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Krystan: Semester One Nursing School > Nursing 2700 Fundamentals: Exam Two > Flashcards

Nursing 2700 Fundamentals: Exam Two Flashcards

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1
Q

What are some aspects of nursing that require critical thinking skills?

A

Complex situations
Unique clients
Need for holistic care
Medication administration

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2
Q

Definition: reasoned thinking, openness to alternatives, ability to reflect, and desire to seek truth

A

Critical thinking

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3
Q

Critical thinking skills are a _____ process

A

Cognitive

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4
Q

Critical thinking attitudes are a ____ trait

A

Feelings

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5
Q

What are some critical thinking attitudes?

A 
Independent thinking
Intellectual curiosity 
Humility
Empathy
Courage
Perseverance
Fair-mindedness
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6
Q

What are the phases of the nursing process?

A 
Assessment
Diagnosis
Planning outcomes
Planning interventions
Implementation
Evaluation
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7
Q

What is a comprehensive assessment?

A

Holistic information about the overall health status

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8
Q

What is a focused assessment?

A

Obtaining data about a suspected or identified problem or potential problem

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9
Q

What is meant by subjective data?

A

Anything the patient says
Anything you gather from family or community statements
Emotion based statements

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10
Q

What is meant by objective data? Give examples

A

Gathered through assessment or tests, things that can be measured or observed
Examples: vital signs, blood work, x-rays

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11
Q

What is primary data?

A

Subjective or objective data that you got directly from the patient

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12
Q

What is secondary data?

A

Data from a non patient source, like family members or the medical chart/record

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13
Q

What is a nursing diagnosis?

A

A statement of health that the nurse can identify, prevent, or treat independently

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14
Q

A nursing diagnosis is stated in terms of…

A

Human response to disease, injury, or stressors

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15
Q

What is included in a nursing diagnosis?

A

Problem, etiology, and intervention

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16
Q

What is a medical diagnosis?

A

Assignment of disease, illness, or injury

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17
Q

What is a collaborative problem?

A

Physiological complications (recognized by doctors) that nurses monitor to detect onset or change in status

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18
Q

What are the five types of nursing diagnosis?

A 
Actual
Risk/potential
Possible
Syndrome
Wellness
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19
Q

Define etiology

A

Factors causing or contributing to problem

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20
Q

What are some different types of etiologies?

A

Pathophysiological, treatment related, situational, social, spiritual, maturational, environmental

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21
Q

What are the four parts of a NANDA-I nursing diagnosis?

A

Diagnostic label
Definition/defining characteristics (S&S)
Related to/risk factors (etiology)
Associated conditions

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22
Q

How does the PES format for writing nursing diagnoses work?

A

Problem
Etiology
Signs/Symptoms

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23
Q

What is a patient goal as pertains to the nursing diagnosis?

A

A broad statement based on the nursing diagnosis that is realistic for the patient

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24
Q

What are some defining characteristics of patient outcome statements?

A 
Has steps
Short term/within defined time frame
Measurable 
Realistic
Patient centered (“patient will...”)
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25
Q

How is a nursing intervention defined?

A

Evidence based actions rooted in clinical knowledge and nursing judgement to achieve client outcomes

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26
Q

What is an independent nursing action?

A

Something the RN can prescribe/perform/delegate based on knowledge and skills without a doctors order

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27
Q

What is a dependent nursing intervention?

A

Action prescribed by physician/APN but carried out by the nurse

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28
Q

What is a collaborative intervention?

A

Intervention carried out with multiple health care team members

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29
Q

What are some characteristics of written nursing interventions?

A 
Nurse focused (“Nurse will...”)
Realistic
Relates to diagnosis and desired outcome 
Action statement 
Says how and when
Rationale
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30
Q

What is included in evaluating a nursing care plan?

A 
Reassessment of patient 
Comparison to previous data
Progress made?
Documentation
Decision about continuing care plan
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31
Q

What developmental factors should be considered when looking at the environmental safety of a preschool child?

