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Nursing Process > Exam 3 > Flashcards

Exam 3 Flashcards

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1
Q

Pain scales

A

Children: Wong’s Faces
Adults: numerical 0-10

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2
Q

Who should not receive PCAs?

A

People who are not cognitively intact or little kids

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3
Q

What does the nurse need to do more often when a pt is on a PCA?

A

Assess vitals signs because of the risk of respiratory depression
-O2, BP, RR

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4
Q

What is a big side effect of PCA?

A

Constipation

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5
Q

Who determines if a pt needs a PCA?

A

anesthesiologist

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6
Q

How much Tylenol can be given to the elderly in one day?

A

1g/day

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7
Q

Alternative methods to ease pain

A
  • Sleep
  • drink lots of water
  • thermal treatments
  • acupuncture
  • acupressure
  • exercise
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8
Q

What do you document with pain patches?

A

Must mention that the old patch was removed and disposed of properly

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9
Q

PQRST pain assessment

A 
P=provokes (what causes the pain)
Q=quality (what does it feel like)
R=radiates (where does the pain radiate)
S=severity (scale of 0-10)
T=time (time pain started)
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10
Q

Where are epidurals administered?

A

in the epidural space

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11
Q

Factors affected by cognitive disorders

A 
Orientation
Attention
Memory
Vocabulary
Calculation ability
Abstract thinking
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12
Q

What is the most common psychiatric syndrome in hospitals?

A

Delirium

-50% of occurrence in elderly inpatients

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13
Q

What is the priority care for patients experiencing delirium?

A

Safety

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14
Q

Delirium

A

Usually results from an acute disruption in the homeostasis of the brain

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15
Q

Dementia

A

-Results from primary brain pathology that usually is irreversible, chronic, and a slow progression

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16
Q

Diagnostic criteria for delirium

A
  • Disordered cognition
  • attention deficit
  • disturbed consciousness
  • disturbed sleep-wake cycles
  • abnormal psychomotor behaviors
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17
Q

How many Americans are affected by Alzheimer’s? Prevalence in ages >65 and >85?

A
  1. 5 million
    - occurs in 10% of people >65 years
    - almost 50% of people >85
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18
Q

Deficits related to dementia

A
  • impaired learning
  • compromised ability for complex tasks
  • impaired reasoning
  • compromised spatial ability and orientation
  • language deficits
  • behavioral problems
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19
Q

Apraxia

A

inability to perform motor tasks despite intact motor function

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20
Q

Aphasia

A

loss of language

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21
Q

Sundowning

A

change in behavior after sunset

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22
Q

Agnosia

A

inability to recognize familiar objects

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23
Q

Risk factors for delirium

A
  • aging
  • postop status
  • metabolic disorders
  • drug withdrawal
  • toxicity secondary to drugs or other exogenous substances
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24
Q

How is dementia characterized?

A
  • several cognitive deficits that result from a general medical condition, use of substance, or multiple biologic etiologies
  • gradual onset
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25
Q

Hallmark sign of Alzheimer’s

A

Post-mortem findings of beta-amyloid plaques in the brain

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26
Q

What does forensic mean?

A

Law

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27
Q

T or F:

You will always be in a forensic milieu even if you aren’t a forensic nurse.

A

True

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28
Q

Forensic nursing environments

A
  • community based outpatient clinics
  • secure units in general hospitals
  • state psych hospitals
  • forensic psych hospitals
  • custodial type setting
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29
Q

Who has the highest population of incarcerated people in the western world?

A

The U.S.

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30
Q

Factors contributing to growing forensic population

A
  • more drug-related activities
  • rising interpersonal & urban violence
  • anticrime & antidrug legislation
  • poor economic conditions and associated homelessness
  • criminalization of the mentally ill
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31
Q

T or F.
Correctional facilities have become the country’s front-line mental health providers representing the mental health institutions of the 21st century.

