Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

nursing fundmentals > final!!! > Flashcards

final!!! Flashcards

You may prefer our related Brainscape-certified flashcards:
Family Nurse Practitioner (FNP) flashcards NCLEX-PN® flashcards
1
Q

Explain the aims of nursing as they interrelate to facilitate maximal health & quality of life for patients

A

patient centered care in order to promote better health care based upon their needs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Discuss professional behaviors that are consistent with those of a professional nurse

A

No gossip, be courteous, kind, dress appropriately, respectful, respect privacy, cultural awareness, advocate, responsibility, and accountability
Clear communication, Nursing organization (ANA), correct body language & word choice, Certifications

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Referent (describe comm.process)

A

the incentive or motivation for comm. between 2 people

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Sender (describe comm.process)

A

The person who initiates & transmits the message

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Receiver (describe comm.process)

A

The person to whom the sender aims the message & who interprets the senders message

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Message (describe comm.process)

A

The verbal & nonverbal information the sender expresses & intends for the receiver

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Channel (describe comm.process)

A

the method of transmitting & receiving a message
Ex: sight, hearing, touch, facial expression, & body language

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Environment (describe comm.process)

A

The emotional & physical climate in which the comm. takes place

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Feedback (describe comm.process)

A

Can be verbal, nonverbal, + or -
The message the receiver returns to the sender that indicates the receipt of the message
An essential component of ongoing communication

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Interpersonal variables (describe comm.process)

A

Factors that influence comm. between the sender & receiver (educational & developmental levels)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Factors that influence communication

A

Dementia
Hearing loss (sensory deficit)
Cultural diff
Language barrier
environmental

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Identify ways individuals send messages through nonverbal communication

A

Body language (posture & gait)
Facial expression, eye contact (varies with culture) & gestures.
Personal space

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Barriers of communication & how to combat

A

Cultural: cultural competence
Language barriers: interpreter, address pt directly
Speech/Hearing: use uncomplicated words, avoid med term, speak at slower pace, make sure room is well lit & limited noise & distractions. Face the pt & make sure they have their assistive devices.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Time (discuss therapeutic communication techniques)

A

Plan & allow adequate time to communicate with others

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Active Listening (discuss therapeutic communication techniques)

A

convey intrest, trust & acceptance

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Caring attitude (discuss therapeutic communication techniques)

A

show concern & facilitate an emotional connection among nurses, pts, families, & significant others

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Honesty (discuss therapeutic communication techniques)

A

be open, direct, truthful, & sincere

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Trust (discuss therapeutic communication techniques)

A

demonstrate to clients, families, & significant others that they can rely on nurses without doubt, question, or judgement

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Empathy (discuss therapeutic communication techniques)

A

Convey an objective awareness & understanding of feelings, emotions, & behavior of clients, families & significant others, including trying to envision what it must be like to be in their position

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Nonjudgemental attitude (discuss therapeutic communication techniques)

A

A display of acceptance of pts, families, & significant others encourages open, honest communication

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Describe the role that communication plays in planning pt centered care

A

keeps the client involved in their own care
Not social or reciprocal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Describe the role that communication plays in planning client centered care

A

It incorporates the whole patient, we learn about cultural beliefs & practices and also express how we feel through communication

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Describe effective communication interventions for clients with impairments in communication

A

Medical interpreters, Make sure assistive devices are working and available.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

SOLER

A

S: encourages the listener to sit (if possible) facing the patient
O: reminds the nurse to maintain an open stance or posture while listening
L: suggests that the listener lean toward the speaker, positioning the body in an open stance
E: refers to maintaining eye contact without standing
R: reminds the nurse to relax. Demonstrating relaxation during a conversation encourages the person sharing to continue. It also conveys a sense of attention, interest, & comfort with the subject being shared

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Receive-Record-Readback
When receiving a prescription or order….

A

Record it
read it
do not just repeat it
read it back as written to the prescriber
verify

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

ISBARR (introductions, situation, background, assessment, recommendation, and readback)

A

Standardized communication tool to establish uniform delivery of information from one provider to another during transfer of care

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

ISBARR (cont)

A

Introductions: give your name & client care role, ask the receiver for their name & client care role
Situation: describe what is currently happening to the client that needs to be addressed
Background: provide pertinent clinical background
Assessment: give a brief eval. of the situation
Recommendation: give suggestions for care
Readback/repeat: summarize, allow time for questions, & repeat or reread info as needed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Discuss clinical decision making in professional nursing practice

A

Evidence based practice
Clinical reasoning to make clinical judgements

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Discuss steps of the nursing process as they relate to the care of clients

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Assessment (Discuss steps of the nursing process as they relate to the care of clients)

A

Recognizing cues!
Separate from a med assessment, focuses on response to health condition
Identify S&S
Gathering accurate info
interview, observation & physical assessment skills
Object & subjective data!!

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Analyze (Discuss steps of the nursing process as they relate to the care of clients)

A

Diagnosis
What potential or actual problems that can be prevented or resolved by nursing interventions?
What needs to be addressed?
Identifies a nursing problem: actual or potential
can be prevented or resolved by nursing interventions
provides a defintion of a patients response to health problems

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Planning

A

determine patient goals
SMART GOALS
Prioritize

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Implementation

A

take action!
review/readvise care
promote self care
carry out planned nursing interventions BUT FIRST REASSESS
clinical decision making
set priorities
time management
delegation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Evaluation

A

Eval. Outcomes
determine if the pt condition. has improved, if client met outcomes
examine results, supporting data
revise plan of care

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Objective

A

Vital signs
medications
what the nurse observes, be descriptive without judgement
Ex: client noted in hallway with stack of books, pacing back and fourth in front of classroom. appears tearful & avoids eye contact
Measured, observed through 5 senses
Heart rate & bleeding
Measurable
Data the nurse obtains through observation & examination.
Facial expressions, i & o, pa findings, & VS
EX: Client grimaces when attempting to brush their hair with their left arm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Subjective

A

WHAT THE PATIENT SAYS
direct quotes (quotation marks), summarize info and attribute to client
opinions
pain & feelings
EX: “Im so stressed out about this test”
What the client tells the nurse
EX: “My shoulder is really, really sore

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Apply basic principles of diagnostic reasoning to identify actual & potential problems in clinical settings

A

identifies a nursing problem: actual or potential can be prevented by nursing interventions
using the nursing process to identify and analyze & specific cues relating to potential problems in a clinical setting

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

describes the steps of the nursing diagnostic process

A

Assessment
analyze
planning
implementation
eval.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

Explain how defining characteristics & the etiological factors individualize a nursing diagnosis

A

each persons symptoms are not the same
nursing diagnosis must be tailored to a specific pt with specific problems. Patients may have chest congestion, but they both may have diff. lung sounds

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Describe person centered care

