Exam 2 (Chapters 13, 14, 15, 16, 17, 18, 19, 33, 37, 38, & 39) Flashcards
1
Q
Can clinical judgement be learned?
Ch 14
A
Yes, clinical judgement can be learned
Clinical Reasoning (=)
Clinical Judgement (+ CDM)
Critical Thinking (+)
2
Q
What’s inductive thinking?
Ch 14
A
How we think about something very specifically
- recognizing patterns
- making connections
- Can I analyze information & make conclusions or hypotheses?
Piaget = cognitive development
3
Q
What is clinical judgement?
Ch 14
A
Skill of recognizing cues & you generate or weigh a hypothesis
- something someone said or did, info from the EMR, etc.
4
Q
How are Clinical Reasoning & Clinical Judgement related?
Ch 14
A
Clinical reasoning is a precursor to clinical judgement
- put all pieces together (Clinical decision making) before making a clinical judgement
5
Q
Tanner’s Clinical Judgement Model
Ch 14
A
- Interpreting: attributing meaning to the data through multiple reasoning patterns
- Responding: deciding on an action (or inaction) & monitoring outcomes
- Reflecting: in-action & on-action
6
Q
What is the Mental Model of the Nursing Process?
Ch 14
A
Organized way of thinking that assists in understanding complex aspects of situations & guides assessments & behaviors
7
Q
What are the steps of the nursing process?
Ch 14
A
A: assessment
D: diagnosis (/ identify actual or potential problems)
P: planning
I: implementation / identify interventions (with rationales)
E: evaluation
8
Q
What is the difference in reflecting in-action vs. on-action?
Ch 14
A
- In-Action: actively engaged
- On-Action: reflection after the fact (post conference)
9
Q
What are the steps of the nursing process
NCSBN Clinical Judgement Measurement Model
Ch 14
A
1.) Assessment
2.) Analysis
3.) Planning
4.) Implementation
5.) Evaluation
10
Q
Which of the following includes all four components of moral reasoning & captures the congitive processes that precede moral action?
a.) Information-Processing Model
b.) Cognitive Continuum Theory
c.) Rest Framework
d.) Humanistic-Intuitive Approach
Ch 14
A
c.) Rest Framework
11
Q
What are you looking for when performing a clinical assessment?
Ch 15
A
- Look for the abnormal findings
- What’s out of the norm?
- Try to find a trend
12
Q
Characteristics of Nursing Assessments
Ch 15
A
- Purposeful
- Prioritized
- Complete
- Systematic
- Factual
- Relevant
- Recorded in a standard manner
13
Q
What is the primary source of information in an assessment?
Ch 15
A
The patinet
14
Q
Which of the following assessments would be performed on a patient to gather about their previously diagnosed liver cancer?
a.) Initial comprehensive assessment
b.) Focused assessment
c.) Emergency assessment
d.) Time-lapsed assessment
Ch 15
A
b.) Focused assessment
15
Q
What are the 5 types of Nursing Assessments?
Ch 15
A
- Comprehensive initial
- Focused
- Emergency
- Time-lapsed
- Assessment of communities and special populations
16
Q
What is a Comprehensive Initial Assessment?
Ch 15
A
Complete exam of all systems
17
Q
What is a Focused Assessment?
Ch 15
A
gathering data about something that has already happened
18
Q
What is an Emergency Assessment?
Ch 15
A
An assessment gathered during a crisis
19
Q
What is a Time-Lapsed Assessment?
Ch 15
A
Comparing current status to a patient’s baseline
- look at points in time
20
Q
True or False:
A nursing assessment duplicates a medical assessment by focusing on the patient’s responses to the health problem.
Ch 15
A
False
Nursing assessment focuses on patient’s responses to health problem
21
Q
What is the difference in the medical model & the nursing assessments?
Ch 15
A
- Medical Assessment: targets data that points to / diagnoses pathological conditions
- Nursing Assessment: focuses on the patient’s response to health problems
22
Q
What is the difference in subjective & objective data?
Ch 15
A
Subjective Data: cannot be measured
* dizziness, anxious, pain
Objective Data: measurable data
* temperature, urine output, BP
23
Q
Who is the primary data source during an assessment?
Ch 15
A
The patient
24
Q
What are the Phases of a Nursing Interview?
