

Stroke, PE, injury, SOB, fatigue, impaired gas exchange, HF, impaired wound healing