A

care that encompasses the whole patient, their entire well being
treating pt with dignity & respect
involving them in their on care & decisions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

Explain the importance of reassessment after implementing interventions

A

we reassess b/c we need to know if the goals were met, & if not then restructure goals and make new interventions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

describe the principals associated with effective delegation in nursing practice

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

5 rights of delegation (describe the principals associated with effective delegation in nursing practice)

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

Right task

A

repetitive, little supervision, and noninvasive
Delegate an AP to assist a client who has pneumonia to use a bedpan

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

Right circumstance

A

determine the health status & complexity of care
Delegate an AP to measure the VS of a client who is post op & stable

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

Right Person

A

determine & verify the competence of the delegatee. Task must be within scope of practice for the delgatee.
Delegate a PN to admin enteral feedings to a client who has a head injury

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

Right communication/direction

A

communicate what data to collect
Delegate an AP to assist Mr.Martin in room 312 with a shower before 0900

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

Right eval/supervision

A

provide indirect or direct supervision, monitor performance, and intervene if necessary
Delegate an AP to assist with ambulating a client after the RN completes the admission assessment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

Prioritize the delivery of client care based on priority frameworks

A

writing down
ABCDE, maslow, least invansive/least restrictive. nursing process, safety & risk reducrt

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

Describe the nurse’s role when providing & managing client care

A

Advocating, care fiver, delegator, educator, change agent

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

Discuss the nurse’s responsibility surrounding delegation of nursing care

A

Do not delegate: nursing process, pt education, nursing judgement tasks, med admin, doc. of a task that the rn performed. V/S on unstable pt,

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

Describe ethical principles & their role in ethical decision making

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

Autonomy

A

patients have the right to make informed decisions for themselves, include clients in making decisions. Even when those decisions may not be in their best interest
EX: right to refuse blood transfusion for religion reasons

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

Beneficence

A

commitment to helping patients & seeking best possible outcomes; taking positive actions to help others. Without any self interest.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

Fidelity

A

faithfulness to promises & responsibilities, agreement to keep promises
loyal!

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

Justice

A

treat all pt fairly
provide treatment, care & resources for all pt regardless of age, sex, race & economic status

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

nonmaleficence

A

do not cause intentional harm
avoidance of harm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

veracity

A

telling the truth
truthfulness
provide truth & accurate info to the patient

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

Confidentiality

A

protection of privacy without diminishing access to high quality care
HIPAA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

Good samaritian laws

A

Protect health care workers when they give aid to people in emergency situations
If they help someone in the field they are not held liable
only applies to volunteers and in good faith

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

Mandatory reporting

A

legal obligation to report findings in accordance with state law
report abuse, neglect, sexual assault, incidents & sentinel events & communicable diseases
Reportable diseases
COVID-19, varicella, syphilis, chlamydia, gonorrhea, Lyme’s disease, mumps, measles, pertussis, rabies (human illness)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

Discuss the legal considerations of nursing practice

A

must be accountable for practicing nursing within the confines of the law to shield from liability. advocating for clients rights, providing care within scope of practice, follow state nurse practice acts

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
62
Q

discuss the ethical considerations of nursing practice

A

advocate for patients if when not agreed with them

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
63
Q

Discuss guidelines legal & accurate for documentation in the health record

A

always include date/time, signature & intials, black ink, single line cross out. If it wasnt documented you didnt do it. Document asap after care is given
never doc. care given by someone else, or ask someone to doc for care you have given

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
64
Q

SOAP note

A

S: subjective
O: objective
A: assessment
P: plan

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
65
Q

PIE

A

P: problem
I: intervention
E: evalulation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
66
Q

Charting by exception

A

focused on unusual/unexpected findings
usually a checklist/ flowsheet

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
67
Q

DAR

A

D: data
A: action
R: response

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
68
Q

Identify wats to maintain confidentiality of electronic & written records

A

only use your own login info
password should be unique & changed freq.
Log off when doc. is complete
log off computer each time you leave the station
computer screen should be protected from others
never leave written doc.
ensure your name is correct
faceup

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
69
Q

Identify commonly used abbreviations & symbols in documentation

A

see ati….

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
70
Q

Explain the nurse’s role surrounding the maintenance of client safety in the home & clinical settings

A

Home: educate on safety with clutter, throw rugs, o2 safety if needed, ramps, fire extinguishers and exits
Clinical: makes sure no wires/tubing on floor, decrease clutter, fall risk assessment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
71
Q

Describe personal environmental hazards that pose a risk to a clients safety

A

open wires, clutter, stairs, throw rugs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
72
Q

Discuss methods to reduce the risk of pt injury

A

fall precautions, risk assessment tools, area clean, call light within reach, & keep personal items within reach. Bed in lowest position. Prevent infection. Identify pt correctly, use med safely. COMMUNICATE WITH STAFF CORRECTLY

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
73
Q

Discuss risk factors associated with client falls & how to identify clients at risk for falling

A

Age, med conditions, incontinence, balance, vertigo, medications
Use morse fall scale

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
74
Q

Discuss methods to prevent falls in the home & clinical setting

A

Provide education on the use of a call light (return demonstration), use color coded wristbands for fall risk, provide adequate lighting, hourly rounding, keep things close to pt, decrease clutter
Sedated, unconscious,: side rails up. Remove scatter rugs
clear path to bathroom

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
75
Q

Identify potential safety hazards in the health care agency

A

Falls
procedure accidents
equipment accidents
patient inherent accidents

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
76
Q

Describe nursing interventions to maintaining pt safety

A

move pt closer to the nurses station
one on one if available
call light within reach
hourly rounding
fall risk assessments (morse scale)
bed low position & lock brakes
non skid footwear
respond to call bells

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
77
Q

Chain of infection

A

Sequence of necessary pieces for an infection to occur
how bacteria, viruses, fungi, parasites & prions move from place to place
includes: Infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, & susceptible host

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
78
Q

Transmission of infection

A

airborne, droplet, contact, vector borne

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
79
Q

Normal defenses of the body

A

skin as a barrier, cilia in the nasal passages, gastric acid in stomach, low ph in vagina, peristalsis, flora of large intestine, & tears

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
80
Q

Explain conditions that promote the transmission of HAI’s

A

no hand washing, coughing and not covering mouth, medical asepsis not done,
overuse of antibiotics

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
81
Q

Medical Asepsis

A

clean technique
reduce the present of disease causing microorganisms
*isolation precautions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
82
Q

Surgical asepsis

A

Sterile technique!
no microorganisms present
use for surgical procedures

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
83
Q

Discuss the principles of hand hygiene

A

decreases the evidence of microorganisms
any type of cleansing of the hands
wash hands for 20 sec
soap & water: normal handwashing
alcohol based sanitizers
antispetic handwash & handrub