Ch 15 (KNOW THIS)
A
1.) Preparatory phase
2.) Introduction
3.) Working phase
4.) Termination phase
25
**What is the purpose of a nursing physical assessment?**
| Ch 15
* helps us gather more data
* helps us identify *actual* health problems
26
**What 5 sources of patient data are useful for nurses?**
| Ch 15
**1.)** Patient
**2.)** Family / Significant Others
**3.)** Patient Record
**4.)** Assistive Technology
**5.)** Other health care professionals
27
**List common problems involved in data collection?**
| Ch 15
* omission of pertinent information
* failure to update the database
* inclusion of irrelevant or duplicate data
28
**A nurse's personal moral code is to assist all patients to the best of one's ability. What blended skill would the nurse use when seeking out special services for a homeless patient with a diabetic foot ulcer?**
**a.)** Cognitive
**b.)** Technical
**c.)** Interpersonal
**d.)** Ethical / Legal
| Ch 13
**d.)** Ethical / Legal
29
**What are the QSEN Competencies?**
| Ch 13
* Patient-centered care
* Teamwork & collaboration
* Evidence-based practice (EBP)
* Quality improvement
* Safety
* Informatics
30
**What are the 3 Problem Solving Approaches to the nursing process?**
| Ch 13
* **Trial & Error** problem solving
* **Scientific** problem solving
* **Intuitive** problem solving
31
**What key events regarding the development of the nursing process occured in**
* **1955**
* **1960s**
* **1973**
* **1982**
| Ch 13
* **1955:** nursing process term is used
* **1960s:** specific steps for the nursing process are outlined
* **1973:** ANA develops Standard of Practice
* **1982:** State board exams use nursing process as a concept
32
**What are the 5 steps of the nursing process?**
| Ch 13
**1.) A**ssessing
**2.) D**iagnosing
**3.) P**lanning
**4.) I**mplementing
**5.) E**valuating
33
**Which step of the nursing process is a nurse using when analyzing patient data to determine a patient's strengths following a CVA?**
**a.)** Assessing
**b.)** Diagnosing
**c.)** Planning
**d.)** Implementing
**e.)** Evaluating
| Ch 13
**b.)** Diagnosing
34
**List the 5 characteristics of the nursing process**
| Ch 13
**1.) Systematic**
**2.) Dynamic:** great interaction & overlapping among the 5 steps
**3.) Interpersonal**
**4.) Outcome oriented:** nurses & patients work together to identify outcomes
**5.) Universally applicable:** a framework for all nursing activities
35
**What steps are involved in concept mapping?**
| Ch 13
**1.)** Collect patient problems & concerns on a list
**2.)** Connect & analyze the relationship
**3.)** Create a diagram
**4.)** Keep in mind key concepts: the nursing process, holism, safety, & advocacy
36
**What are Nursing COncerns & Responsibilities when it comes to diagnosing?**
| Ch 16 **(KNOW THIS)**
* **Recognizing** safety & infection-transmission risks
* **Identifying** human responses
* **Anticipating** possible complications
* **Initiating urgent interventions**
37
**What is a nursing diagnosis?**
| Ch 16
Describes patient problems nurses can treat independently
38
**What are the four steps of data interpretation & analysis?**
| Ch 16
**1.) Recognizing significant data** (comparing data to standards)
**2.) Recognizing patterns or clusters**
**3.) Identifying strengths & problems** (and potential complications associated with these problems)
**4.) Reaching conclusions**
39
**A nurse decides that a patient has a possible problem with high blood pressure. During which step of data interpretation would this most likely be determined?**
**a.)** Recognizing significant data
**b.)** Recognizing patterns or clusters
**c.)** Identifying strengths & problems
**d.)** Reaching conclusions
| Ch 16
**d.)** Reaching conclusions
40
**What are the 3 types of nursing diagnoses?**
| Ch 16
**1.) Problem-focused**
**2.) Risk**
**3.) Health promotion**
41
**What are the 4 components of a diagnosis?**
| Ch 16 **(KNOW THIS)**
* **Label**
* **Definition**
* **Defining characteristics**
* **Related factors**
42
**What are some benefits of nursing diagnoses?**
| Ch 16
**Benefits**
* individualizing patient care
* defining domain of nursing to healthcare administrators, legislators, & providers
* Seeking funding for nursing & reimbursement for nursing services
43
**What are limitations of nursing diagnoses?**
| Ch 16
**Limitations**
* patient could be misdiagnosed (if used incorrectly)
* Nursing practice might be restricted
44
**Which of the following nursing diagnoses is written correctly?**
**a.)** Child abuse related to maternal hostility
**b.)** Breast cancer related to family history
**c.)** Deficient knowledge related to alteration in diet
**d.)** Imbalanced nutrition related to insufficient funds in meal budget
| Ch 16
**d.)** Imbalanced nutrition related to insufficient funds in meal budget
45
**What are the goals of Planning / Outcome Identification?**
| Ch 17
* establish priorities
* identify & write expected patient outcomes
* select evidence-based nursing interventions
* communicate the care plan
46
**Which nursing action would most likely occur during the ongoing planning stage of the comprehensive care plan?**
**a.)** The nurse collects new data & uses them to update the plan & resolve health problems
**b.)** The nurse uses teaching & counseling skills to help the patient carry out self-care behaviors at home
**c.)** The nurse who performs the admission nursing history develops a patient care plan
**d.)** The nurse consults standardized care plans to identify nursing diagnoses, outcomes, and interventions
| Ch 17
**a.)** The nurse collects enw data & uses them to update the plan & resolve health problems
47
**What are the 3 elements of comprehensive planning?**
| Ch 17
* **Intial:** developed by the nurse; addresses each problem listed in nursing diagnoses; identifies appropriate patient goals & related nursing care
* **Ongoing:** Keeps the plan up to date, manages risk factors, promotes function**;** states nursing diagnoses more clearly**;** develops new diagnoses
* **Discharge:** uses teaching & cousneling skills effectively to ensure that home care behaviros are performed commpetently
48
**Which nursing diagnosis would most likely be considered a high priority?**
**a.)** Disturbed personal identity
**b.)** Impaired gas exchange
**c.)** Risk for powerlessness
**d.)** Activity intolerance
| Ch 17
**b.)** Impaired gas exchange
49
**What are Maslow's Hierarchy of Human Needs?**
| Ch 17 **(KNOW THIS)**
* Physiologic needs
* Safety needs
* Love & belonging needs
* Self-esteem needs
* Self-actualization needs
50
**What is the difference in long-term and short-term outcomes?**
| Ch 17
**Long-Term:** longer than 3 months**;** may be used as discharge goal
**Short-Term:** under 3 months**;** may be accomplished in a specified period fo time (SMART goals)
51
**What are cognitive outcomes?**
| Ch 17
Describes increases in patient knowledge or intellectual behaviors
52
**What are psychomotor outcomes?**
| Ch 17
Describes patient's achievement of new skills
53
**What are affective outcomes?**
| Ch 17
Describes changes in patient values, beliefs, and attitudes
54
**What are the different types of nursing interventions?**
| Ch 17
**1.)** Nurse-initiated
**2.)** Physician-initiated
**3.)** Collaborative
55
**What are nurse-initiated interventions?**
| Ch 17
actions performed by a nurse without a physician's order
56
**List some actions that can be performed in Nurse-Initiated Interventions**
| Ch 17
* Monitor health status
* Reduce risks
* Resolve, prevent, or manage a health problem
* Facilitate independence or assist with ADLs
* Promote optimum sense of physical, psychological, & spiritual well-being
57
**What is the implementation phase of the nursing process?**
| Ch 18
"Nursing Orders"
| romote health, prevent disease, restore health, cope w/ altered fxn
58
**What are Alfaro's Rules for Clinical Reasoning & Implementation?**
| Ch 18
Assess, reassess, revise, & record
59
**Give examples of different types of nursing interventions**
| Ch 18
* Interventions aimed at **providing direct & indirect care**
* Interventions aimed at **individuals, family, & community**
* Interventions aimed for **nurse-initiated & other provider-initiated treatments**