A

True

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32
Q

Approaches to prevent incarceration of the mentally ill

A
  • Forensic assertive community treatment

- Sequential intercept model

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33
Q

Forensic assertive community treatment

A

integrates assertive community treatment and community justice intitiatives

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34
Q

Sequential intercept model

A

Envisions 5 points of interception, from law enforcement to community corrections and support, to prevent people from entering the criminal justice system

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35
Q

Characteristics of forensic clients

A
  • demonstrate poor judgment
  • have limited reasoning
  • have a history of not learning from mistakes
  • report an exceptionally high level of substance abuse at the time of arrest
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36
Q

Role of forensic nurse

A

To come up with alternatives to incarceration of offenders with mental illness

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37
Q

T or F

People with substance use disorders are at increased risk for mental illness

A

True

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38
Q

Forensic Populations

A
  • suspects or convicts
  • sentenced or unsentenced
  • not guilty by reason of insanity
  • incompetent to stand trial
  • not criminally responsible because of mental disorders
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39
Q

What percentage of any prison or jail population has a mental disorder?

A

15%

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40
Q

Types of offenders in the prison population

A
  • mentally ill
  • violent
  • juvenile
  • female
  • older adult
  • offenders with HIV/AIDS or hepatitis
  • offenders with terminal illness
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41
Q

Expressive violence

A

interpersonal altercations, usually with people known to the assailant and of similar age, ethnicity, and cultural background

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42
Q

Instrumental violence

A

usually involves premeditated, motive-driven acts

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43
Q

Gang violence

A

associated with group alliances and committed for retaliation or revenge

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44
Q

Custody vs caring

A

Doing what is beneficial for the community while advocating for the client

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45
Q

Characteristics of skilled forensic nurses

A
  • Good communicators
  • wide range of physical and psychosocial assessment skill
  • solid critical thinking and decision making
  • social maturity, adaptability, professionalism, and analytical skills
  • confidence
  • nonjudgmental attitudes
  • ability to work independently and within teams
  • decisiveness
  • ability to work in a secure environment
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46
Q

A forensic psychiatric nurse performs crisis intervention for an inmate in a prison setting. What level of prevention does this action reflect?

A

Secondary

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47
Q

Factors affecting the provision of forensic psychiatric nursing care

A
  • context of care
  • number of clients
  • lengths of stay
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48
Q

Recurring themes dominating therapeutic intervention

A
  • power
  • control
  • negotiation
  • trust building
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49
Q

when can children go back to regular activities after loss of function in a limb?

A

when they regain strength in that limb

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50
Q

how do you manage shoulder dislocation?

A

sling

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51
Q

difference between sprain and strain

A
  • strain effects the muscles and tendons and could happen over time
  • sprains effect the ligaments and happen immediately
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52
Q

therapeutic management of soft tissue injuries

A

RICE:

Rest
Ice
Compression 
Elevation
Immobilization and support
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53
Q

how do you diagnose fractures?

A

xray

54
Q

5 Ps of fracure assessments

A 
Pain and point of tenderness
Pulse
Pallor
Paresthesia
Paralysis
55
Q

DDH

A

developmental dysplasia of the hip

-test if child isn’t walking by 12 months

56
Q

talipes carus

A

inversion, or bending inward

57
Q

talipes valgus

A

eversion, or bending outward

58
Q

talipes equinus

A

plantarflexion with the toes lower than the heel

59
Q

talipes calcaneus

A

dorsiflexion with the toes higher than the heels

60
Q

osteogenesis imperfecta

A
  • excessive fragility and bone defects
  • defective periosteal bone formation and reduced cortical thickness of bones
  • hyperextensibility of ligaments
61
Q

therapeutic management of osteogenesis imperfecta

A
  • primarily supportive care
  • caution with handling to prevent further fractures
  • family education
  • occupational planning and genetic counseling
62
Q

most common spinal deformity

A

scoliosis

63
Q

at what age should kids be screened for scoliosis?

A

girls 10-12 years

boys 13-14 years

64
Q

hematocrit values

A

36-52%

65
Q

erythrocyte sedimentation rate values

A

0-30

66
Q

calcium values

A

3.9-4.6 mg/dl

67
Q

When would C-reactive protein be elevated?

A

in RA

68
Q

fracture definition

A

an interruption and/or disruption in the normal continuity of a bone that results from excessive force or stress

69
Q

6 different directions of force for fractures

A

tensile, compressive, shearing, torsion, pulling, greenstick

70
Q

causes of fractures

A

traumatic, pathologic, stress

71
Q

closed vs open fractures

A

closed- skin is intact; open- skin is broken

72
Q

complete vs incomplete fractures

A
  • complete- both cortices are penetrated, producing two bone fragments
  • incomplete- only one of the cortices are penetrated
73
Q

clinical manifestations of fractures

A
  • pain (immediate, severe, aggravated)
  • loss of or unusual function (crepitus)
  • structure, malalignment/ deformity
  • exessive motion at sight
  • local changes: edema, warmth, ecchymosis
  • bleeding
  • discoloration
  • loss of sensation
  • signs of shock
  • evidence on xray
74
Q

goal of fracture therapy

A
  • reduce fracture by aligning the fragments
  • maintain fragments in correct alignment
  • restore function and prevent loss of mobility and muscle tone
75
Q

optimal reduction treatment for fractures

A

(reduction: replacing bone fragments in their correct anatomical position)
- traction
- manual manipulation: moving fragments into position by applying traction and pressure to distal fragment (closed fractures only)
- open reduction (surgery)

76
Q

immobilization treatments for fractures

A
  • external fixation
  • internal fixation
  • traction
77
Q

most common external fixation device

A

casts

78
Q

plastic/fiberglass casts

A
  • lightweight, dry quickly (30 mins), may feel warm during application, can get wet
  • skin integrity is a major issue regardless of cast type
79
Q

plaster of paris casts

A

cannot get wet- cover for bathing

80
Q

traction

A

a pulling force applied to a part of the body while a counter traction pulls in the opposite direction

81
Q

when would you use traction?

A
  • to reduce a fracture
  • immobilize a limb while healing
  • overcome muscle spasm
  • stretch adhesion
  • correct deformities
82
Q

5 types of traction

A
  • Bucks and Russel: skin traction used to align a lower extremity fracture
  • Skeletal: ex. crutchfiled tongs to correct cervial spine
  • Bryants
  • Pelvic
  • Cervical: ex. halo- heavy and requires education regarding balance
83
Q

weights and pulleys

A

should always be free hanging- no one should touch them

84
Q

surgical management of fractures

A
  • external

- internal

85
Q

fat embolism syndrome

A

most frequently seen after long-bone fx., multiple fx, or pelvic fx., or surgery to these sites

86
Q

clinical manifestations of fat embolism syndrome

A

look up

87
Q

compartment syndrome

A
  • high pressure in the muscle compartment in the close fascial space
  • causes capillary blood perfusion to be reduced below the level of tissue viability
88
Q

causes of compartment syndrome

A
  • external compression (tight dressing, cast, brace)
  • increased compartment content trauma
  • bleeding
89
Q

6 Ps of compartment syndrome

A

pain, paresthesia, paresis, pressure, pallor, pulse

90
Q

hallmark signs of compartment syndome

A
  • unrelenting pain (even with opioids)

- pain on passive stretch

91
Q

what is often the FIRST sign of compartment syndrome

A

sensory deficit- feeling of “pins and needles”

92
Q

most common surgical procedure in adults over 85

A

surgery for hip fractures

93
Q

s/s of hip fracture

A

pain, immobility, *external rotation, *one leg shorter than the other

94
Q

hip fracture treatment

A

pins or hip replacement

95
Q

discharge teaching for post-hip replacement

A

advice to get an elevated toilet seat

96
Q

knee trauma

A

cartilage (meniscus) or ligament

97
Q

dx/tx of knee injuries

A

arthroscopy

98
Q

meniscetomy

A

surgery for damaged cartilage

99
Q

release surgery

A

for knee malalignment

100
Q

osteotomies

A

surgery for joint restructuring

101
Q

total knee replacement

A

metal/ polyethylene prostheses

102
Q

post-op care of total knee replacement

A
  • narcotic analgesics
  • anti-infectives for the first 24hrs
  • anticoagulants
  • leg elevation
  • hemovac
  • CPM machine
  • early ambulation with progression from non-weight bearing to partial weight bearing
103
Q

amputation

A

removal of a limb/ appendage for ischemia, trauma, malignancy, infection

104
Q

types of amputation

A
  • closed or “flap”

- guillotine

105
Q

post-op amputation

A
  • pressure dsg

- elevate stump 24 hrs; after 24 hrs position prone

106
Q

pathophysiology of gout

A

the overproduction of uric acid and the underexcretion (renal) of uric acid

107
Q

prevention of renal calculi in pts with gout

A

2-3 liters of fluid per day

108
Q

Risk factors for aggression

A
  • impulsivity
  • unfair application of rules
  • unjust practice
  • discrimination
  • shaming
  • humiliation
109
Q

Manifestations of Negative Emotionality

A
  • irregularity in biologic function
  • behavioral inhibition
  • slow adaptability
  • intense and negative mood
110
Q

Contributing factors to problems with anger and violence

A
  • psychiatric illness
  • medical conditions
  • traumatic life events
  • biologic factors and temperament
  • social environmental factors
111
Q

Staff behavior contributing to anger in clients

A
  • rules that prevent clients from leaving activities
  • power disputes over medications
  • blocked access to phones, televisions, or rooms
  • denials of requests in general
  • physical restraint
  • ignoring clients
  • ordering clients to do or not to do something
112
Q

Criteria for involuntary outpatient commitment

A

There must be imminent danger to themselves or others

113
Q

T or F
Regarding the rights of clients in hospitals and clinics, voluntary clients may refuse any treatment, although staff at the facility may then ask clients to leave

A

True

114
Q

Which of the following is a result of the Tarasoff decision?

A

Mandatory reporting of threats with intent to harm people

115
Q

Overall goal for aggressive or violent clients

A
  • not threatening or harming anyone

- gaining insight into, and skill at, managing aggressive impulses

116
Q

5 steps to communication

A
  • Making personal contact
  • Discovering the source of distress
  • Relieving the distress
  • Keeping everyone safe
  • Assisting with alternative behaviors and problem solving
117
Q

Diagnoses relevant to aggression

A
  • Risk for self directed violence
  • Risk for other directed violence
  • Ineffective coping r/t psychopathology
  • Poor impulse control
118
Q

Goals of therapy

A
  • impulse control
  • aggression control
  • abusive behavior self-restraint
  • coping
119
Q

Treating pain in the elderly

A
  • start low
  • be careful with ice packs because of vasoconstriction in already-low areas of blood flow, could cause ischemia
  • may need more time between doses of medication
120
Q

Who might have problems being on a PCA (of those who are eligible)?

A

People with sleep apnea

121
Q

hallmark sign of dementia

A

aphasia

122
Q

perioperative nursing diagnoses

A
  • risk for imbalanced fluid volume

- risk for perioperative positioning injury

123
Q

preoperative nursing diagnoses

A
  • anxiety

- risk for infection

124
Q

postop assessments for early detection of complications

A
  • frequent vitals
  • respiratory status
  • BP
  • wound
  • temp
  • CNS status (alertness, movement, shivering)
  • fluid status
  • GI status (N/V, movement of bowels)
125
Q

signs of thrombophlebitis

A
  • pain on the calf or thigh of the involved extremity

- redness, swelling in effected area, elevated temp and increased diameter of the extremity

126
Q

safety measures during intraoperative period

A

-positioning: body alignment is a must, lifting rather than sliding to prevent shearing

127
Q

DIC (disseminated intravascular coagulation)

A

phenomenon where the patient is clotting and bleeding at the same time; all the clotting factors get sent to the site of damage and leave no clotting factors in the rest of the body

128
Q

malignant hyperthermia s/s

A
  • muscle stiffness
  • hypercarbia (increase in CO2), tachycardia, tachypnea, hypoxia,
  • temp will rise 1-2 degrees Celsius every 5 minutes
129
Q

treatment of hyperthermia

A

DISOCONTINUE the agent, stop surgery, 100% oxygen, and administer DANTROLENE SODIUM stat
-COOL the patient (ice lavage open cavities)

130
Q

alkaline phosphatase values

A

adults 25-100 U/L

Nursing Process (4 decks)

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