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
84
Q

Standard precautions

A

gloves, gown, mask, & eye cover
handwashing
protects from blood, body fluids, secretions & excretions,

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
85
Q

contact precautions

A

PPE: glove & gown
private room, no sharing of pt care equipment
cdiff, VRE, RSV, MRSA, shigella, impetigo

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
86
Q

droplet precautions

A

PPE: surgical maskminimum
Gown & gloves if secretions are likely
Influenza, pneumonia, rhinovirus, rubella, mumps, adenovirus, diphtheria
mask outside of room
private room
mask for provider & visitors

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
87
Q

Airborne precautions

A

private room, - air room 12 exchanges per hr
N95 mask
tb, varicella, measles, & COVID 19
pt must wear mask outside of room
spraying/splashing: full face mask

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
88
Q

explain nursing interventions which protect both the client & the nurse from infection

A

HAND HYGIENE, oral hygiene, gloves, proper ppe,

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
89
Q

discuss pt teaching surrounding infection prevention

A

hand hygiene, education on self care & hand hygiene, respiratory hygiene, cough etiquette, importance of vaccines (flu)
reasons for transmission precautions
nutrition

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
90
Q

Identify clients most at risk for infection

A

Elderly: slow response to antibiotic therapy & immune response, thinning of skin, dementia, bladder incontinence,
Immunocompromised
poor nutrition

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
90
Q

Blood pressure

A

120/80
a measurement of force, of the ciruluating blood on the interior walls of the blood vessels

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
91
Q

determine & discuss risk factors for infection

A

poor nutrition, smoker, stress, alcohol, immunocompromised, chronic/acute disease like diabetes & lung disease, old age, a break in the skin, indwelling devices, poor oxygenation, impaired circulation, surgery, poor hygiene, living in crowded environment, & older adult

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
92
Q

Pulse

A

60-100
the rhythmic dilation of the arteries that occurs with the beating of the heart

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
93
Q

Respiratory rate

A

12-20
the number of breaths taken per minute

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
93
Q

Body temp

A

96.8-100.4
the balance of heat produced by the body & the heat lost to the environment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
94
Q

Oxygen sat

A

95-100%
the estimated amt of oxygen bound to the hemoglobin molecule in the rbc, indicating the amt of oxygen being transported to body tissues

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
95
Q

Identify factors that cause variations in Temperature & the management

A

infection/illness, environment, exercise, tod ,stress, hydration, & medications
antipyretics, tepid bath, cooler environment/compress
Hydration: sips of cool fluids

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
96
Q

Identify factors that cause variations in Pulse & the management

A

body position, age, emotion, activity level, health cond, body temp, pain, meds, caffeine
protect from injury, deep breathing & fluids

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
97
Q

Identify factors that cause variations in RR & the management

A

age, exercise, anxiety, meds, pain, smoking, body position, emotion, resp diseases
deep breathing & fluids

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
98
Q

Identify factors that cause variations in O2 sat & the management

A

movement, hypothermia, jaundice, pvd, peripheral edema, nail polish
oxygen via NC & deep breathing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
99
Q

Identify factors that cause variations in BP & the management

A

age, gender, race, food intake, excercise, weight, emotional state, drugs/meds, body position, circadian rhythm, fluid level
antihypertensive meds

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
100
Q

Identify when to measure VS

A

admission, pt status change, once every shift, & discharge

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
101
Q

describe assessment techniques used to obtain each vs across varying clinical scenarios, & accurate documentations of each

A

check ati

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
102
Q

analyze alt. in BP & plan interventions to response to alts

A

High BP: low calorie & low fat diet, weight loss, limit alcohol & salt, exercise, stress reduction
Low BP: + fluids, upright position, eval. meds, educate pt on dizziness & falling, change positions slowly, avoid extreme temps, stay well hydrated

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
103
Q

analyze alt. in temp rate & plan interventions to response to alts

A

fever/hyperthermia: rest, fluids, remove excess clothing, antipyretics, cooler environment, tepid bath

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
104
Q

discuss the steps to assess for orthohypo

A

have pt lay down & assess bp, move to sitting position & wait 1 min, reassess BP in sitting position, move to standing position, after 1 min reassess BP in sitting position,
diagnosed with orthobp when SBP drops by 20 or DBP drops by 10 within 3 minutes after taking bp

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
105
Q

eval. the effectiveness of interventions on vs assessment

A

reassess vitals

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
106
Q

Explain hypertension & the risk factors associated with this cond.

A

elevated bp, leading caus of cv disorder,
the heart is working too hard
thickening of walls & loss of elasticity
RF: NM: family history/race, older adults, diabetes. M: obesity, smoking, excessive alcohol use, high sodium intake,
weight, stress, anxiety/fear

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
107
Q

Describe clinical manifestations & management of hypertension

A

headaches, shortness of breath, lightheadness, nausea, vision problems, & palpitations
management: low cal/fat diet, weight loss, limit salt & alcohol, excercise, antihypertensive, and manage stress

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
108
Q

Explain hypotension & postural hypotension & the risk factors associated with these cond.

A

Hypotension: low bp, sbp less than 90 or dbp less than 60
dizziness, nausea, blurred vision, increased pulse, & fatigue
Management: increase fluids, upright pos, change pos. slowly, avoid extreme temps, HYDRATION
Postural hypotension (ortho): sudden drop in bp when a pt changes position.
dizziness, blurred vision, weakness, fatigue, headache, palpitations
managment: change positions slowly, dangle before moving, hydration!

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
109
Q

Discuss conditions that place pt at risk for impaired oral mucous membranes

A

medications, exposure to radiation, mouth breathing which impairs salivary secretion
XEROSTOMIA: dry mouth
gingivitis: inflammation of gums
Dental caries: tooth decay

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
110
Q

Differentiate between expected findings, typical variations, & unexpected findings when performing a physical assessment of the skin

A

Integrity: Expected: smooth & intact. Unexpected: lesions, rashes
Temperature: Expected: warm as hands. Variations: temp outside cold. Cooler if in cast or immbolized. Unexpected: hypothermia & hyperthermia
Skin mobility & turgor: Expected: rise easily & rapidly returns. Variation: older pt. Unexpected: tenting (dehydration), Edema (accumulation of fluid)
Brusing? cyanosis? jaundice? erythema?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
111
Q

Differentiate between expected findings, typical variations, & unexpected findings when performing a physical assessment of the nails

A

transparent, smooth, convex, with a pink nail bed & translucent white tip
Clubbing? nail bed color? Brittleness?

112
Q

Differentiate between expected findings, typical variations, & unexpected findings when performing a physical assessment of the Hair

A

Lesions, dandruff, ticks, alopecia, lice, color? distribution, texture, lubrication. Hirsutism?