60
**What is involved in the implementation phase of the nursing process?**
| Ch 18
* Carry out the plan
* Continue data collection & plan modifications
* Document care
61
**What are some patient & nurse variables that influence outcome achievement?**
| Ch 18
**Patient Variables**
* developmental stage
* phsychosocial background & culture
**Nurse Variables**
* resources
* current standards of care
* research findings
* ethical & legal guides to practice
62
**Which example illustrates a nurse variable influencing patient outcomes?**
**a.)** A patient in a nursing home refuses to take his medications.
**b.)** A low-income family is unable to afford formula for their newborn infant.
**c.)** An alcoholic patient is unwilling to participate in AA meetings.
**d.)** A rape victim does not receive counseling in the emergency department because a counselor is not available.
| Ch 18
**d.)** A rape victim does not receive counseling in the emergency department because a counselor is not available
63
**What are the 5 Rights of Deligation?**
| Ch 18 **(KNOW THIS)**
**Right**
* Task
* Circumstances
* Person
* Directions & Communication
* Supervision & Evaluation
64
**What is involved in the evaluation phase of the nursing process?**
| Ch 19
Measure **how well** the patient has achieved desired outcomes
65
**What are actions that can be taken based on a patient's response to a care plan?**
| Ch 18
**1.)Terminate the care plan** when each expected outcome is achieved
**2.) Modify the care plan** if there are difficulties achieving the outcomes
**3.) Continue the care plan** if more time is needed to achieve the outcomes
66
**What are 4 types of outcomes?**
| Ch 19 **(KNOW THIS)**
**1.) Cognitive:** increase in patient knowledge
**2.) Psychomotor:** patient's achievement of new skills
**3.) Affective:** changes in patient values, beliefs, and attitudes
**4.) Physiologic:** physical changes in the patient
67
**What is a cognitive outcome?**
| Ch 19
increase in patient knowledge
68
**What is a psychomotor outcome?**
| Ch 19
patient's achievement of new skills
69
**What is an affective outcome?**
| Ch 19
changes in patient values, beliefs, and attitudes
70
**What is a physiologic outcome?**
| Ch 19
physical changes in the patient
71
**Which exmaple is a psychomotor outcome?**
**a.)** A patient learns how to control his weight using the Choose MyPlate food guide.
**b.)** A patient is able to test for glucose levels & inject insulin as needed.
**c.)** A patient values his health enough to decide to quit smoking.
**d.)** A patient is able to ambulate the hallway following knee surgery.
| Ch 19
**b.)** A patient is able to test for glucose levels & inject insulin as needed
72
**How are each of the 4 types of outcomes evaluated?**
| Ch 19
* **Cognitive:** asking patient to repeat information or apply new knowledge
* **Psychomotor:** asking patient to demonstrate new skills
* **Affective:** observing patient behavior & conversation
* **Physiologic:** using physical assessment skill to collect & compare data
73
**What are the elements of evaluation?**
| Ch 19 **(KNOW THIS)**
**1.) Identifying criteria & standards**
**2.) Collecting data** to determine if criteria & standards are met
**3.) Interpreting & summarizing findings**
**4.) Terminating, continuing, or modifying the care plan**
74
**What are elements of healthy work environments?**
| Ch 19
* skilled communication
* true collaboration
* effective decision making
* appropriate staffing
* meaningful recognition
* authentic leadership
75
**What are the 8 Crucial Conversations in Health Care?**
| Ch 19
**1.)** Broken rules
**2.)** Mistakes
**3.)** Lack of support
**4.)** Incompetence
**5.)** Poor teamwork
**6.)** Disrespect
**7.)** Micromanagement
76
**What does Vitamin A affect ?**
| Ch 37
* visual acuity
* skin & mucous membranes
* immune function
77
**What is the job of Vitamin D?**
| Ch 37
* provides calcium & phosphorus metabolism
* stimulates calcium reabsorption
78
**What is the job of Vitamin E?**
| Ch 37
antioxidant that protects Vitamin A
79
**What is the job of Vitamin K?**
| Ch 37
helps with the **synthesis** of certain proteins necessary for **blood clotting**
80
**What are macrominerals & microminerals?**
| Ch 37
**Macrominerals:** *calcium*, *phosphorus* (phosphates), *sulfur* (sulfates), *sodium*, *chloride*, *potassium*, & *magnesium*
**Microminerals:** *zinc*, *iron*, manganese, chromium, *copper*, molybdenum, selemnium, *fluoride*, & *iodine*
81
**What percentage of body water is ICF vs ECF?**
| Ch 37
**ICF:** 2/3 (66.66%)
**ECF:** 1/3 (33.33%)
82
**What are some nursing interventions involving diet & nutrition?**
| Ch 37
* Teaching nutritional information
* Monitoring nutritional status
* Stimulating appetite
* Assisting with eating
* Providing oral nutrition
* Providing long-term nutritional support
83
**What is short-term nutritional support?**
| Ch 37
Tubes via the nasogastric (ng) or nasointestinal route
84
**What is long-term nutritional support?**
| Ch 37
* tubes in the stomach (gastrostomy) or into the jejunum (jejunostomy)
* Specifically a **percutaneous endoscopic gastrostomy (PEG)** or surgically (open or laparoscopically placed gastrostomy tube
85
**What is litigation?**
| Ch 7
process of bringing & trying a lawsuit
86
**What is a plaintiff?**
| Ch 7
person bringing the lawsuit
87
**What is a defendant?**
| Ch 7
person being acused of a crime
88
**What are 4 sources of law?**
| Ch 7
* Contitutions
* Statutory Law
* Administrative law
* Common law
89
**Give examples of Statutory, administrative, and common law as it related to nursing**
| Ch 7
* **Statutory Law:** nurse practice acts (varies from state to state)
