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Adult Nursing I (NUR 240) > Exam 2 (Chapters 13, 14, 15, 16, 17, 18, 19, 33, 37, 38, & 39) > Flashcards

Exam 2 (Chapters 13, 14, 15, 16, 17, 18, 19, 33, 37, 38, & 39) Flashcards

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1
Q

Can clinical judgement be learned?

Ch 14

A

Yes, clinical judgement can be learned

Clinical Reasoning (=)
Clinical Judgement (+ CDM)

Critical Thinking (+)

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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

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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.
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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
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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
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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

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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

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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)
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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

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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

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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
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12
Q

Characteristics of Nursing Assessments

Ch 15

A
  • Purposeful
  • Prioritized
  • Complete
  • Systematic
  • Factual
  • Relevant
  • Recorded in a standard manner
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13
Q

What is the primary source of information in an assessment?

Ch 15

A

The patinet

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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

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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
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16
Q

What is a Comprehensive Initial Assessment?

Ch 15

A

Complete exam of all systems

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17
Q

What is a Focused Assessment?

Ch 15

A

gathering data about something that has already happened

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18
Q

What is an Emergency Assessment?

Ch 15

A

An assessment gathered during a crisis

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19
Q

What is a Time-Lapsed Assessment?

Ch 15

A

Comparing current status to a patient’s baseline

  • look at points in time
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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

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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
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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

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23
Q

Who is the primary data source during an assessment?

Ch 15

A

The patient

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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

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25
Q

What is the purpose of a nursing physical assessment?

Ch 15

A
  • helps us gather more data
  • helps us identify actual health problems
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26
Q

What 5 sources of patient data are useful for nurses?

Ch 15

A

1.) Patient
2.) Family / Significant Others
3.) Patient Record
4.) Assistive Technology
5.) Other health care professionals

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27
Q

List common problems involved in data collection?

Ch 15

A
  • omission of pertinent information
  • failure to update the database
  • inclusion of irrelevant or duplicate data
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28
Q

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

A

d.) Ethical / Legal

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29
Q

What are the QSEN Competencies?

Ch 13

A
  • Patient-centered care
  • Teamwork & collaboration
  • Evidence-based practice (EBP)
  • Quality improvement
  • Safety
  • Informatics
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30
Q

What are the 3 Problem Solving Approaches to the nursing process?

Ch 13

A
  • Trial & Error problem solving
  • Scientific problem solving
  • Intuitive problem solving
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31
Q

What key events regarding the development of the nursing process occured in

  • 1955
  • 1960s
  • 1973
  • 1982

Ch 13

A
  • 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
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32
Q

What are the 5 steps of the nursing process?

Ch 13

A

1.) Assessing
2.) Diagnosing
3.) Planning
4.) Implementing
5.) Evaluating

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33
Q

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

A

b.) Diagnosing

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34
Q

List the 5 characteristics of the nursing process

Ch 13

A

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

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35
Q

What steps are involved in concept mapping?

Ch 13

A

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

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36
Q

What are Nursing COncerns & Responsibilities when it comes to diagnosing?

Ch 16 (KNOW THIS)

A
  • Recognizing safety & infection-transmission risks
  • Identifying human responses
  • Anticipating possible complications
  • Initiating urgent interventions
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37
Q

What is a nursing diagnosis?

Ch 16

A

Describes patient problems nurses can treat independently

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38
Q

What are the four steps of data interpretation & analysis?

Ch 16

A

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

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39
Q

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

A

d.) Reaching conclusions

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40
Q

What are the 3 types of nursing diagnoses?

Ch 16

A

1.) Problem-focused
2.) Risk
3.) Health promotion

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41
Q

What are the 4 components of a diagnosis?

Ch 16 (KNOW THIS)

A
  • Label
  • Definition
  • Defining characteristics
  • Related factors
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42
Q

What are some benefits of nursing diagnoses?

Ch 16

A

Benefits
* individualizing patient care
* defining domain of nursing to healthcare administrators, legislators, & providers
* Seeking funding for nursing & reimbursement for nursing services

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43
Q

What are limitations of nursing diagnoses?