113
Q

Describe the steps for providing pt hygiene including giving a bed bath

A

start at top and work down. Only uncover what is needed. Always clean from clean to dirty

113
Q

Describe the components of performing a wound assessment & interpret the findings

A

Wound assessment: measure entire wound (ht, width& depth) Tunneling? Undermining?. Note drainage: amt, color, consistency, & odor. Note any slough, exudate or necrotic tissue. Palpate for appearance & pain.

114
Q

Discuss the risk factors that contribute to impairment in skin integrity

A

Very thin & obese
Excessive perspiration sweating
Diseases of the skin
Dehydration
Developmental level
State of health

115
Q

Explain factors which promote wound healing

A

Keep skin clean & intact
keep wound free of foreign material (exudate, debris, dead tissue)
Proper nutrition
encourage protein: meat, fish poultry, eggs, dairy products, beans, nuts, & whole grains

116
Q

Describe complications of wound healing & the management of each

A

Local/Systemic Infection: erythema, purlent drainage, pain, swelling warmth around skin.
Treatment: antibiotics, irrigation of wound. Rest. Aspetic technique, & nutrition
Dehiscence: a partial or total rupture (separation) of a sutured wound, usually with separation of underlying skin layer
Treatment: cover with sterile towel, keep pt supine with hips & knees bent, keep npo,
Evisceration: total separation of the tissue layers, allowing the protrusion of visceral organs through the incision.
Treatment: cover with sterile dressing, contact surgical team, keep pt NPO, observe for shock, prepare pt for surgery, call for help. Low fowlers position

117
Q

Explain factors that impede wound healing

A

Vascular disease, diabetes, malnutrition, meds, excessive mositure, external forces, and the aging process

118
Q

Pressure Injury Stage 2

A

partial-thickness loss of skin with exposed dermis
wound bed is pink/red and is moist
appears as an intact or ruptured serum filled blister
Is shallow & superficial with a pink wound bed
no slough, eschar, granulation tissue, or adipose tissue

118
Q

Pressure Injury Stage 1

A

intact skin with a localized area of nonblanchable
erythema

119
Q

Pressure Injury Stage 3

A

full thickness skin loss. Visible adipose with granulation tissue & epibolen(rolled wound edges)
Possible undermining & tunneling
Fascia, muscle, tendon, ligament, cartilage are not exposed!!!

120
Q

Pressure injury stage 4

A

Full thickness skin & tissue loss with exposed fascia, muscle, tendon, ligament, cartilage, and bone.

121
Q

Unstageable pressure injury

A

obscured full thickness skin & tissue loss. Full thickness skin & tissue loss cannot be confirmed b/c it is obscured by slough or eschar
if slough or eschar is removed stage 3 or 4 pressure injury will reveal

122
Q

Deep tissue pressure injury

A

intact/nonintact skin with localized area of persistent nonblanchable deep red, maroon, or purple discoloration. Tissue is boggy
shearing, intense and prolonged pressure
true depth is not apparent, but can progress rapidly which exposes deeper layers of tissue

123
Q

Identify risk factors for the development of pressure injury using the Braden scale

A

sensory perception, moisture, activity, mobility, friction & shear

124
Q

Braden scale

A

lowest score: 6
max: 23
the lower the overall score equals the greater risk the pt has for alts. in skin & tissue integrity

125
Q

Identify nursing interventions to minimize trauma to the skin

A

keep skin clean & dry, reposition every 2hr, supportive surfaces/devices for transfers, dressings, toileting schedules, hydration

126
Q

Describe methods for assessing risk for impairment in the integrity of the skin

A

examine bony prominences for erythema, blanchable or non?
Temp changes: inflammation= hot. Cooler: - blood flow.
Edema?
Check skin folds
Check skin underneath pressure devices
Braden scale
nutritional status
immobility
reduced skin perfusion

127
Q

Discuss nursing roles & responsibilities in med admin

A

Having knowledge of federal, state (nurse practice acts), and local laws, & facilities policies that govern the prescribing, dispensing, & admin of meds
Preparing & administering medications, and evaluate clients responses to medications
Developing & maintaining an up to date knowledge base of medications they administer, including uses, mechanisms of action, routes of admin, safe dosage range, adverse effects, precautions, contraindications, & interactions.
Maintaining knowledge of acceptable practice & skills competency
Determining the access of medication prescriptions
Reporting all medication errors
Safeguarding & storing medication

128
Q

Recognize nursing actions to prevent med errors

A

3 checks
1. mar & order
2. actual med & mar
3. mar & pt id band
Second nurse check with high alert meds

129
Q

compare & contrast the various routes by which medication can be admin

A

Oral: PO, Sublingual: under the tongue, Buccal: between cheek & gum
Enteral: through enteral/gtube
Parenteral: ID (under epidermis), SUB (subcutaneous tissue) , IM (into the muscle) , & IV (into the vein)
Topical: skin/mucous membranes
Instillation: directly onto skin, drops, ointments, & sprays

130
Q

Describe factors to consider when choosing routes of med admin

A

consider absorption, metabolism & excretion. Do you want it to be absorbed metabolized or excreted faster or slower?
IV: fast
Oral: slower

131
Q

Interpret med orders to prevent med errors & ensure pt safety

A

Must contain
PT name
Date.time order written
drug name (generic)
dosage
route of admin
route
freq
indication for use
providers signature

132
Q

Perform dosage calculations needed for med admin

A

practice on ati & hienkes book

133
Q

use clinical decision making when calculating dosages

A

check ati/hienkes book

134
Q

Correctly & safely prepare & admin meds for oral, parenteral routes, topical, inhalation & intraocular routes

A

Oral: place med cup on flat surface before pouring & ensure base of meniscus (lowest fluid line) is at the level of the dose
Parenteral: use needle size & length that is appropriate for the injection.
Topical: wear gloves no bare hand, skin application: soap & water. Open wound: surgical asepsis
Check ati for more

135
Q

Compare & contrast the types of insulin

A

Rapid acting (clear): onset: 5-15 min, peak 1-2hr, duration 2-4hr. ex: humalog
Short acting/regular (clear): onset 30 min, peak 105hr, duration 3-7hr, Ex: Humulin R
Intermediate: (cloudy): onset 1-4hr, peak 4-12 hr, duration 12-24 hr Ex; NPH
Long Acting: duration 24hr, no peak, Ex Lantus DO NOT MIX
clear to cloudy

136
Q

Discuss proper technique for calculating & admin insulin to a pt

A

mix insulin: NPH, Reg, Reg, NPH (air, air, med, med)
Give sub fatty areas, (abdomen & back of arms)
remove air bubbles
clear to cloudy
draw regular insulin first