A

Lack of balance = falls
Unable to swim = drowning
Lack of coordination = injury
Like to put things in mouth = choking hazard

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32
Q

What is the number one overall cause of death in the US?

A

Poisoning

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33
Q

What is the main cause of injury in the adolescent period?

A

Motor vehicle accidents

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34
Q

What things make older adults more injury prone?

A

Reduced strength and flexibility
Sensory losses
Slower reflexes

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35
Q

What are some potential poisons that could be ingested by children?

A

Chemicals
Medicines
Vitamins
Cosmetics

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36
Q

KEEP MEDICATIONS AND FIREARMS LOCKED UP

A

…

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37
Q

What are some sources of carbon monoxide?

A

Gas ranges and ovens

Running cars in closed spaces

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38
Q

What are major contributing factors to injuries in motor vehicle accidents?

A 
Failure to use seatbelts
Failure to use correct car seats
Speed
Alcohol
Distraction
Having children in the front seat (airbags)
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39
Q

What are some steps to avoid food poisoning?

A

Make sure meat is fully cooked
Cool cooked food properly
Throw away leftovers after 3-5 days
Watch older/homeless patients for food hoarding

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40
Q

What are typical causes of fire in a healthcare setting?

A

Anesthesia

Improperly grounded or malfunctioning medical equipment

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41
Q

What measures should be taken, in what order, if a fire occurs?

A

Move patient to safety
Sound alarm
Try to confine fire

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42
Q

What is the RACE acronym in case of a fire?

A

Rescue
Alarm
Confine
Extinguish and/or evacuate

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43
Q

What are some things healthcare workers can do to reduce exposure to radiation?

A

Follow correct standards for time, distance, and shielding when it comes to radiation exposure

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44
Q

How can one reduce equipment related injuries in the healthcare facility?

A

Make sure you know how to use it
Inspect before using
Pay attention to signage
Follow policy

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45
Q

What assessment tool looks at ability to live alone and perform ADLs safely?

A

Safety assessment scale

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46
Q

What are the risk factors identified by the Morse Fall Scale?

A 
History of falls
Multiple medical diagnoses
Ambulatory aids
IV line or saline lock
Change in gait
Mental status
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47
Q

What are some assessment tools to see if an older adult needs a comprehensive falls evaluation?

A

Safety assessment scale

Get up and go test

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48
Q

What are some risk factors for burns in children?

A

Pot handles turned towards front of stove
Improperly heated bottles
Cooking while holding children
Improper bath temperatures

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49
Q

What are some ways to reduce possibilities of fire in the home?

A

Smoke detector
Inspect electrical cords for damage
No open flame near oxygen

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50
Q

The best thing to do when working in an environment with toxins is…

A

Shower and change before leaving work or remove work clothes before entering the house

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51
Q

What are the guidelines for using restraints?

A

Must be removed every 2 hours
Nurse must assess patient every two hours when restraints removed
Patient should be given fluid and allowed to use bathroom every 2 hours
Range of motion every 2 hours
Get patient comfortable before putting restraints back on

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52
Q

What specifically must the nurse assess when restraints are removed?

A 
Presence of edema
Capillary refill
Sensation
Function
Skin integrity
Erythema
Pain
Readiness to come out of restraints
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53
Q

DOCUMENT ON PATIENTS WITH RESTRAINTS AT LEAST EVERY TWO HOURS

A

DO NOT FORGET THIS

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54
Q

Are mittens considered restraints?

A

Yes

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55
Q

What are medical restraints and in what situations would they be used?

A

Soft limb restraints for clients pulling at IV tubes and lines

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56
Q

How often must medical restraints be removed and documented?

A

Every two hours

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57
Q

If a patient is incredibly strong but only needs medical restraints, what can be done?

A

Violent restraints can be used

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58
Q

Is an isolation room a proper substitute for a patient who needs restraints?

A

Yes, if they are non violent, but the camera looking at the room must be continually monitored

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59
Q

When are pelvic restraints used?

A

When the client is at risk for falls due to poor safety judgement

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60
Q

How often must pelvic restraints be documented, assessed, and removed?

