Foundations (Hygiene, Positioning, Safety, Sleep, Rest)

Question 1

Bathing, grooming, dressing, eating, toileting, and “being mobile” are referred to as

Answer 1

ADLs-Activity of Daily Living

Question 2

are wipes used for patients with central lines and patients who are immune compromised.

Answer 2

Chlorhexidine(CHG) bath

Question 3

Baths promote cleanliness, decrease infections, allow the nurse the assess the skin thoroughly, and, most importantly, they

Answer 3

promote circulation

Question 4

The dirtiest area on the patient is the

Answer 4

Perineum

Question 5

should always be worn for men and women perineal care

Answer 5

Gloves

Question 6

Vaginal areas should always be washed ____________ toward the rectum to prevent fecal contamination from being carried toward the vagina

Answer 6

“front to back”

Question 7

Patients with diabetes have poor ____________, therefore, impaired wound healing. They can become infected or even gangrenous. Their skin also burns easily, and they don’t heal well.

Answer 7

peripheral circulation

Question 8

Clean and moisturize the feet but avoid

Answer 8

the areas of the toes(want to keep the areas between the toes dry)

Question 9

Do NOT use ____________ as they have a drying effect on the oral mucosa, and they can change the pH in the mouth

Answer 9

lemon glycerin mouth swabs

Question 10

When using a bed pan you want to do this to help with elimination

Answer 10

elevate the head of the bed

Question 11

a state of decreased or absent use of an organ or body part

Answer 11

Disuse

Question 12

the inability to move the whole body or a body part

Answer 12

Immobility

Question 13

decrease in size of a tissue or organ due to inactivity

Answer 13

Atrophy

Question 14

abnormal shortening of a muscle that causes resistance to stretching and eventually, if not management, a state of permanent flexion

Answer 14

Contractures

Question 15

Lesion caused by unrelieved pressure that damages underlying tissue because of diminished perfusion

Answer 15

pressure injury

Question 16

The pressure exerted against the skin in a direction parallel to thebody surface

Answer 16

shear

Question 17

A general term for damage to the epidermis

Answer 17

Excoriation

Question 18

Softening of the skin due to prolonged contact with water (think of the “wrinkles” on your fingertips after being in water for a long time

Answer 18

Maceration

Question 19

Straining against a closed glottis (bearing down like having a bowel movement)

Answer 19

Valsalva’s Maneuver

Question 20

increases whenthe patient is on bedrest (related to the effects of the heart having to push bloodagainst gravity) even though demand of body cells for oxygen is decreased.

Answer 20

Paradoxically, cardiovascular workload

Question 21

Defined as a drop in SBP (systolic) of 20 mmHg or more, or a drop in DBP (diastolic) of 10 mmHg or more, along with symptoms such as dizziness or lightheadedness within 3 minutes of the patient going from a supine to a standing position

Answer 21

Orthostatic Intolerance (also called Orthostatic Hypotension)

Question 22

Triangular-shaped bar on a chain that is attached to a bar over the bed. Allows a patient whose arms are strong enough to lift him/herself off the bed surface for bedpan placement

Answer 22

Trapeze

Question 23

Prolonged plantar flexion causes damage to the peroneal nerve and can cause permanent plantar flexion known as

Answer 23

Footdrop

Question 24

Prolonged ___________ causes damage to the peroneal nerve and can cause permanent plantar flexion known as footdrop

Answer 24

plantar flexion

Question 25

Prevents external rotation of the hip (which can become a permanent disability) by keeping the hip adducted. A rolled upback blanket or sandbag is used-extended from the lateral aspect of the hip to the popliteal space.

Answer 25

Trochanter roll

Question 26

High-Fowler’s: HOB

Answer 26

60–90-degree elevation

Question 27

Semi-Fowler’s: HOB

Answer 27

45–60-degree elevation

Question 28

Low-Fowler’s:

Answer 28

30-degree elevation

Question 29

Whole bed “slant” with the feet higher than the head

Answer 29

Trendelenburg

Question 30

Whole bed “slant with head higher than the feet

Answer 30

Reverse Trendelenburg

Question 31

Flat on the back (also called dorsal recumbent)

Answer 31

Supine

Question 32

Chest down, flat. Face can be down or turned to the side

Answer 32

Prone

Question 33

Weight on hip and shoulder

Answer 33

Side Lying

Question 34

Side lying but further toward prone (not completely on chest) with one leg over the other.

Answer 34

Sims

Question 35

Less restrictive than wrist restraints

Answer 35

Vest-type (Posey)

Question 36

All 4 limbs are restrained

Answer 36

4-point restraints

Question 37

excessive sleepines.

Answer 37

Hypersomnolence

Question 38

related to difficulty falling asleep, staying asleep-experiencing frequent awaking from sleep, only able to sleep in short periods, or even sleep that leaves you feeling like you need more sleep

Answer 38

Insomnia

Question 39

results from a lack of airflow through nose and mouth for periods of 10 seconds or longer while the individual is sleeping

Answer 39

Sleep apnea

Question 40

the mechanism of sleeping and waking is not functioning correctly. Most sufferers report excessive daytime sleepiness. Patients with this disorder fall asleep without being able to control it and not necessarily at appropriate sleep times

Answer 40

Narcolepsy