Ch 16

A

Limitations
* patient could be misdiagnosed (if used incorrectly)
* Nursing practice might be restricted

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44
Q

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

A

d.) Imbalanced nutrition related to insufficient funds in meal budget

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45
Q

What are the goals of Planning / Outcome Identification?

Ch 17

A
  • establish priorities
  • identify & write expected patient outcomes
  • select evidence-based nursing interventions
  • communicate the care plan
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46
Q

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

a.) The nurse collects enw data & uses them to update the plan & resolve health problems

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47
Q

What are the 3 elements of comprehensive planning?

Ch 17

A
  • 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
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48
Q

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

A

b.) Impaired gas exchange

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49
Q

What are Maslow’s Hierarchy of Human Needs?

Ch 17 (KNOW THIS)

A
  • Physiologic needs
  • Safety needs
  • Love & belonging needs
  • Self-esteem needs
  • Self-actualization needs
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50
Q

What is the difference in long-term and short-term outcomes?

Ch 17

A

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)

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51
Q

What are cognitive outcomes?

Ch 17

A

Describes increases in patient knowledge or intellectual behaviors

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52
Q

What are psychomotor outcomes?

Ch 17

A

Describes patient’s achievement of new skills

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53
Q

What are affective outcomes?

Ch 17

A

Describes changes in patient values, beliefs, and attitudes

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54
Q

What are the different types of nursing interventions?

Ch 17

A

1.) Nurse-initiated
2.) Physician-initiated
3.) Collaborative

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55
Q

What are nurse-initiated interventions?

Ch 17

A

actions performed by a nurse without a physician’s order

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56
Q

List some actions that can be performed in Nurse-Initiated Interventions

Ch 17

A
  • 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
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57
Q

What is the implementation phase of the nursing process?

Ch 18

A

“Nursing Orders”

romote health, prevent disease, restore health, cope w/ altered fxn

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58
Q

What are Alfaro’s Rules for Clinical Reasoning & Implementation?

Ch 18

A

Assess, reassess, revise, & record

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59
Q

Give examples of different types of nursing interventions

Ch 18

A
  • Interventions aimed at providing direct & indirect care
  • Interventions aimed at individuals, family, & community
  • Interventions aimed for nurse-initiated & other provider-initiated treatments
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60
Q

What is involved in the implementation phase of the nursing process?

Ch 18

A
  • Carry out the plan
  • Continue data collection & plan modifications
  • Document care
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61
Q

What are some patient & nurse variables that influence outcome achievement?

Ch 18

A

Patient Variables
* developmental stage
* phsychosocial background & culture

Nurse Variables
* resources
* current standards of care
* research findings
* ethical & legal guides to practice

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62
Q

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

A

d.) A rape victim does not receive counseling in the emergency department because a counselor is not available

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63
Q

What are the 5 Rights of Deligation?

Ch 18 (KNOW THIS)

A

Right
* Task
* Circumstances
* Person
* Directions & Communication
* Supervision & Evaluation

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64
Q

What is involved in the evaluation phase of the nursing process?

Ch 19

A

Measure how well the patient has achieved desired outcomes

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65
Q

What are actions that can be taken based on a patient’s response to a care plan?

Ch 18

A

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

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66
Q

What are 4 types of outcomes?

Ch 19 (KNOW THIS)

A

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

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67
Q

What is a cognitive outcome?

Ch 19

A

increase in patient knowledge

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68
Q

What is a psychomotor outcome?

Ch 19

A

patient’s achievement of new skills

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69
Q

What is an affective outcome?

Ch 19

A

changes in patient values, beliefs, and attitudes

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70
Q

What is a physiologic outcome?

Ch 19

A

physical changes in the patient

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71
Q

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

A

b.) A patient is able to test for glucose levels & inject insulin as needed

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72
Q

How are each of the 4 types of outcomes evaluated?

Ch 19

A
  • 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
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73
Q

What are the elements of evaluation?

Ch 19 (KNOW THIS)

A

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

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74
Q

What are elements of healthy work environments?

Ch 19

A
  • skilled communication
  • true collaboration
  • effective decision making
  • appropriate staffing
  • meaningful recognition
  • authentic leadership
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75
Q

What are the 8 Crucial Conversations in Health Care?