137
Q

Identify complications of IV therapy & nursing interventions

A

Phlebitis: inflammation of vein. Intervention: discontinue IV, contact provider, warm compress & elevation
Infiltration/Extravasation: meds/fluids move to surrounding tissues. S/S: coolness of skin, edema, pain, burning, Intervention: stop iv & discontinue, skin marker to outline area
Circulatory Overload: infusion of excessive amt of fluids that occurs too quickly. S/S: tachycardia, + bp, increase wt, edema, cough, tachypnea, crackles in lungs. Interventions: stop infusion, semi high fowler position, daily weight, VS, I&O, O2 therapy
Air Embolism: air in vessel. S/S abrupt onset, diff. breathing, cough, wheezing, decrease bp, tachycardia, chest & shoulder pain, Intervention: stop/clamp, call rr, provide o2

138
Q

Describe nursing interventions when recognizing a med error

A

check pt immediately & observe for adverse effects
VS & assessment
incident report

139
Q

Demonstrate techniques used to perform musculoskeletal & neuromuscular assessments

A

ROM, cranial nerves, dtr, tone & strength of muscles/extremities, morse fall scale, symmetry, contour, gait, balance & spine

140
Q

Assess pt mobility status

A

morse fall scale

141
Q

Discuss the physiological & influences on mobility

A

muscle weakness, - rom, high bp, trauma/injury, poor posture, impaired CNS, health status & age
developmental
mental health & physical
life style
fatigue & stress

142
Q

Discuss the pathological influences on mobility

A

Ischemia: reduced blood flow
Hemiparesis: weakness on one side of the body
Paraplegia: lower body paralysis
Quadriplegia: inability to move all 4 extremities

143
Q

Assess body alignment, mobility, & activity tolerance, using appropriate interview & assessment skills

A

check ati

144
Q

Use safe pt handling & movement techniques & equipment when positioning, moving, lifting, & ambulating pt

A

gait belt, wedges, hoyer lift, grab pants to lift pt to standing position, draw sheet, transfer boards, crutches, walker, wheel chair, & cane

145
Q

Identify factors which impact a pt nutritional status

A

Religious/Cultural practices: guides food prep & choices
financial issues:
appetite
negative experiences
environmental factors
disease & illness: can affect funct. ability to prepare & eat food
medications: alters taste & appetite and interferes with the absorption of certain nutrients
age

146
Q

Describe the proper technique for drawing up & admin insulin

A

Wash your hands and don gloves
Roll the rounds and do loverween the palms of the hands to mix the ingredients because if you don’t mix the contents it can alter how much cloudy insulin you are actually drawing up. DON’T SHAKE the vial because this will cause air bubbles!
Clean off tops of vials with alcohol prep for 5 to 10 seconds.
Remove cap from syringe.
Inject_ units of air into the Humulin-N vial & then remove syringe from vial.
Inject_ units of air into the Humulin-R vial & turn bottle upside down (while syringe still inserted into the bottle) and then withdraw _ units of clear insulin… REMOVE SYRINGE.

147
Q

Describe assessments related to nutrtitonal status

A

weight, lab results, number of meals per day, allergies, appetite, meds, & activity level

148
Q

Describe the procedure for initiating & maintaining enteral feedings

A

NG: nose to ear, ear to xiphoid process. Nose to stomach. Short term use.
Nasointestinal tube: nose to ear, ear to xiphoid process, add 8-10 in,
G/J & Peg tube: surgical procedure

149
Q

Discuss interventions to prevent aspiration during feeding

A

high fowler position or in chair. 90 degrees
support upper back, neck, & heaf
tuck chin when swallowing. Look down
avoid straw
check for pocketing in cheeks
keep hob semi fowler elevated for 1 hr after eating.
provide good oral hygiene after
no rushing & reduce distraction

150
Q

Describe how to assist pt with eating in specific circumstances

A

Vision impairment: explain placement of foods on tray/plate using clock pattern

151
Q

Type 1 diabetes

A

pancreas doesnt produce insulin
dependent on insulin
genetic/born with it
cannot be prevented/cured
requires insulin injections for life

152
Q

Type 2

A

developed, insulin resistance
Obesity
can be prevented through lifestyle modifications
the body does nor create enough insulin or develops resistance
manage by: exercise, diet, hydration, glucose monitor

153
Q

Discuss patient centered management of NPO pt

A

restricts pt from eating or drinking until the diet is advanced

154
Q

Signs and Symptoms of Hyperglycemia

A

greater than 100-125mg/dl
dry mouth, increased thirst, blurred vision, weakness, headache, freq. urination

155
Q

S/S hypoglycemia

A

less than 70mg/dl
sleepiness, sweating, pallor, lack of coordination, irritability, hunger,
15 g of carbs,
4oz of soda or juice
1tb od honey
5-6 candies

156
Q

Clear liquid diet

A

liquids that leave little residue. What ever you can see through
broth, gelatin, water,tea, fruit juices, sport drinks

157
Q

Full Liquid

A

clear liquid plus liquid diary products & all juices. Liquid @ room temp
ice cream, juices, tea, soups, geltain, protein shakes, pudding

158
Q

pureed

A

clear & full liquids plus pureed meats, fruits & scrambled eggs
doesnt need to be chewed
soft & smooth
pudding, mashed potatoes, yogurt, juices no pulp, baby food, pureed meats, broths, icecream

158
Q

cardiac diet

A

heart healthy
limit sodium
consume more fruits & veggies, whole grains, limit unhealthy fats, low fat protein, control portion
lean meats, skim milk & fish

159
Q

renal diet

A

limit potassium & sodium

160
Q

Calculate I&O

A

check ati & henke book

161
Q

Discuss principles surrounding abdominal assessment of a pt

A

Inspection: look for distention, contour,symmetry, abnormalities, skin changes & umbilicus (belly button)
Auscultation: listen for hyper/hypoactive bowel sounds. RLQ to RUQ, to LUQ & LLQ
Palpation: press 1 inch down on the abdomen to check for massess, tenderness, any abnormalities starting from RLQ to RUQ, to LUQ & LLQ

162
Q

Describe & perform a physical assessment focused on urinary elimination

A

Palpate/ percuss bladder or use a bedside scanner
Check for infection, discharge or odor
Assess color, texture, turgor & excretion of wastes
Assess urine for color, odor, clarity & sediment
Incontience?
Self Care/ADLs?

163
Q

Normal urine

A

clear, light yellow odorless

164
Q

Discuss anatomical & physiological factors that influence urinary elimination

A

age, food, fluids, anxiety, stress, diabetes, surgical procedures, obstructions (kidney/bladder stones), & medications (direutics).

