Final Exam Flashcards by Jillian Bumgarner

Informed Consent

An agreement by a client to accept a course of treatment or a procedure after being provided complete information.

-Expressed (Oral/Written)
-Implied (Non-verbal)

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5 Rights of Delegation

-Right task
-Right circumstances
-Right person
-Right direction & communication
-Right supervision & evaluation

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LPN

Basic / predictable situation

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Complex / not predictable situations

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Negligence

misconduct or practice that is below the standard expected of ordinary, reasonable, and prudent person

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Malpractice

professional negligence

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Assault

to threaten someone

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Battery

touching of another person without the person’s consent

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False Imprisonment

clients are made to believe they cannot leave a place

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Defamation

information is communicated to a 3rd party that causes damage to someone else’s reputation

libel-writing
slander-verbally

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Autonomy

right to make one’s own decision

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Nonmaleficence

do no harm

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Beneficence

doing good

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Justice

Fairness

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Fidelity

to be faithful to agreements/promises

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Veracity

truth-telling

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Client Advocate

acts to protect the client

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5 Steps to Nursing Process

Assessment
Nursing Diagnosis
Planning
Interventions
Evaluation

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Nursing Diagnosis

the diagnosis and treatment of human responses to actual and potential health problems

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Maslow’s Hierarchy of Needs
BOTTOM TO TOP

Physiological needs
Safety
Love
Self-esteem
Self-actualization

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Which of these is an example of a primary source of data?

a) the client
b) the client’s family
c) the client’s record
d) the client’s physician

a) the client

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Assessing includes which of the following activities?

a) Talking, writing, organizing, evaluating
b) Communicating, writing, listening, organizing
c) Collecting, organizing, validating, documenting
d) Communicating, listening, collecting, documenting

c) Collecting, organizing, validating, documenting

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What is a key characteristic of nursing diagnosis?

a) they refer to conditions that nurses are educated and licensed to treat
b) they are judgements made prior to data collection
c) they include a few independent nursing functions that must be ordered by the physician
d) they must be agreed upon by the physician and client

a) they refer to conditions that nurses are educated and licensed to treat

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Which of the following is a complete nursing diagnosis statement?

a) ineffective individual coping as evidenced by alcoholism
b) ineffective individual coping related to loss of job as evidence by increased daily use of alcohol
c) ineffective individual coping as evidenced by increased daily use of alcohol
d) ineffective individual coping related to increased use of alcohol

b) ineffective individual coping related to loss of job as evidence by increased daily use of alcohol

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Which of the following is a description of a useful goal or desired outcome? a) they begin with "the client will..." and are measurable & realistic b) they begin with "the nurse will..." and are realistic, measurable, and considered important by the client c) they begin with "the nurse will..." and are measurable and realistic d) they begin with "the client will..." and include the medical diagnosis

b) they begin with "the nurse will..." and are realistic, measurable, and considered important by the client

Which of the following is a purpose of the desired outcomes or goals? a) it provides direction for discharge planning b) it provides direction for planning nursing interventions c) it delineates the roles of the client and the nurse d) it itemizes what needs to be done

b) it provides direction for planning nursing interventions

Which of the following examples best demonstrates the need for reassessing a client before implementing a planned intervention? a) just before doing relaxation exercises, the client complains of tenseness b) just before ambulating a client for the first time, the nurse checked the blood pressure and the reading is very low for the client c) the client's incision is inflamed and the nurse is ready to change the dressing d) the client complains of agitation while the nurse is offering an anti-anxiety medication

b) just before ambulating a client for the first time, the nurse checked the blood pressure and the reading is very low for the client

Colonization

multiplication of micro-organisms does not result in cellular damage

Infection

an invasion & multiplication of micro-organisms in body tissue that results in cellular injury

4 Major types of Micro-organisms

-Bacteria -Viruses -Fungi -Parasites

Stages of Infectious Process

1. Incubation 2. Prodromal 3. Illness 4. Convalescence

Most common sites of Nosocomial Infections

-urinary tract -surgical sites -bloodstream -respiratory tract

Clostridium Difficile

a spore-producing bacillius infects the GI tract transfered-indirectly

Chain of Infection

-Infectious Agent -Reservoir or source -Portal of exit -Mode of Transmission -Portal of Entry -Susceptible Host

Modes of Transmission

-Contract -Droplet -Airborne -Vehicle -Vector

Non-Specific Immune Defense

-Skin/Normal flora -Mucous membranes -Sneeze -Cough -Tears -Elimination -Inflammation

Stages of the Inflammatory Response

1st Stage- vascular & cellular response 2nd Stage- exudate(pus) production 3rd Stage- Reparative

Specific Immune Defense

Antibody- B cells Cell- T cells

Humoral Immunity

Active Immunity -infection -vaccination Passive Immunity -Nursing mother -Artificial antibodies

HIV Human Immunodeficiency Virus

cell-mediated immunity is lost

Neutrophils

WBC Bacteria

Lymphocytes

WBC Viral

Medical Asepsis

practice that reduces the number & spread of micro-org. (clean technique)

Surgical Asepsis

practices that eliminate all micro-org. & spores from an area (surgical asepsis)

Antiseptics

agents inhibit the growth of some micro-org.

Disinfectants

agents that destroy pathogens other than spores

Sterilization

destroys all micro-org. & spores

An example of a specific body defense against infection is

Vaccinations

Describe the different cleanliness of wounds

Clean wounds Clean contaminated wounds Contaminated wounds Dirty & infected wounds

Incision

straight cut

Contusion

bruise

Abrasion

scrap

Laceration

jagged edge

Avulsion

skin tears

Puncture

sharp object punches

Penetrating wounds

gun shots/stabbing wound

Thickness of wounds

Partial thickness (dermis & epidermis) Full thickness ( dermis, epidermis, SQ, muscle, bone)

Burns degrees

1-4 4 being the worst

Ischemia

lack of blood supply

Thickness of wounds

Partial thickness (dermis & epidermis) Full thickness ( dermis, epidermis, SQ, muscle, bone)

Maceration

Tissue

Excoriation

loss of superficial layer of skin

Pressure Ulcer Stages

Stage 1- Redness Stage 2- Abrasion Stage 3- Fat Layer Stage 4- Muscle & Bone Suspected Deep Tissue Injury- Purple/maroon Unstageable-Slough/Eschar