Fundamentals Final Exam Flashcards
after surgery, what do you do for a pt who has constipation?
get them moving (walking up and down the hall), fiber, water
how do you decrease lifestyle stress?
exercise, healthy diet, prayer, rest
Who is most at risk for fluid volume deficit?
6mo learning to drink from sippy cup
12yo moderately active in 80 degree weather
43yo with severe diarrhea
90yo with headaches
43 yo with severe diarrhea
what do you check stool for?
color, odor, consistency
what’s the best way to determine fluid status?
daily weights (same time, same clothes, same scale, after voiding, before breakfast)
what are some myths about older adults?
they have to be in ECFs, they smell, they have grey hair, they’re confused
range of motion exercises
flexion, extension, rotation, abduction, adduction, supination, pronation, inversion, eversion
what do you do for pain during ROM exercises?
give pain meds 30 minutes beforehand; only extend to the point of discomfort
in a nursing dx, what are the “defining characteristics”?
signs and symptoms (AEB)
when talking to a patient, what is clarifying?
restating what they say to show that you understand
how do you chart hearing clear breath sounds?
no adventitious sounds
what’s the difference between a nursing diagnosis and a medical diagnosis?
medical diagnoses deal with the physiologic or medical condition; nursing diagnoses deal with the response to alteration in health (signs and symptoms)
where is the apical pulse taken?
fifth intercostal space on the left
fahrenheit to celsius conversion?
F = 9/5C + 32 C = 5/9(F-32)
what’s the difference between subjective and objective data?
subjective - what the pt tells you (symptom)
objective - data (sign)
what’s the difference between closed and open ended questions?
closed ended questions have a definite answer
open ended questions require a longer explanation
which pulse cannot accurately be taken on both sides of the body at the same time?
carotid
which is an independent nursing action? administering meds ordering a CT scan providing teaching sending the pt to PT
providing teaching
what’s one advantage to using a nursing dx?
it’s universal
what’s the important diagnosis acronym and what does it stand for?
NANDA - north american nursing diagnosis association
pt with serious vitamin c deficiency would have: muscle weakness bleeding gums night blindness confusion
bleeding gums
what is the soft palate?
the fleshy, flexible part toward the back of the roof of the mouth; responsible for closing off the nasal passageway during swallowing and for closing off the airway
what do you do before repositioning a pt with a urinary cath, IV, and O2 via nasal cannula?
make sure all the tubes are connected, stable, and correctly positioned
what do you do for a pt who has difficulty swallowing aspirin?
crush it (first option) or see if they have a different format
what are some barriers to effective communication?
being defensive, giving your opinion, making assumptions
what’s the best way to control transmission of organisms?
hand hygiene
what’s the difference between empathy and sympathy?
empathy - relating to your pt because you have been in a similar situation
sympathy - comforting your pt and/or their familiy
maslow’s hierarchy of needs
1) physiological needs
2) safety
3) love and belonging
4) self-esteem
5) self-actualization
what’s the most therapeutic response to a pt who wants you to pray with him?
“how would you like us to pray?”
what’s the best way to obtain a clean catch midstream urine specimen (CCMS)?
wipe first with towelette, start stream of urine, obtain specimen, finish urinating
what’s the primary purpose of TED hose?
to prevent deep vein thrombosis (DVT)
what’s the primary reason you don’t want pts to strain during BMs?
arrhythmias
what’s the trend with the color of blood in stool?
the higher up the bleeding, the darker the blood in the stool
what do you do if you have a pt that reports feeling dizzy after getting out of bed?
1) help him sit down
2) take vitals
how do you transfer pt from bed to chair using a gait belt?
have your feet planted flat on the floor with the pt facing you (and don’t forget - the gait belt goes on the pt, not you!)
how do you administer eyedrops?
head tilted back, have them look up, drop it in the lower conjunctival sac, do not let the dropper touch the eye
what do we use instead of “cc”?
mL
rules regarding pt restraints
physician’s order every 24 hours, take restraints off every 1-2 hours, check skin, observe the pt more often
what does inversion of the foot look like?
ankle is turned so the sole of the foot moves medially toward the footline
which fluid loss is most difficult to measure?
insensible (lungs, skin)
documentation - know what you should and shouldn’t chart
- bilateral breath sounds clear (yes)
- needle tracks on right arm (no because it’s an assumption that they’re needle tracks)
- “i’m happy i’m going home” -pt (yes)
- transfer pt from bed to chair with one assist (yes)
which vitamin is associated with weak bones? how do you supplement a deficiency?
vitamin D - sunlight and milk/dairy products
what do you do to determine level of anxiety for a pt who seems nervous and has had no visitors?
ask if something is bothering him
what can poor people eat that is high in protein?
beans and peas
what is anorexia nervosa?
self-imposed starvation
if you have a worried pt with a high degree of emotional stress and loss of income, what should you assess?
suicide risk
difference between ileostomy and colostomy?
ileostomy is higher up because of the location of the ileum
when you deal with scientific principles, what is your main focus?
rationale
when you talk about bathing a pt, when would you give a full bath as opposed to a partial bath?
it depends on the pt ability (mobility related to surgery, strength, etc.)
your pt is unable to expand lungs completely - what type of breath sounds will you hear?
diminished breath sounds
what do you do to promote respiratory function in an immobilized pt?
have the pt cough, incentive spirometry, deep breathing
which part of the nursing process is taking vitals part of?
assessment
what is the primary reason for pressure ulcers?
immobility/not repositioning pt
is the nursing process dynamic or static?
dynamic (changing)
what do you do during the evaluation step of the nursing process?
see if pt met goals; if not, determine why and revise the goals
kubler-ross stages of death and dying
denial anger bargaining depression acceptance (DABDA)
how would you respond to a pt in stages of death and dying?
ask open ended questions and reaffirm them
what food is a complete protein?
EGGS!!!
what do you give a confused and disoriented pt to eat?
chicken soup
when cleaning pt’s eyes, what do you do?
turn the pt on the same side as you’re going to clean
clear liquid diet
broth, coffee, tea, carbonated beverages, popsicles
full liquid diet
same as clear liquid with addition of smooth-textured dairy products (ice cream, custards, pureed vegetables, pudding)
pureed diet
same as liquid diet, with addition of scrambled eggs, pureed meats/veggies/fruits, mashed potatoes
mechanical soft diet
ground or finely diced meats, cottage cheese, rice, pancakes, cooked veggies, bananas, peanut butter
soft/low residue diet
pastas, casseroles, tender meats, desserts without nuts or coconut
hard palate
bony front part of the roof of the mouth; important for feeding and speech
what type of chicken would you offer to a pt with dementia?
chicken fingers (finger foods)
steps of pt eye care
see page 799 for process
what are appropriate foods/fluids for a pt with diarrhea?
bananas, rice, applesauce, and toast (BRAT diet)
before you take care of people from other cultures, what should you do?
understand your own culture
the same goes for spirituality
what’s the primary function of the large intestine?
absorption of fluids
when you observe a pt for signs of distress, what are you doing?
inspecting
stress
physiological or psychological tension that threatens homeostasis or a person’s psychological equilibrium
hemiparesis
weakness on one side of the body
vagal response
fainting
insensible water loss
water loss that is continuous and not perceived by the person
inference
a conclusion reached on the basis of evidence and reasoning
name the part of a nursing diagnosis
PES:
problem (diagnostic label)
etiology (related to)
signs and symptoms (defining characteristics/AEB)