165
Q

Discuss anatomical & physiological factors that influence bowel elimination

A

age, diet, fluid intake, physical activity, personal habits, pain, pregnancy, surgery & anesthesia, meds, stress, anxiety, obstructions

166
Q

Expected/Unexpected in Urinary elimination

A

Expected: normal patterns/freq, normal color & consistency
Unexpected: cloudy, pinkish/reddish tint, burning during urination, diff. urination, feeling of pressure, & strong odor

167
Q

Expected/Unexpected in Bowel Elimination

A

Blood, diarrhea, constipation, hemmorrhoids, incontinence, impaction, flatulence,

168
Q

Discuss cond. that alter a pt elimination patterns

A

Bowel
Diverticulitis
IBS
ulcerative colitis
chrons disease

169
Q

Urgency

A

immediate & strong desire to void
uti & full bladder

170
Q

dysuria

A

pain or diff. urination
uti, enlarged prostate, lower urinary tract trauma

171
Q

frequency

A

increased incidence of voiding
caffeine, uti, pregnancy, high fluid intake

172
Q

polyuria

A

voiding excess amts or urine (diuresis)
high volumes of fluid intake & uncontrolled diabetes

173
Q

Oliguria

A

small amt of urine
f&E imbalance
kidney dysfunction
urinary tract obstruction

174
Q

nocturia

A

awakened from sleep b/c of urge to void
meds, excess intake of fluids
uti, overactive bladder

175
Q

Hematuria

A

blood in urine
tumors, trauma, & uti

176
Q

retention

A

inability to completely empty the bladder
obstruction, meds, absent or weak bladder contractlity

177
Q

discuss nursing care measures required for pt with a bowel diversion

A

change appliance as needed or prescribed, empty when 1/3-1/2 full, warm water only, keep free of odor, keep skin around site dry, monitor for infection
education

178
Q

Describe nursing interventions to promote normal bowel elimination

A

increase fluids, exercise, diet mod, increase fiber in diet, physical activity,

179
Q

Identify diagnostic tests related to urinary elimination & the nurse’s role in obtaining specimens (urinalysis, c&s)

A

Urinalysis: random, sterile specimen. Eval for disorders, bladder infections or UTI, kidney infection, kidney disease, & diabetes. Visual examination or urine, dipstick testing, & microscopic examination
Urine Culture: eval urine for presence of bacteria & yeast for caus of UTI. BActeria on test strip?

180
Q

Describe nursing interventions for the client with different types of urinary incontience

A

Keep skin dry, toliet schedule, monitor intake, good perineal care, incontient garments
lifestyle modifications: improving diet & excercising, reducing caffeine/alcohol intake, avoiding meds that cause incontinence. Quit smoking. Pelvic floor excersises, bladder retaining, meds, cathether last resort, & surgery

181
Q

Stress incontinence

A

loss of urine after increased abdominal pressure
Cough/sneeze/laughing
Females: childbirth & menopause
males: alts in urethra following prostatectomy

182
Q

Urge incontinence

A

Overactive detrusor muscle & increased bladder pressure = inability to hold urine long enough to make it to the bathroom
bladder irritation from uti, or overactive bladder

183
Q

Overflow

A

Results from urinary retention/ bladder overdistention- frequent loss of small amounts of urine; usually results from neurologic dysfunction or enlarged prostate

184
Q

Reflex

A

Involuntary loss of moderate amount of urine; hyperreflexia of detrusor muscle from spinal cord dysfunction, or impairment of CNS (MS, CVA, cord lesion)

185
Q

Functional

A

Loss of continence due to outside factors (cognitive, environmental, mobility)

186
Q

Transient

A

Temporary, reversible incontinence (UTI, medications, temporary cognitive impairment, disease processes (hyperglycemia)

187
Q

Identify how the nurse assess for urinary retention

A

have the pt void no more than 10 min before assessment, bladder scanner, 30ml every hr

188
Q

Perform an assessment of the resp cardiac systems

A

Respiratory: Listen to lung sounds., measure rr, assess rate, rhythm & depth
Cardiac: listen to heart sounds (aortic, pulmonic, erbs point, tricuspid, mitral), assess hr, rhythm, cap refill, check peripheral pulses & check for edema

188
Q

Insert & maintain urinary cath

A

check ati

188
Q

Dyspnea

A

shortness of breath, diff/labored breathing
causes: exercise, sedentary lifestyle, & med cond.

189
Q

Examine assessment findings related to cardiopulmonary functioning

A

breathing pattern, pulses (peripheral & aortic), breath sounds & heart sounds, edema, cap refill, skin turgor, & skin color

190
Q

Hypoxia

A

below the expect level of oxygen in body tissue
decrease amt of oxygen in blood

191
Q

Crackles

A

caused by fluid filling the air sacs, sound like popping & crackling
Pneumonia & infection

192
Q

Wheezes

A

high pitched noise creating a whistling sound due to air going through narrowed airways
whistling or musical note

193
Q

Rhonchi

A

rattling & is caused by obstruction of airway
asthma & copd

194
Q

Stridor

A

sounds like wheezing, caused by constriction in the upper airways.
med emergency

195
Q

Pleural friction rub

A

low pitched, coarse, grating tone like rubbing 2 pieces of leather together, caused b inflammation of pleura

196
Q

Assess for risk factors affecting a clients oxygenation

A

smoking
environmental hazards (dust & fumes)
diet
exercise
stress
age
genetics
pregnancy, obesity, nm disease, trauma, musculoskeletal abnormalities, cns

197
Q

Identify methods to prevent atelectasis

A

Incentive spirometer (deep breathing)
Flutter valve: clears mucous and makes breathing more comfortable
coughing & deep breathing
mobility

198
Q

Assess for the physical manifestations that occur with alt in oxygenation

A

Hyperventilation: weakness, dizziness, headache, anxiety, increased hr, diff. breathing, numbness & tingling in fingers
Hypoventilation: anxiety, dyspnea with exertion, confused, disturbed sleep pattern, weakness, & impaired cough
Hypoxia: tachypnea, tachycardia, restlessness, anxiety, smoking, clubbing, pale skin/mucous membranes, elevated bp, accessory muscles, nasal flaring, advenitious lung sounds, stupor, cyanotic skin & mucous membranes, bradypnea, bradycardia, hypotension, cardia dysrhythmias

199
Q

Describe nursing intervention used to promote oxygenation in the primary care, acute care, & restorative & continuing care settings

A

Elevated HOB, o2 therapy, IS, deep breathing, forced coughing, pursed lip breathing, meds, monitor o2 abgs, sputum collection, sputum collection, chest physiotherapy, & suctioning

200
Q

Describe the processes involved in regulating fluid & electrolyte balance in the body

A

Electrolytes: balance the amt of water in the body, balance body ph,move nutrients into cells & move waste out of cells.Maintain funct. of muscles, heart, nerves & brain
Promotes homeostatsis

201
Q

Identify risks factors for fluid & electrolyte imbalances

A

dehydration
hypovolemia
over hydration
certain meds
heart/kidney/liver disorders
incorrect IV fluids/feedings
profuse sweating
vomiting & diarrhea