* **Administrative Law:** board of nursing
* **Common Law:** malpractice laws
90
**What is Tort?**
| Ch 7
a wrong committed by a person against another person or that person's property
| tried in civil court
91
**What is a crime?**
| Ch 7
wrong aginst a person or the person's property, as well as the public
92
**What is a misdemeanor?**
| Ch 7
punishable by fines or less than 1 year imprisionment
93
**What is a felony?**
| Ch 7
punishable by imprisionment for more than 1 year
94
**Which is the correct term for this nursing action: A nurse falsely imprions a patient by an unauthorized use of restraints.**
**a.)** Crime
**b.)** Tort
**c.)** Misdemeanor
**d.)** Felony
| Ch 7
**b.)** Tort
95
**What is a felony?**
| Ch 7
punishable by imprisionment for more than 1 year
96
**What are some categories of malpractice claims?**
| Ch 7
**Failure to:**
* follow standards of care
* use equipment in a responsible manner
* assess & monitor
* communicate
* document
* act as a patient advocate
97
**What are the top 4 reasons for malpractice in Michigan?**
| Ch 7
**1.)** Impaired condition / substance use
**2.)** Incompetence
**3.)** Scope of practice
**4.)** Sexual misconduct
98
**What are the 4 elements of liability?**
| Ch 7 **(KNOW THIS)**
**1.) D**uty
**2.) B**reach of duty
**3.) C**ausation
**4.) D**amages
99
**What are the elements of informed consent?**
| Ch 7 **(KNOW THIS)**
* Disclosure
* Comprehension
* Competence
* Voluntariness
100
**What are complementary health approaches (CHA)?**
| Ch 29
interventions that can be used with conventional medical interventions & thus complement them
101
**What is integrative health (IH)?**
| Ch 29
combination of complementary health & conventional health approaches in a coordinated way
102
**What is allopathic medicine?**
| Ch 29
traditional medical care
103
**What is Holism?**
| Ch 29
connection & interactions between parts of the whole
104
**What is integrative health care?**
| Ch 29
a combination of allopathic & complementary & alternative health care
105
**What are the 3 categories of complementary health approaches?**
| Ch 29
* **Mind-body practices:** relaxation, meditation, yoga, guided imagery, acupuncture, chiropractic health care
* **Natural products:**
* **Other CHAs**
106
**True or False: blood vessels in the skin dilate to dissipate heat**
| Ch 33
True
107
**What is a wound and what are different types of wounds?**
| Ch 33
**Wound: break or disruption in the integument**
* Intentional or unintentional
* Open or closed
* Acute or chronic
* Partial thickness, full thickness, complex
108
**What is a contusion?**
| Ch 33
**caused by a blunt instrument & may result in ecchymosis or a hematoma**
109
**What is an abrasion?**
| Ch 33
**rubbing or scraping of epidermal layers of the skin**
110
**What is a laceration?**
| Ch 33
**tearing of the skin & tissue with blunt or irregular instrument**
111
**What is an avulsion?**
| Ch 33
**tearing a structure from normal anatomic position**
* possible damage to blood vessels, nerves, & other structures
| **structures are removed**
112
**Which type of wound is caused by a blunt instrument that causes injury to underlying soft tissue with the overlying skin remaining intact?**
**a.)** Contusion
**b.)** Abrasion
**c.)** Laceration
**d.)** Avulsion
| Ch 33
**a.)** Contusion
113
**What are the phases of wound healing?**
| Ch 33 **(KNOW THIS)**
* **H**emostasis
* **I**nflammation
* **P**roliferation
* **M**aturation
114
**In which phase of wound healing is new tissue built to fill the wound space, primarily through the action of fibroblasts?**
**a.)** Hemostasis phase
**b.)** Inflammatory phase
**c.)** Proliferation phase
**d.)** Maturation phase
| Ch 33
**c.)** Proliferation phase
115
**What is the hemostasis phase of wound healing?**
| Ch 33
* activation of WBCs
* blood vessels constrict
* fibrin clot formation
* **exudate, swelling, pain, heat, redness**
116
**What is the inflammatory phase of wound healing?**
| Ch 33
* lasts **2 - 3 days**
* WBCs (mainly leukocytes) are involved
* **Ingest debris & release growth factor**
117
**What is the proliferation phase of wound healing?**
| Ch 33
* lasts **several weeks**
* **New tissue is built, capillaries grow, granulation tissue forms**
118
**What happens to the WBC count during the proliferation phase?**
| Ch 33
WBC count **increases**
119
**What is the maturation phase of wound healing?**
| Ch 33
* begins 3 weeks after injury, possibly continuing for months or years
* **Collagen is remodeled & deposited**
* **Scar becomes flat, thin, white line**
120
**What are local factors affecting wound healing?**
| Ch 33 **(KNOW THESE)**
* **Pressure**
* **Desiccation** (dehydration)
* **Maceration** (overhydration)
* **Trauma**
* **Edema**
* **Infection**
* **Excessive bleeding**
* **Necrosis** (death of tissue)
* **Presence of biofilm** (thick grouping of microorganisms)
121
**What are desiccation & maceration?**
| Ch 33
* **D**esiccation is **D**ehydration of skin
* **Maceration:** overhydration of the skin
122
**What is dehiscence?**
| Ch 33
partial or total separation of wound layers
123
**What is evisceration?**
| Ch 33
* abdominal wound separates completely
* **protrusion of viscera** (internal organs extends out / comes out of the incision)
124
**What are the stages of pressure injuries?**
| Ch 33
**Stage 1:** non-blanchable erythema of intact skin
**Stage 2:** partial-thickness loss with exposed dermis
**Stage 3:** full-thickness loss NOT involving underlying fascia
**Stage 4:** full-thickness skin & tissue loss
125
**What is an unstageable pressure injury?**
| Ch 33
obscured full-thickness skin & tissue loss
126
**What is a deep tissue pressure injury?**
| Ch 33