Ch 19

A

1.) Broken rules

2.) Mistakes

3.) Lack of support

4.) Incompetence

5.) Poor teamwork

6.) Disrespect

7.) Micromanagement

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76
Q

What does Vitamin A affect ?

Ch 37

A
  • visual acuity
  • skin & mucous membranes
  • immune function
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77
Q

What is the job of Vitamin D?

Ch 37

A
  • provides calcium & phosphorus metabolism
  • stimulates calcium reabsorption
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78
Q

What is the job of Vitamin E?

Ch 37

A

antioxidant that protects Vitamin A

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79
Q

What is the job of Vitamin K?

Ch 37

A

helps with the synthesis of certain proteins necessary for blood clotting

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80
Q

What are macrominerals & microminerals?

Ch 37

A

Macrominerals: calcium, phosphorus (phosphates), sulfur (sulfates), sodium, chloride, potassium, & magnesium

Microminerals: zinc, iron, manganese, chromium, copper, molybdenum, selemnium, fluoride, & iodine

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81
Q

What percentage of body water is ICF vs ECF?

Ch 37

A

ICF: 2/3 (66.66%)

ECF: 1/3 (33.33%)

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82
Q

What are some nursing interventions involving diet & nutrition?

Ch 37

A
  • Teaching nutritional information
  • Monitoring nutritional status
  • Stimulating appetite
  • Assisting with eating
  • Providing oral nutrition
  • Providing long-term nutritional support
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83
Q

What is short-term nutritional support?

Ch 37

A

Tubes via the nasogastric (ng) or nasointestinal route

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84
Q

What is long-term nutritional support?

Ch 37

A
  • tubes in the stomach (gastrostomy) or into the jejunum (jejunostomy)
  • Specifically a percutaneous endoscopic gastrostomy (PEG) or surgically (open or laparoscopically placed gastrostomy tube
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85
Q

What is litigation?

Ch 7

A

process of bringing & trying a lawsuit

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86
Q

What is a plaintiff?

Ch 7

A

person bringing the lawsuit

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87
Q

What is a defendant?

Ch 7

A

person being acused of a crime

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88
Q

What are 4 sources of law?

Ch 7

A
  • Contitutions
  • Statutory Law
  • Administrative law
  • Common law
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89
Q

Give examples of Statutory, administrative, and common law as it related to nursing

Ch 7

A
  • Statutory Law: nurse practice acts (varies from state to state)
  • Administrative Law: board of nursing
  • Common Law: malpractice laws
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90
Q

What is Tort?

Ch 7

A

a wrong committed by a person against another person or that person’s property

tried in civil court

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91
Q

What is a crime?

Ch 7

A

wrong aginst a person or the person’s property, as well as the public

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92
Q

What is a misdemeanor?

Ch 7

A

punishable by fines or less than 1 year imprisionment

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93
Q

What is a felony?

Ch 7

A

punishable by imprisionment for more than 1 year

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94
Q

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

A

b.) Tort

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95
Q

What is a felony?

Ch 7

A

punishable by imprisionment for more than 1 year

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96
Q

What are some categories of malpractice claims?

Ch 7

A

Failure to:
* follow standards of care
* use equipment in a responsible manner
* assess & monitor
* communicate
* document
* act as a patient advocate

97
Q

What are the top 4 reasons for malpractice in Michigan?

Ch 7

A

1.) Impaired condition / substance use

2.) Incompetence

3.) Scope of practice

4.) Sexual misconduct

98
Q

What are the 4 elements of liability?

Ch 7 (KNOW THIS)

A

1.) Duty
2.) Breach of duty
3.) Causation
4.) Damages

99
Q

What are the elements of informed consent?

Ch 7 (KNOW THIS)

A
  • Disclosure
  • Comprehension
  • Competence
  • Voluntariness
100
Q

What are complementary health approaches (CHA)?

Ch 29

A

interventions that can be used with conventional medical interventions & thus complement them

101
Q

What is integrative health (IH)?

Ch 29

A

combination of complementary health & conventional health approaches in a coordinated way

102
Q

What is allopathic medicine?

Ch 29

A

traditional medical care

103
Q

What is Holism?

Ch 29

A

connection & interactions between parts of the whole

104
Q

What is integrative health care?

Ch 29

A

a combination of allopathic & complementary & alternative health care

105
Q

What are the 3 categories of complementary health approaches?