202
Q

Discuss management & nursing interventions for fluid volume overload

A

manage the cause, diuretics, limit fluid & sodium intake, daily weights, & fluid removal
interventions: obtain diet history, educate on fluid, sodium & pot. intake, diuretic info, monitor weight daily, monitor for jvd, hyper tension, bounding pulse, dyspena, abnormal lung sounds, Monitor I&Os

203
Q

S/S of dehydration & nursing interventions

A

altered cognitive & nm funct. thirst, lethargy, dry mucosa, oliguira, tachycardia, hypotension, coma, seizures,
Interventions: restoration of fluid balance, oral hydration & iv fluids, monitor I&O

204
Q

S/S of hypovolemia & nursing interventions

A

thirst, dryness of mucous membranes, fatigue, increase in hr, syncope, weakness, ortho hypo, tachycardia, oliguria,
Interventions: control fluid/blood loss, replace lost, restore circulation in body. oral hydration & IV fluids, monitor I&Os

205
Q

apply the nursing process to caring for patients with fluid & electrolyte imbalance sodium, calcium, magnesium, and potassium

A

check ati/ slideshow & notes

206
Q

Discuss the purpose & procedure for initiation & maintenance of iv therapy

A

replace fluids that have been lost, hydration or medications that cannot be taken by mouth

207
Q

calculate input & output

A

intake: anything that goes in (ice chips are cut in half)
Output: anything that comes out (urine, vomit, & wound drainage

207
Q

calculate flow rate

A

check ati

208
Q

Assess the client experiencing pain

A

pain scale
FACEs:
Numeric scale
cries
flacc
Nonverbal scale visual analog
assess quality, quantity, when it started, what makes it better/worst, how long its been there

209
Q

Explain factors which influence the pt’s experience with pain

A

Age
Fatigue
Genetic sensitivity
cognitive funct
prior experience
anxiety & fear
support systems & coping styles
culture

210
Q

Describe applications for use of nonpharmacological pain interventions

A

Distraction
Massage
cold/hot therapy
acupuncture
tens unit
aroma therapy
deep breathing
pet & music therapy

211
Q

Identify nursing implications when treating clients with pain

A

pain is what the patient says. Treat all pt pain. Whatever they say it is, it is what it is. provide med as ordered

212
Q

Eval. a pt response to pain interventions

A

reevaulate pt pain level after receiving meds or nonpharmacological therapies

213
Q

Identify alt. in sleep patterns

A

Insomnia: inability to sleep
Narcolepsy: sudden attacks of uncontrollable sleep
Hypersomnia: excessive daytime sleepiness lasting at least 3 months
Nocturia: waking up to urinate
Environment: too hot.cold, sounds & lights

214
Q

Discuss S/S of obstructive sleep apnea & nursing considerations

A

snoring, periods of apnea when sleeping, morning headaches, easily irritable, depression, diff remembering things
Avoid caffeine, no exercise before bedtime, cpap, & sleep study

215
Q

Assess a pt sensory status

A

assess eyes, ears, neuro (cranial nerves)

216
Q

Sensory deficit

A

deficit in the normal funct. of sensory reception & perception

217
Q

Sensory deprivation

A

inadequate quality or quantity of stimulation.
ex: blindness

218
Q

Sensory overload

A

reception of multiple sensory stimuli
caus pt to feel anxious, restless, & confused

219
Q

Identify factors & cond, which interfere with the pt ability to process sensory input & perception

A

injury, illness, infection, head injury/trauma, cavities, meds, aging, nasal sinus disorders, & smoking

220
Q

Describe nursing interventions for facilitating and/or maintaining a pt sensory perception

A

SAFETY, orient to room, call light, keep personal items within reach, learn preferred method of communication, keep objects in same position, tablets, rom, sensory stimulation

221
Q

Cataracts

A

cloudy area on the eye lens (visible opacity) caused by proteins in the eye breaking down & clumping together
interventions: routine eye exams, sunglasses, mangifying glasses, & large print

222
Q

Diabetic retinopathy

A

leakage & blockage of the retinal blood vessels, which can lead to retinal hypoxia, retinal hemorrhages, & blindness. Blurred vision, seeing spots & floaters
irreversible
- Control & monitor glucose level
- low sodium diet

223
Q

Glaucoma

A

increase in intraocular pressure, primary more common,
outflow of fluid is decreased due to progressive blockages in drainage system.
progressive & painless
monitor eye pressure, med admin education

224
Q

Macular degeneration

A

Wet: leaky overgrown vessels, any age
Dry: most common, macula becomes ischemia & necrotic from blockage of cap flow in retina
assist with adl, driving & eating

225
Q

Hearing loss

A

conductive: structual issue, cerumen, foreign body
Sensorineural loss: damage to cranial nerve VIII
assessing for hearing loss, inflamed tympanic membrane, tinnitus, dizzy, issues with balance
Interventions—safety – falls

226
Q

Describe common physiological changes of aging

A

skin elasticity decreases, decrease in skin turgor, loss of sub fat which makes it diff. to adjust to cold temp, thinning & graying of hair, thickening of finger&toenail. Decrease ability of eyes to adjust to light & dark (night blindness). Decreased visual acuity, decrease senses to touch, smell, & taste sensation. decrease ability to hear high pitched sounds, constipation, slow reaction time, decrease salvia production, healing decreases, reduce in CO, high bp, risk for infection, bowel & urinary incontinence, decreased chest wall movement, decrease in peripheral pulses

227
Q

Delirium

A

state of temporary but acute mental confusion
causes
surgery, drug & drug interactions, infection, hypoglycemia, fever, pain, emotional stress, chf, pneumonia

228
Q

Dementia

A

Chronic & gradual onset
progressive loss of intellectual functioning impairment of memory, & abstract thinking, personality changes
chronic, progressive cognitive disorder (Alzheimer’s, vascular dementia); sudden onset possible after stroke; characterized by memory loss, disorientation, and/ or impaired reasoning, language, judgment; may involve personality changes & behavioral problems (delusions, hallucinations) and affect ability to interact with others, work, perform ADLs

229
Q

Describe the clinical manifestations, diagnostic studies, & collaborative management of Alzheimers disease

A

Chronic, progressive, neurodegenerative disease of the brain
Early signs:
Memory loss, forgetfulness
Difficulting completing familiar tasks
Disorientation to time and place
Misplacing belongings
Changes in mood or behavior
Personality changes; social withdrawal
Progression:
Mild
Forgetfulness
Depression
Moderate
Confusion, memory gaps
Self-care gaps
Wandering, behavioral problems
Severe
Unable to identify familiar objects
Cannot perform ADLs
Difficulty eating, immobility

230
Q

Describe nursing assessment & nursing interventions for caring with Alzheimers disease

A

Assess: safety, orientation, adls, bowel/bladder, & head to toe
Interventions
Reassure pt, speak slowly, face-face contact, allow pt to keep control, and keep a routine