persistent non-blanchable deep red, maroon, or purple discoloration
127
**How are wounds measured?**
| Ch 33
* **L** x **W** x **D**
* Presence of undermining or tunnling
128
**What are the different types of wound drainage?**
| Ch 33 **(KNOW THIS)**
* **Serous:** mainly clear & thin; hint of yellow
* **Sanguineous:** bright red; slightly thick
* **Serosanguineous:** pinkish (mix of serous & sanguineous)
* **Purulent:** pus, thick & viscous; yellow or green
129
**What is serous drainage?**
| Ch 33
**mainly clear, thin drainage**
* may have a hint of light yellow
130
**What is sanguineous drainage?**
| Ch 33
**bright red, slightly thick drainage**
131
**What is serosanguineous drainage?**
| Ch 33
**pinkish drainage**
* combination of serous & sanguineous drainage
132
**What is purulent drainage?**
| Ch 33
**pus, thick & visocus drainage; usually yellow or green color**
133
**What are the 6 classes of nutrients?**
| Ch 37
* Carbohydrates
* Proteins
* Lipids
* Vitamins
* Minerals
* Water
134
**What's the difference in micturation & voiding?**
| Ch 38
* **Micturation:** whole process of urination
* **Voiding:** act of releasing urine
135
**Which term describes a condition in which 24-hour urine output is less than 50 mL?**
**a.)** Dysuria
**b.)** Glycosuria
**c.)** Anuria
**d.)** Pyuria
**c.)** Anuria
136
**What are diuretics?**
| Ch 38
prevents reabsorption of water & certain electrolytes in the tubules
137
**What are cholinergic medications?**
| Ch 38
stimulate contraction of detrusor muscle, producing urination
138
**What are analgesics & tranquilizers in terms of how they work on urine production & elimination?**
| Ch 38
suppress CNS, diminish effectiveness of neural reflex
139
**What medications can be used to effect urine production & elimination?**
| Ch 38
* diuretics
* cholinergics
* analgesics & tranquilizers
140
**What color do anticoagulants make the urine?**
| Ch 38
red / hematuria
141
**What color can diuretics make urine?**
| Ch 38
pale yellow
142
**What color does pyridium make urine?**
| Ch 38
orange to orange-red urine
143
**What color can amitriptyline (anti-depressant) or B-complex vitamins make urine?**
| Ch 38
green or blue-green urine
144
**What color can levodopa make urine?**
| Ch 38
brown or black urine
145
**What patient populations are at risk for developing UTIs?**
| Ch 38
* Sexually active women
* Women who use diaphragms for contraception
* Postmenopausal women
* Individuals with indwelling urinary catheters
* Individuals with diabetes mellitus
* Older adults
146
**List types of urinary incontience**
| Ch 38
* Transient
* Overflow / Chronic Retention
* Functional
* Reflex
* Stress
* Mixed
* Total
147
**What is Overflow / Chronic Retention urinary incontinence?**
| Ch 38
overdistention & overflow of the bladder
148
**What is functional urinary incontience?**
| Ch 38
caused by factors OUTSIDE the urinary tract
149
**What is reflex urinary incontience?**
| Ch 38
emptying of the bladder without sensation of the need to void
150
**What is stress urinary incontience?**
| Ch 38
involuntary loss of urine related to an increase in intra-abdominal pressure
151
**What parts make up the small intestine?**
| Ch 39
* Duodenum
* Jejunum
* Ileum
152
**What parts make up the large intestine?**
| Ch 39
* **Cecum**
* **Colon** (ascending --> transverse --> descending --> sigmoid)
* **Rectum**
* **Anal canal**
153
**What is peristalsis?**
* involuntary contraction & relaxation of the intestine (controled by the nervous system)
* **allows for the movement of food through the intestines**
* contractions occur every 3 - 12 minutes
154
**What is IBD?**
| Ch 39
**Irritable Bowel Disease:** chronic inflammation of the intestines
* Crohn's
* Colitis
155
**How do the following medications impact stool?**
**a.) Aspirin & Anticoagulants**
**b.) Iron salts**
**c.) Bismuth subsaclicylate**
**d.) Antacids**
**e.) Antibiotics**
| Ch 39
**A.) Aspirin & Anticoagulants:** pink to red to black stool
**B.) Iron salts:** black stool
**C.) Bismuth subsalicylate:** used to treat diarrhea, but can also make the stool black
**D.) Antacids:** white discoloration or speckling
**E.) Antibiotics:** green-gray stool
156
**What is ISBAR?**
* **I**ntroduction
* **S**ituation
* **B**ackground
* **A**ssessment
* **R**ecommendations
157
**What are SMART goals?**
* **S**pecific
* **M**easurable
* **A**chievable
* **R**ealistic
* **T**imely
158
**What are the 7 patient rights of medication administration?**
**Right**
**1.)** Patient
**2.)** Medication
**3.)** Dose
**4.)** Route
**5.)** Time
**6.)** Reason
**7.)** Documentation
159
**What are the signs & symptoms of hyperglycemia?**
* **polydipsia** (increased thirst)
* **polyuria**
* **blurred vision**
* **feeling weak, fatigued, or tired**
| * **unintentional weight loss**
160
**What are signs & symptoms of hypoglycemia?**
* **tachycardia**
* **diaphoresis**
* **dizziness** (feeling shakey)
* **Irritable or confused**
* **Hunger**
* **Nervous or anxious**
161
**What is the difference in laxatives & stool softeners?**
**Laxatives:** facilitate bowel movement
**Stool softener:** softens stool for easier passage & less strain
162
**True or False:**
**The state nurse practice act is the most important law affecting nursing practice.**
True
163
**What are the nursing process steps of the clinical judgement model?**
| Ch 14
**1.) A**ssessment
**2.) A**nalysis
**3.) P**lanning
**4.) I**mplementation
**5.) E**valuation
164
**What are methods of data collection?**
| Ch 15
* Nursing history
* Patient interview
* Physical assessment
165
**What are the 6 ANA Standards of Practice?**
**1.) Assessment:** The RN collects pertinent data & information relative to the healthcare consumer's health or situation.
**2.) Diagnosis:** The RN analyzes the assessment data to determine actual or potential diagnoses, problems, & issues.
**3.) Outcomes Identification:** The RN identifies expected outcomes for a plan individualized to the healthcare consumer or the situation.
**4.) Planning:** The RN develops a plan that prescribes strategies to attain expected, measurable outcomes.
**5.) Implementation:** The RN implements the identified plan.
**6.) Evaluation:** The RN evaluates progress toward attainment of goals & outcomes.
166
**What is the ANA Standard of Practice 1?**
| Ch 15
**Assessment:** The RN collects pertinent data & information relative to the healthcare consumer's health or the situation.
167
**What is the ANA Standard of Practice 2?**
| Ch 16
**Diagnosis:** The RN analyzes the assessment data to determine actual or potential diagnoses, problems, and issues.
168
**What is the ANA Standard of Practice 3?**
| Ch 17
**Outcomes Identification:** The RN identifies expected outcomes for a plan individualized to the healthcare consumer or the situation.
169
**What is the ANA Standard of Practice 4?**
| Ch 17
**Planning:** The RN develops a plan that prescribes strategies to attain expected, measurable outcomes.
170
**What is the ANA Standard of Practice 5?**
| Ch 18
**Implementation:** The RN implements the identified plan.
171
**What is the ANA Standard of Practice 6?**
| Ch 19
**Evaluation:** The RN evaluates progress toward attainment of goals & outcomes.
172
**What is informal planning?**
| Ch 17
a link between **identifying a patient's strength or problem** and **providing an appropriate nursing response,** often while rearranging priorities.
173
**What are functions of the integumentary system?**
| Ch 33
* Protection
* Temperature regulation
* Sensation
* Immunologic
* Absorption & Elimination
* Vitamin D Production
174
**What factors affect skin integrity?**
| Ch 33
* **Unbroken healthy skin & mucous membranes:** helps defend against harmful agents
* **Resistance to injury is affected by age, amount of underlying tissues, & illness**
* **Adequately nourished & hydrated cells:** help resist injury
* **Adequate circulation:** necessary to maintain cell life
175
**What is a normal or healthy BMI?**
| Ch 37
18.5 - 24.9
176
**What is the significance of waist circumference?**
| Ch 37
Greater waist circumference = higher risk of disease
177
**Where does digestion primarily occur?**
| Ch 37
Small intestine
178
**What are developmental considerations to keep in mind regarding nutrition?**
| Ch 37
* **Growth:** infancy, adolescence, pregnancy, & lactation increase nutritional needs
* **Activity increases nutritional need**
* **Nutritional needs level off in adulthood**
* Fewer calories required in adulthood because of decreased BMR
179
**What factors can be used to assess Nutritional Status?**
| Ch 37
* **Dietary data**
* **Medical & Socioeconomic data**
* **Anthropometric data** (body measurements)
* **Clinical data**
* **Biochemical data**
180
**What are nutritional nursing interventions?**
| Ch 37
* Teach nutritional information
* Monitor nutritional status
* Stimulating appetite
* Assist with eating
* Provide oral nutrition
* Provide long-term nutritional support
181
**Signs & Symptoms of Vitamin A, D, E, & K deficiency**
| Ch 37
* **Vitamin A:** hair loss, brittle hair & nails, skin pathces, scaly skin, mouth ulcers
* **Vitamin D:** fatigue, not sleeping well, bone pain, achiness, depression, hair loss, muscle weakness, loss of appetite, getting sick easily
* **Vitamin E:** nerve & muscle damage like muscle weakness, vision problems, loss of body movement control, loss of feeling in the arms or legs
* **Vitamin K:** hemorrhage can lead to bruising easily
182
**Which of the following assessments would be performed on a patient to gather data when on a second home health visit?**
**a.)** Initial comprehensive assessment
**b.)** Focused assessment
**c.)** Time lapsed assessment
**d.)** Emergency assessment
**c.)** Time lapsed assessment
183
**Patient reports shortness of breath, fatigue, edema in legs & feet, and persistant cough. What part of ADPIE is this?**
**a.)** Diagnosis
**b.)** Evaluation
**c.)** Assessment
**d.)** Implementation
**c.)** Assessment
184
**A patient who has been hospitalized for anorexia nervosa genuinly tries to gain weight to be healthy.**
**a.)** Cognitive outcome
**b.)** Affective outcome
**c.)** Physiologic outcome
**d.)** Psychomotor outcome
**b.)** Affective outcome
185
**What is assessing?**
**a.)** Problem, etiology, defining characteristics
**b.)** SMART Goals
**c.)** Measuring how well the patient achieved outcomes in the care plan
**d.)** Continuous collection, analysis, validation, & communication of data
**d.)** Continuous collection, analysis, validation, & communication of data
186
**Distinguishing normal/abnormal, relevant/irrelevant, detecting bias, & identifying assumptions and inconsistencies is known as...**
**a.)**Collecting data
**b.)** Planning
**c.)** Planned communication
**d.)** Clinical reasoning
**d.)** Clinical reasoning
187
**What does the HELP mnemonic (used for systematic person centered observation) mean?**
**a.)** **H:** help, **E:** environmental equipment, **L:** look at patient, **P:** people in the room
**b.)** **H:** help, **E:** educate, **L:** look at patient, **P:** people in the room
**c.)** **H:** help, **E:** environmental equipment, **L:** leave and ask, **P:** people in the room
**d.)** **H:** help, **E:** environmental equipment, **L:** look at patient, **P:** pull the alarm
**a.)** **H:** help, **E:** environmental equipment, **L:** look at patient, **P:** people in the room
188
**SMART goals are:**
**a.)** Special, Measurable, Attainable, Realistic, Time bound
**b.)** Specific, Measurable, Affordable, Realistic, Time bound
**c.)** Specific, Measurable, Attainable, Realistic, Time bound
**d.)** Specific, Mathematic, Attainable, Realistic, Time bound
**c.)** Specific, Measurable, Attainable, Realistic, Time bound
189
**A risk for pressure injury is considered which priority level?**
**a.)** High priority
**b.)** Medium priority
**c.)** Low priority
**b.)** Medium priority
190
**A nurse consults with the medical team regarding the patient's plan of care.**
**a.)** Direct care
**b.)** Indirect care
**b.)** Indirect care
191
**A patient is unwilling to participate in therapy.**
**a.)** Nursing variable
**b.)** Health care system variable
**c.)** Patient variable
**c.)** Patient variable
192
**There is inadequate staffing therefore the patient does not have their vitals taken every 4 hours.**
**a.)** Nursing variable
**b.)** Health care system variable
**c.)** Patient variable
**b.)** Health care system variable
193
**Which nursing diagnosis would be used for a patient who reports "I take naps often, but have trouble sleeping and am always tired" ?**
**a.)** Activity intolerance
**b.)** Anxiety
**c.)** Depression
**d.)** Fatigue
**d.)** Fatigue
194
**What is the passive phase of ventilation?**
**a.)** Inspiration
**b.)** Expiration
**b.)** Expiration
195
**What is a catheter that is placed in the nose and attached to oxygen called?**
**a.)** Nasopharyngeal catheter
**b.)** Nasal canula
**c.)** Transtracheal catheter
**d.)** Simple mask
**a.)** Nasopharyngeal catheter
196
**What is the total amount of air inhaled and exhaled on a single breath called?**
**a.)** Vital Capacity (VC)
**b.)** Tidal Volume (TV)
**c.)** Total Lung Capacity (TLC)
**d.)** Forced Vital Capacity
**b.)** Tidal Volume (TV)
197
**A nurse is caring for a patient with COPD. What is an expected finding for this patient?**
**a.)** Bradycardic heart rate
**b.)** 37.8 °C oral temperature
**c.)** 10 breaths per minute
**d.)** Low pulse oximetry reading
**d.)** Low pulse oximetry reading
198
**What happens in the hear and now of an activity; known as "thinking on your feet" ?**
**a.)** Reflection in action
**b.)** Reflection on action
**c.)** Reflection for action
**a.)** Reflection in action
199
**Patient centered care, teamwork & collaboration, evidence based practice, quality improvement, informatic, & safety are ...**
**a.)** QSEN Competencies
**b.)** Blended Competencies
**c.)** Nursing Practice
**d.)** Concept Mapping
**a.)** QSEN Competencies
200
**What is the tearing of a structure from the normal anatomical position?**
**a.)** Avulsion
**b.)** Laceration
**c.)** Pressure injury
**d.)** Contusion
**a.)** Avulsion
## Footnote
****
201
**What are the stages of wound healing in order?**
**a.)** Maturation, Inflammation, Proliferation, Hemostasis
**b.)** Inflammation, Hemostasis, Maturation, Proliferation
**c.)** Hemostasis, Proliferation, Inflammation, Maturation
**d.)** Hemostasis, Inflammation, Proliferation, Maturation
**d.)** Hemostasis, Inflammation, Proliferation, Maturation
202
**When wounded, what happens to the BMR?**
**a.)** BMR increases
**b.)** BMR decreases
**a.)** BMR Increases
203
**What is excitable tissue formation (when extra tissue is formed) called?**
**a.)** Exudate
**b.)** Erythema
**c.)** Granulation tissue
**d.)** Keloid
**d.)** Keloid
204
**The nurse would recognize which client as being particularly susceptible to impaired wound healing?**
**a.)** A patient whose breast reconstruction surgery required numerous incisions
**b.)** A patient who is NPO following bowel surgery
**c.)** A patient who is obese with a history of type 1 DM
**d.)** A patient who is sedentary lifestyle & a long history of cigarette smoking
**c.)** A patient who is obese with a history of type 1 DM
205
**Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury?**
**a.)** Lubricating the area with skin oil
**b.)** Pulling the patient up from under the arms
**c.)** Improving the patient's hydration
**d.)** Preventing the patient from sliding in bed
**d.)** Preventing the patient from sliding in bed
206
**The nurse is assessing the wounds of a patient in a burn unit. Which wound would most likely heal by primary intention?**
**a.)** A large wound with considerable tissue loss allowed to heal naturally
**b.)** A surgical incision with sutured approximated edges
**c.)** A wound healing naturally that becomes infected
**d.)** A wound left open fro several days to allow edema to subside
**b.)** A surgical incision with sutured approximated edges
207
**A postoperative patient says during a transfer, "I feel like something just popped". The nurse immediately assessed for...**
**a.)** Evisceration
**b.)** Dehiscence
**c.)** Herniation
**d.)** Infection
**b.)** Dehiscence
208
**Increases or decreases the flow fo Qi along the meridian, restoring the balance of Yin and Yang is known as what?**
**a.)** Qi Gong
**b.)** Shamanism
**c.)** Acupuncture
**c.)** Acupuncture
209
**The combination fo allopathic & complementary & alternative modalities.**
**a.)** Integrative Health Care
**b.)** Holism
**c.)** Allopathic Medicine
**a.)** Integrative Health Care
210
**A patient having bowel surgery & asks why being NPO after surgery is necessary. Which best describes the reason?**
**a.)** To rest the gastrointestinal tract & promote healing
**b.)** To allow gas to accumulate & promote healing
**c.)** To increase mucus in the bowel to help promote healing
**d.)** To prevent gas from forming in the bowel & interfering with h
**a.)** To rest the gastrointestinal tract & promote healing
211
**When assessing a client's nutritional status, which findings would lead the nurse to suspect poor nutritional status?**
**a.)** Tongue that is deep red with surface apaillae present
**b.)** Firm, pink nail beds
**c.)** Flaking facial skin, facial edema, pale skin color
**d.)** Firm hair that is resistant to plucking
**c.)** Flaking facial skin, facial edema, pale skin color
212
**Which type of fat raises cholesterol levels?**
**a.)** Saturated
**b.)** Unsaturated
**c.)** Trans-Fat
**d.)** All types of fat
**a.)** Saturated
213
**Which vitamin is only found in food made from animals?**
**a.)** Vitamin K
**b.)** Vitamin B12
**c.)** Vitamin C
**d.)** Vitamin D
**b.)** Vitamin B12
214
**A nurse is managing a continuous tube feeding via NG tube. How often should the nurse check for residual?**
**a.)** every 1 - 2 hours
**b.)** every 4 - 6 hours
**c.)** every 6 - 8 hours
**d.)** every 8 - 10 hours
**b.)** Every 4 - 6 hours
215
**Where does most absorption occur in the GI tract?**
**a.)** Mouth
**b.)** Esophagus
**c.)** Stomach
**d.)** Small Intestine
**d.)** Small Intestine
216
**A patient on warfarin would be educated to have caution about eating foods containing which nutrients?**
**a.)** Albumin
**b.)** Vitamin B12
**c.)** Vitamin K
**d.)** Potassium
**c.)** Vitamin K
217
**Which vitamin or mineral does the nurse need to teach pregnant women about to prevent neural tube defects?**
**a.)** Folic Acid
**b.)** Vitamin K
**c.)** Vitamin C
**d.)** Iron
**a.)** Folic Acid
218
**Which is not a function of the large intestine & colon?**
**a.)** Absorption of water
**b.)** Formation of feces
**c.)** Acid formation
**d.)** Expulsion of feces from the body
**c.)** Acid formation
219
**Which of the following factors is related to developmental changes in bowel habits for elderly patients?**
**a.)** Increase in dietary fiber, decrease in peristalsis
**b.)** Weakened pelvic muscle leading to constipation
**c.)** Peeling fruits before eating
**d.)** Milk products causing constipation
**b.)** Weakened pelvic muscle leading to constipation
220
**Which can casue black stool?**
**a.)** Aspirin / Anticoagulants
**b.)** Antacids
**c.)** Antibiotics
**d.)** Iron salts
**d.)** Iron salts
221
**Which are characteristics of an upper GI bleed?**
**a.)** Black, tarry, coffee ground emesis
**b.)** Hemorrhoids
**c.)** Bright red streaks
**a.)** Black, tarry, coffee ground emesis
222
**How should a nurse position the patient in anticipation of administering a cleansing enema?**
**a.)** Lying on the right side
**b.)** Prone
**c.)** Lying on the left side
**d.)** Supine
**c.)** Lying on the left side
223
**Which type of enema will lubricate the stool & intestinal mucosa to ease defecation?**
**a.)** Carminative enema
**b.)** Oil-retention enema
**c.)** Medicated enema
**d.)** Anthelmintic enema
**b.)** Oil-retention enema
224
***True or False:* when using a timed specimen the nurse should consider the first stool passed as the start of the collection period.**
True
225
**Which of the following is inserted & used to decompress or drain the stomach of fluid or unwanted stomach contents?**
**a.)** Chest tube
**b.)** Nasopharyngeal tube
**c.)** Ileocecal tube
**d.)** Nasogastric tube
**d.)** nasogastric tube
226
**What is it called when the 24 hour urine output level is less than 50 mL?**
**a.)** Dysuria
**b.)** Oliguria
**c.)** Anuria
**d.)** Polyuria
**c.)** Anuria
227
**What is not a common problem a patient can experience when using a condom catheter?**
**a.)** It may restrict blood flow to skin & tissues
**b.)** It will burst
**c.)** It may accumulate moisture beneath the sheath
**d.)** It may lead to frequent leakage
**b.)** It will burst
228
**When does a 24 hour urine sample begin?**
**a.)** When the patient needs to pee
**b.)** When the order is signed
**c.)** After the patient urinates & that sample is discarded
**d.)** In the morning when the patient wakes up
**c.)** After the patient urinates & that sample is discarded
229
**What is involuntary loss of urine related to an increase in intra-abdominal pressure called?**
**a.)** Stress incontinence
**b.)** Reflex incontinence
**c.)** Functional incontinence
**d.)** Overflow / Chronic retention
**a.)** Stress incontinence
230
**What are factors that affect micturation?**
| Ch 38
* Developmental considerations
* Food & fluid intake
* Psychological variables
* Activity & muscle tone
* Pathologic conditions
* Medications
231
**What are developmental considerations that can affect urinary function in children & older adults?**
**Children:** toilet training 2 - 5 years old & enuresis
**Older Adults**
* Nocturia
* Increased frequency
* Urine retention & stasis
* Voluntary control affected by physical problems
232
**What is urinary diversion?**
| Ch 38
procedure to create a new way for urine to exit the body when urine flow is blocked or needs to bypass the normal exit route
233
**What is the role of the pelvic floor in micturation?**
| Ch 38
Micturation (passage of urine) can occur when the pelvic floor **relaxes**
234
**What is bladder training?**
| Ch 38
Used to help treat urinary incontinence
235
**What is peristalsis? What controls peristalsis? How often do contractions occur?**
| Ch 39
**involuntary contraction & relaxation of the intestinal wall to push contents forward**
* occurs every **3 - 12 minutes**
* Under the control of the **nervous system**
236
**What are the signs & symptoms of chronic and acute GI bleeds?**
| Ch 39
* Black tarry stools
* Rectal bleeding
* Vomiting blood (bright red or brown coffee ground emesis)
237
**What are the 5 types of ostomies?**
| Ch 39
* **Sigmoid** colostomy
* **Descending** colostomy
* **Transverse** colostomy
* **Ascending** colostomy
* **Ileostomy**
238
**What is flatus?**
| Ch 39
Intestinal Gas