Ch 29

A
  • Mind-body practices: relaxation, meditation, yoga, guided imagery, acupuncture, chiropractic health care
  • Natural products:
  • Other CHAs
106
Q

True or False: blood vessels in the skin dilate to dissipate heat

Ch 33

A

True

107
Q

What is a wound and what are different types of wounds?

Ch 33

A

Wound: break or disruption in the integument

  • Intentional or unintentional
  • Open or closed
  • Acute or chronic
  • Partial thickness, full thickness, complex
108
Q

What is a contusion?

Ch 33

A

caused by a blunt instrument & may result in ecchymosis or a hematoma

109
Q

What is an abrasion?

Ch 33

A

rubbing or scraping of epidermal layers of the skin

110
Q

What is a laceration?

Ch 33

A

tearing of the skin & tissue with blunt or irregular instrument

111
Q

What is an avulsion?

Ch 33

A

tearing a structure from normal anatomic position

  • possible damage to blood vessels, nerves, & other structures

structures are removed

112
Q

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

a.) Contusion

113
Q

What are the phases of wound healing?

Ch 33 (KNOW THIS)

A
  • Hemostasis
  • Inflammation
  • Proliferation
  • Maturation
114
Q

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

A

c.) Proliferation phase

115
Q

What is the hemostasis phase of wound healing?

Ch 33

A
  • activation of WBCs
  • blood vessels constrict
  • fibrin clot formation
  • exudate, swelling, pain, heat, redness
116
Q

What is the inflammatory phase of wound healing?

Ch 33

A
  • lasts 2 - 3 days
  • WBCs (mainly leukocytes) are involved
  • Ingest debris & release growth factor
117
Q

What is the proliferation phase of wound healing?

Ch 33

A
  • lasts several weeks
  • New tissue is built, capillaries grow, granulation tissue forms
118
Q

What happens to the WBC count during the proliferation phase?

Ch 33

A

WBC count increases

119
Q

What is the maturation phase of wound healing?

Ch 33

A
  • begins 3 weeks after injury, possibly continuing for months or years
  • Collagen is remodeled & deposited
  • Scar becomes flat, thin, white line
120
Q

What are local factors affecting wound healing?

Ch 33 (KNOW THESE)

A
  • Pressure
  • Desiccation (dehydration)
  • Maceration (overhydration)
  • Trauma
  • Edema
  • Infection
  • Excessive bleeding
  • Necrosis (death of tissue)
  • Presence of biofilm (thick grouping of microorganisms)
121
Q

What are desiccation & maceration?

Ch 33

A
  • Desiccation is Dehydration of skin
  • Maceration: overhydration of the skin
122
Q

What is dehiscence?

Ch 33

A

partial or total separation of wound layers

123
Q

What is evisceration?

Ch 33

A
  • abdominal wound separates completely
  • protrusion of viscera (internal organs extends out / comes out of the incision)
124
Q

What are the stages of pressure injuries?

Ch 33

A

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
Q

What is an unstageable pressure injury?

Ch 33

A

obscured full-thickness skin & tissue loss

126
Q

What is a deep tissue pressure injury?

Ch 33

A

persistent non-blanchable deep red, maroon, or purple discoloration

127
Q

How are wounds measured?

Ch 33

A
  • L x W x D
  • Presence of undermining or tunnling
128
Q

What are the different types of wound drainage?

Ch 33 (KNOW THIS)

A
  • 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
Q

What is serous drainage?

Ch 33

A

mainly clear, thin drainage
* may have a hint of light yellow

130
Q

What is sanguineous drainage?

Ch 33

A

bright red, slightly thick drainage

131
Q

What is serosanguineous drainage?

Ch 33

A

pinkish drainage

  • combination of serous & sanguineous drainage
132
Q

What is purulent drainage?

Ch 33

A

pus, thick & visocus drainage; usually yellow or green color

133
Q

What are the 6 classes of nutrients?

Ch 37

A
  • Carbohydrates
  • Proteins
  • Lipids
  • Vitamins
  • Minerals
  • Water
134
Q

What’s the difference in micturation & voiding?

Ch 38

A
  • Micturation: whole process of urination
  • Voiding: act of releasing urine
135
Q

Which term describes a condition in which 24-hour urine output is less than 50 mL?

a.) Dysuria
b.) Glycosuria
c.) Anuria
d.) Pyuria

A

c.) Anuria

136
Q

What are diuretics?

Ch 38

A

prevents reabsorption of water & certain electrolytes in the tubules

137
Q

What are cholinergic medications?

Ch 38

A

stimulate contraction of detrusor muscle, producing urination

138
Q

What are analgesics & tranquilizers in terms of how they work on urine production & elimination?

Ch 38

A

suppress CNS, diminish effectiveness of neural reflex

139
Q

What medications can be used to effect urine production & elimination?

Ch 38

A
  • diuretics
  • cholinergics
  • analgesics & tranquilizers
140
Q

What color do anticoagulants make the urine?

Ch 38

A

red / hematuria

141
Q

What color can diuretics make urine?

Ch 38

A

pale yellow

142
Q

What color does pyridium make urine?

Ch 38

A

orange to orange-red urine

143
Q

What color can amitriptyline (anti-depressant) or B-complex vitamins make urine?

Ch 38

A

green or blue-green urine

144
Q

What color can levodopa make urine?

Ch 38

A

brown or black urine

145
Q

What patient populations are at risk for developing UTIs?

Ch 38

A
  • Sexually active women
  • Women who use diaphragms for contraception
  • Postmenopausal women
  • Individuals with indwelling urinary catheters
  • Individuals with diabetes mellitus
  • Older adults
146
Q

List types of urinary incontience

Ch 38

A
  • Transient
  • Overflow / Chronic Retention
  • Functional
  • Reflex
  • Stress
  • Mixed
  • Total
147
Q

What is Overflow / Chronic Retention urinary incontinence?

Ch 38

A

overdistention & overflow of the bladder

148
Q

What is functional urinary incontience?

Ch 38

A

caused by factors OUTSIDE the urinary tract

149
Q

What is reflex urinary incontience?

Ch 38

A

emptying of the bladder without sensation of the need to void

150
Q

What is stress urinary incontience?

Ch 38

A

involuntary loss of urine related to an increase in intra-abdominal pressure

151
Q

What parts make up the small intestine?

Ch 39

A
  • Duodenum
  • Jejunum
  • Ileum
152
Q

What parts make up the large intestine?

Ch 39

A
  • Cecum
  • Colon (ascending –> transverse –> descending –> sigmoid)
  • Rectum
  • Anal canal
153
Q

What is peristalsis?

A
  • 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
Q

What is IBD?

Ch 39

A

Irritable Bowel Disease: chronic inflammation of the intestines

  • Crohn’s
  • Colitis
155
Q

How do the following medications impact stool?

a.) Aspirin & Anticoagulants
b.) Iron salts
c.) Bismuth subsaclicylate
d.) Antacids
e.) Antibiotics

Ch 39

A

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
Q

What is ISBAR?

A
  • Introduction
  • Situation
  • Background
  • Assessment
  • Recommendations
157
Q

What are SMART goals?

A
  • Specific
  • Measurable
  • Achievable
  • Realistic
  • Timely
158
Q

What are the 7 patient rights of medication administration?

A

Right

1.) Patient
2.) Medication
3.) Dose
4.) Route
5.) Time
6.) Reason
7.) Documentation

159
Q

What are the signs & symptoms of hyperglycemia?

A
  • polydipsia (increased thirst)
  • polyuria
  • blurred vision
  • feeling weak, fatigued, or tired

* unintentional weight loss

160
Q

What are signs & symptoms of hypoglycemia?

A
  • tachycardia
  • diaphoresis
  • dizziness (feeling shakey)
  • Irritable or confused
  • Hunger
  • Nervous or anxious
161
Q

What is the difference in laxatives & stool softeners?

A

Laxatives: facilitate bowel movement
Stool softener: softens stool for easier passage & less strain

162
Q

True or False:

The state nurse practice act is the most important law affecting nursing practice.

A

True

163
Q

What are the nursing process steps of the clinical judgement model?

Ch 14

A

1.) Assessment
2.) Analysis
3.) Planning
4.) Implementation
5.) Evaluation

164
Q

What are methods of data collection?