231
Q

Discuss issues related to psychosocial changes of aging

A

Depression, suicide, adjusting to lifestyle changes, mulitple losses (spouse), body image changes, social development

232
Q

Describe common health concerns of older adults

A

Pneumonia, shingles, skin breakdown, diabetes, CAD, heart failure, stroke, decreased perfusion to tissues, Malnutrition, arthritis, osteoporosis, falls, cataracts, chronic pain, glaucoma, dry eye

233
Q

Identify nursing interventions related to the physiological, cognitive, & psychosocial changes of aging

A

assist with
ambulation
reorientation
consuling family members
health screenings
nutritional education
therapeutic communication
assist with adl & self care
safety precaution
med management

234
Q

Health Promotion

A

the process of enabling people to increase control over & improve their health

235
Q

Wellness

A

positive state of health
actions taken by individuals to achieve their fullest potential for complete holistic health

236
Q

Disease prevention

A

encompasses measures taken to limit exposure or effects of illness or disease.
ex: hand hygiene & immunizations

237
Q

Primary prevention

A

risk reduction
decrease risk for developing medical cond. by changing behaviors or minimizing exposure
ex: vaccines, smoking cessation, & seatbelt education

238
Q

Secondary

A

early screening to detect a disease process b/f it progresses to cause symptoms or complications to a pt
screening tests
bp for hypertension
blood wrong
pap test

239
Q

Tertiary

A

control of chronic effects of disease that has occurred
Ex:
self care for diabetics, cardiac rehab, support groups

240
Q

Diversity

A

broad range of individual, population, social charactersitc, age, ethnicity, gender identity, geographic location, language, religious belief, socioeconmic status

241
Q

cultural awareness

A

being able & willing to investigate & understand differences between perceptions

241
Q

Cultural competence

A

appreciating, accepting & respecting all individuals cultural influences, beliefs, customs & values
being able to incorporate effective nursing care with emic & etic knowledge

242
Q

Describe cultural influences on health & illness

A

view of medication & remedies, language barriers, cultural bias, end of life practices & decisions on procedures based on cultural practice

243
Q

Explain the role of the nurse when providing care to clients from diverse populations

A

cultural health assessments
medical interpreter
learn their culture
respect their wishes

244
Q

Discuss the influence of spirituality on pt health practices

A

decisions on procedures based on spirituality, end of life practices, & forms of comfort

245
Q

Complementary therapy

A

combination of complementary therapy & conventional therapy. Focuses on optimal health of the whole person
enhances medical care

246
Q

Alternative therapy

A

treatment approaches that become the primary treatment replaces allopathic care. use instead of complementary therapy

247
Q

Integrative medicine

A

an approach to health using conventional, complementary, & alt medicine approaches

248
Q

Discuss nonpharmacologic therapies (mind-body) & how these can be used in nursing practice

A

distractions
acupuncture
aromatherapy
imagery
music therapy
relaxation, theraputic touch, pet therapy, hypnosis, biofeedback, mind body technique: indivduals learn how to modify their physiology for the purpose of improving physical, mental, emotional, & spirtual health, reflexology

249
Q

Aloe

A

wound healing
but can reduce efficacy of some oral meds

250
Q

Echinacea

A

enhances immunity

250
Q

chamomile

A

antinflammatory & calming
can trigger allergic reactions
negative interactions with cyclosporine & warfarin

251
Q

Garlic

A

inhibits platelet aggregation

252
Q

Ginger

A

antiemetic

253
Q

Ginkgo biloba

A

improves memory
interfers with anticoag

253
Q

Ginseng

A

improves physical endurance
anticoag?

254
Q

Valerian

A

promotes sleep & reduces anxiety
dont use with alcohol or sedatives due to increase in drowsiness

255
Q

Describe the physiological & psychological response to natural products

A

benefical effect on physical & psychological being

256
Q

Describe safe & unsafe herbal therapies

A

ginkgo biloba cannot be used with blood thinners
natural does not equal safe
check for USP
herbal medicines are not regulated by fda
some can interact with prescription & otc meds

257
Q

Palliative care

A

comfort care with/without intent to cure
improve quality of life for pt

258
Q

Hospice care

A

comfort care without curative treatment or intent, pt has no other treatment options. Side effects of treatment outweighs the benefits

259
Q

Discuss the physiological alt. of a client at the end of life & nursing interventions

A

Dyspnea
Death rattle: secretion build up in throat
cheyne stokes breathing: rapid, slow with periods of apena that gets longer
still feel pain, temp decreases
vision
hearing is the last to go
Nursing interventions
Turning the clients head to the side or rolling the client to the side can assist with drainage of the secretions from the throat & lungs
using a fan
warm blanket

260
Q

Discuss end of life goals for the pt & family

A

we want the pt to die in dignity & comfort

261
Q

Discuss grief & stages of kubler ross

A

the feelings or reactions an individual has to a loss in ones loss.

262
Q

Denial

A

pt refuses to believe reality
Avoidance, Confusion, Elation, Shock, & Fear
The mind is trying to adjust to a loss of someone or something and wonders how life will continue in this altered state.
terminal diagnosis

263
Q

Anger

A

in which the client is trying to adjust to the loss and is feeling severe emotional distress. The client thinks, “Why me?” and “It’s not fair.”
divorce
- Frustration, Irritation, and Anxiety

264
Q

Bargaining

A

as the client tries a different approach in an attempt to relieve or minimize the pain felt from the loss.
Struggling to find meaning, Reaching out to others, & Telling ones story
I promise to do this

265
Q

Depression

A

the stage where reality sets in, and the loss of the loved one or thing is deeply felt.
overwhelmed, hosility, fight,helplessness,

266
Q

acceptance

A

It is the point at which the person still feels the pain of the loss but realizes that all will eventually be well.
exploring
moving on
new plan in place

267
Q

Describe characteristics & response of a pt experiencing grief & lost

A

shock
anger
anxiety
with draw
numbness
denial
guild
sadness
relief
depression

268
Q

explore factors that influence an individuals response to grief & lost

A

situations
disenfranchised grief

269
Q

Nursing interventions for post mortem care

A

washing of body, account for positions, remove invasive devices, give pt family time, id tags in 2 areas toe arm & outside body bag

270
Q

Identify the role of the nurse in relation to pt education

A

truthful
knowledgable about education you are providing within your scope of practice

271
Q

Explore domains of learning & basic principles of learning

A

Cognitive: thinking domain, thinking through info & being able to comprehend it
Affective: the feeling domain involves the pt feelings regarding values, attitudes, & beliefs
Psychomotor: doing domain, the physical or mental activity required to learn skills
Principles
Motivation: the pt ability to engage in the learning process by deciding when, where, & how they will learn
Relevance: pt understanding of why they should be learning the info being provided to them

272
Q
A

nursing fundmentals (2 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions