NLCEX FUNDAMENTALS Flashcards
Amish society
- funerals are conducted in the home without a eulogy, flower decorations. Caskets are plain and simple, without adornment.
- At death, a woman is usually Buried in her bridal dress
- risk of certain genetic disorders due to intermarriage = sexual abuse is common
- remain separate from other communities, physically and socially.
- Woman are unequal in terms of authority
- highly value responsibility, generosity, and helping others
- use traditional healthcare and alternative healthcare, such as healers, herbs, and massage
- May not choose to have health insurance
Documentation guidelines
- Factual documentation it contains descriptive, objective information about what the nurse sees,hears, feels,or smells.
- Vague terms such as “seems” or ”appears” is not acceptable because these were suggesting those is stating an opinion
The legal implications associated with living wills
- Living wills are required to be in writing and signed by the client
- The client signature either must be witnessed by specified individuals or notarized.
- Many states prohibit any employee from being a witness including the nose in a facility in which the client is receiving care.
Nursing responsibilities related to an incident report
- The incident report is confidential and privileged information, and it should not be copied, Placed in the chart, or have any reference any Made it to it’s in the clients record.
- The incident report is not a substitute for incomplete entry in the clients record concerning the incident.
Issues surrounding informed consent
- There are only two instances in which the informed consent of an adult client is not needed :
(1) when it is an emergency and delaying treatment would result in injury or death
(2) when the client waves the right to give informed consent
Triage classification in emergency department
There are four categories of triage:
(1) Emergent=Red, highest priority
- Trauma, chest pain, severe respiratory distress, cardiac arrest, limb amputation,Or acute neurological deficit’s.
- Have life-threatening injuries and require immediate attention
(2) urgent = yellow,Priority #2
- Simple fractures, asthma without respiratory distress,fever, hypertension, abdominal pain, or renal stones
- Not life-threatening, CD within 30 to 60 minutes
(3) non-urgent= Green,priority #3
- minor lacerations, sprains, or cold symptoms
- treated within 1 to 2 hours, Non-life-threatening
(4) Expectant = Black, dead
- Victim is dead or will be deceased because of severe injuries
Significance of Cheyne - Stokes respirations
Rhythmic respirations with periods of apnea
- Obtain data about neurological functioning, starting with determining the client ability to respond to verbal stimuli
Types of Health and physical assessments
- completed data collection includes a complete health history and physical examination and forms a baseline database.
- Focused data collection focuses on a limited or short-term problem, such as a clients complaint.
- Episodic/follow-up data collection focuses on evaluating a clients progress
- Emergency data collection involves the rapid collection of data, often during the provision of lifesaving measures
Rhomberg test
Vestibular Neurological signs that is found when a client elicits a loss of balance when closing the eyes.
- stand with the feet together ,arms at the sides, And eyes closed
- A significant sway is a positive sign
Signs and symptoms of meningeal irritation
- Nuchal Rigidity =Brudzinski sign
- Pain with flexion occurs in the knee and hip when the leg is extended= Kernig Sign
Care of a client with C.difficile
- Contact precaution
- Private room or room shared
- Wash hands with soap and water
- gloves And gown
Radiation safety principles
- Follow standard precautions
- Linens re kept in the room as a safety precaution
- Film dorsimeter badge
- Private room
- Lead apron
Pre-operative care
- Obtain informed consent
- Void prior to surgery
- NPO eight hours prior to surgery
Health factors that affect the pre-operative client
- Allergies
- Recent smoking cessation
- Client concerns
- History of DVT, Diabetes, bleeding disorders, chronic respiratory disease, immuno logical disorders, and abuse of street drugs
Evaluation of a post operative care findings
- Vitals
- any feeling of dizziness
- PACU VITALS
- last recorded analgesics