Ch 15

A
  • Nursing history
  • Patient interview
  • Physical assessment
165
Q

What are the 6 ANA Standards of Practice?

A

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
Q

What is the ANA Standard of Practice 1?

Ch 15

A

Assessment: The RN collects pertinent data & information relative to the healthcare consumer’s health or the situation.

167
Q

What is the ANA Standard of Practice 2?

Ch 16

A

Diagnosis: The RN analyzes the assessment data to determine actual or potential diagnoses, problems, and issues.

168
Q

What is the ANA Standard of Practice 3?

Ch 17

A

Outcomes Identification: The RN identifies expected outcomes for a plan individualized to the healthcare consumer or the situation.

169
Q

What is the ANA Standard of Practice 4?

Ch 17

A

Planning: The RN develops a plan that prescribes strategies to attain expected, measurable outcomes.

170
Q

What is the ANA Standard of Practice 5?

Ch 18

A

Implementation: The RN implements the identified plan.

171
Q

What is the ANA Standard of Practice 6?

Ch 19

A

Evaluation: The RN evaluates progress toward attainment of goals & outcomes.

172
Q

What is informal planning?

Ch 17

A

a link between identifying a patient’s strength or problem and providing an appropriate nursing response, often while rearranging priorities.

173
Q

What are functions of the integumentary system?

Ch 33

A
  • Protection
  • Temperature regulation
  • Sensation
  • Immunologic
  • Absorption & Elimination
  • Vitamin D Production
174
Q

What factors affect skin integrity?

Ch 33

A
  • 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
Q

What is a normal or healthy BMI?

Ch 37

A

18.5 - 24.9

176
Q

What is the significance of waist circumference?

Ch 37

A

Greater waist circumference = higher risk of disease

177
Q

Where does digestion primarily occur?

Ch 37

A

Small intestine

178
Q

What are developmental considerations to keep in mind regarding nutrition?

Ch 37

A
  • 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
Q

What factors can be used to assess Nutritional Status?

Ch 37

A
  • Dietary data
  • Medical & Socioeconomic data
  • Anthropometric data (body measurements)
  • Clinical data
  • Biochemical data
180
Q

What are nutritional nursing interventions?

Ch 37

A
  • Teach nutritional information
  • Monitor nutritional status
  • Stimulating appetite
  • Assist with eating
  • Provide oral nutrition
  • Provide long-term nutritional support
181
Q

Signs & Symptoms of Vitamin A, D, E, & K deficiency

Ch 37

A
  • 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
Q

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

A

c.) Time lapsed assessment

183
Q

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

A

c.) Assessment

184
Q

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

A

b.) Affective outcome

185
Q

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

A

d.) Continuous collection, analysis, validation, & communication of data

186
Q

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

A

d.) Clinical reasoning

187
Q

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

a.) H: help, E: environmental equipment, L: look at patient, P: people in the room

188
Q

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

A

c.) Specific, Measurable, Attainable, Realistic, Time bound

189
Q

A risk for pressure injury is considered which priority level?

a.) High priority
b.) Medium priority
c.) Low priority

A

b.) Medium priority

190
Q

A nurse consults with the medical team regarding the patient’s plan of care.

a.) Direct care
b.) Indirect care

A

b.) Indirect care

191
Q

A patient is unwilling to participate in therapy.

a.) Nursing variable
b.) Health care system variable
c.) Patient variable

A

c.) Patient variable

192
Q

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

A

b.) Health care system variable

193
Q

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

A

d.) Fatigue

194
Q

What is the passive phase of ventilation?

a.) Inspiration
b.) Expiration

A

b.) Expiration

195
Q

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

a.) Nasopharyngeal catheter

196
Q

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

A

b.) Tidal Volume (TV)

197
Q

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

A

d.) Low pulse oximetry reading

198
Q

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

a.) Reflection in action

199
Q

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

a.) QSEN Competencies

200
Q

What is the tearing of a structure from the normal anatomical position?

a.) Avulsion
b.) Laceration
c.) Pressure injury
d.) Contusion

A

a.) Avulsion

201
Q

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

A

d.) Hemostasis, Inflammation, Proliferation, Maturation

202
Q

When wounded, what happens to the BMR?

a.) BMR increases
b.) BMR decreases

A

a.) BMR Increases

203
Q

What is excitable tissue formation (when extra tissue is formed) called?

a.) Exudate
b.) Erythema
c.) Granulation tissue
d.) Keloid

A

d.) Keloid

204
Q

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

A

c.) A patient who is obese with a history of type 1 DM

205
Q

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

A

d.) Preventing the patient from sliding in bed

206
Q

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

A

b.) A surgical incision with sutured approximated edges

207
Q

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

A

b.) Dehiscence

208
Q

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

A

c.) Acupuncture

209
Q

The combination fo allopathic & complementary & alternative modalities.

a.) Integrative Health Care
b.) Holism
c.) Allopathic Medicine

A

a.) Integrative Health Care

210
Q

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

a.) To rest the gastrointestinal tract & promote healing

211
Q

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

A

c.) Flaking facial skin, facial edema, pale skin color

212
Q

Which type of fat raises cholesterol levels?

a.) Saturated
b.) Unsaturated
c.) Trans-Fat
d.) All types of fat

A

a.) Saturated

213
Q

Which vitamin is only found in food made from animals?

a.) Vitamin K
b.) Vitamin B12
c.) Vitamin C
d.) Vitamin D

A

b.) Vitamin B12

214
Q

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

A

b.) Every 4 - 6 hours

215
Q

Where does most absorption occur in the GI tract?

a.) Mouth
b.) Esophagus
c.) Stomach
d.) Small Intestine

A

d.) Small Intestine

216
Q

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

A

c.) Vitamin K

217
Q

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

a.) Folic Acid

218
Q

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

A

c.) Acid formation

219
Q

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

A

b.) Weakened pelvic muscle leading to constipation

220
Q

Which can casue black stool?

a.) Aspirin / Anticoagulants
b.) Antacids
c.) Antibiotics
d.) Iron salts

A

d.) Iron salts

221
Q

Which are characteristics of an upper GI bleed?

a.) Black, tarry, coffee ground emesis
b.) Hemorrhoids
c.) Bright red streaks

A

a.) Black, tarry, coffee ground emesis

222
Q

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

A

c.) Lying on the left side

223
Q

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

A

b.) Oil-retention enema

224
Q

True or False: when using a timed specimen the nurse should consider the first stool passed as the start of the collection period.

A

True

225
Q

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

A

d.) nasogastric tube

226
Q

What is it called when the 24 hour urine output level is less than 50 mL?

a.) Dysuria
b.) Oliguria
c.) Anuria
d.) Polyuria

A

c.) Anuria

227
Q

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

A

b.) It will burst

228
Q

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

A

c.) After the patient urinates & that sample is discarded

229
Q

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

a.) Stress incontinence

230
Q

What are factors that affect micturation?

Ch 38

A
  • Developmental considerations
  • Food & fluid intake
  • Psychological variables
  • Activity & muscle tone
  • Pathologic conditions
  • Medications
231
Q

What are developmental considerations that can affect urinary function in children & older adults?

A

Children: toilet training 2 - 5 years old & enuresis

Older Adults
* Nocturia
* Increased frequency
* Urine retention & stasis
* Voluntary control affected by physical problems

232
Q

What is urinary diversion?

Ch 38

A

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
Q

What is the role of the pelvic floor in micturation?

Ch 38

A

Micturation (passage of urine) can occur when the pelvic floor relaxes

234
Q

What is bladder training?

Ch 38

A

Used to help treat urinary incontinence

235
Q

What is peristalsis? What controls peristalsis? How often do contractions occur?

Ch 39

A

involuntary contraction & relaxation of the intestinal wall to push contents forward

  • occurs every 3 - 12 minutes
  • Under the control of the nervous system
236
Q

What are the signs & symptoms of chronic and acute GI bleeds?

Ch 39

A
  • Black tarry stools
  • Rectal bleeding
  • Vomiting blood (bright red or brown coffee ground emesis)
237
Q

What are the 5 types of ostomies?

Ch 39

A
  • Sigmoid colostomy
  • Descending colostomy
  • Transverse colostomy
  • Ascending colostomy
  • Ileostomy
238
Q

What is flatus?

Ch 39

A

Intestinal Gas

Adult Nursing I (NUR 240) (6 decks)

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