A

Every two hours

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61
Q

When are violent restraints used?

A

When patients are combative and might cause harm to self or others and all other options have already been tried

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62
Q

What are guidelines for assessing and documenting with violent restraints?

A

They must be documented and assessed every fifteen minutes, and someone must be with the patient continually for the first hour after putting restraints on

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63
Q

What are guidelines for removing violent restraints?

A

Always approach the patient with at least two healthcare workers
Take them off one at a time
LPN or CNA can remove the restraints if the RN is present
Healthcare workers must be certified to handle these patients

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64
Q

What is the role of the joint commission?

A

Set standards to promote patient safety and help identify risks

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65
Q

What is the role of the Institute of Medicine as pertains to safety?

A

Assess healthcare related deaths/incidents

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66
Q

What are some examples of “never events”?

A

Artificial insemination with wrong donor sperm or egg
Death or disability due to error (medication, blood transfusion, falls, contaminated equipment, etc)
Death or injury to staff d/t assault
Sexual assault

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67
Q

What percentage of nurses report chronic back pain?

A

52%

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68
Q

What are some other common safety issues/injuries faced by nurses?

A

Needlestick injury
Radiation injury
Ebola/highly contagious diseases

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69
Q

How is Ebola transmitted?

A

Direct contact with body fluids

Exposure to objects contaminated with body fluids

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70
Q

What is to be done with suspected/confirmed hemorrhagic fever cases?

A

ISOLATE

And keep suspected and confirmed separate

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71
Q

The fifth leading cause of death in the US is…

A

Unintentional injuries

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72
Q

What are the top causes of unintentional death?

A

Motor vehicle accidents
Poisoning
Falls

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73
Q

When do most fatal home fires occur?

A

When people are asleep

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74
Q

What percentage of falls occur in the home?

A

More than half

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75
Q

What percentage of falls involve people older than 65?

A

About 80%

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76
Q

How often must medical prescriptions for restraints be renewed?

A

Every 24 hours

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77
Q

What might early identification of patient anxiety do?

A

Prevent the patient from becoming aggressive

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78
Q

How does the Heimlich differ from the American Red Cross choking rescue?

A

Red Cross includes back blows, heimlich does not

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79
Q

Decreased sensation puts elderly patients at risk for…

A

Burns and sunburns

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80
Q

If a patient verbalizes a suicide plan, the nurse should…

A

Not leave the room until someone else comes to assess and help
Pay attention to everything in the surroundings and how the patient could use it

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81
Q

A handoff report is also called…

A

Change of shift report

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82
Q

What is the purpose of a handoff report?

A

To promote continuity of care

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83
Q

When it comes to interdisciplinary communication, what has been proven to improve patient outcomes?

A

Nurses having input on patient care

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84
Q

What was found to be the root cause in 65 to 70 percent of patient care errors?

A

Communication issues

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85
Q

What information is given during the handoff report?

A 
Patient name, doctor, and condition(s)
Changes in status or condition
Upcoming activities/procedures
Current medications and last doses
Concerns and things that need follow up
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86
Q

What is the drawback of a face to face oral report?

A

Patient is not directly observed

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87
Q

What is the disadvantage of an audio-recorded report?

A

Time consuming
No ability to ask questions of the nurse
Things may have changed since it was recorded

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88
Q

What are the benefits of a bedside report?

A

Nurse can meet patient and start assessment

Patient is included in the process and can ask questions

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89
Q

With each handoff, there is a risk for…

A

Error

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90
Q

What does PACE stand for and what is it used for?

A 
It is a standardized format for reporting
Stands for..
Patient/Problem
Assessment/Actions
Continuing/Changes
Evaluation
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91
Q

Why is SBAR so useful?

A

It’s a standardized way to communicate what’s most important, especially in critical/emergency situations

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92
Q

When is a transfer report given?

A

When a patient is transferred from one unit to another or one facility to another

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93
Q

Who is especially vulnerable to risks/errors when transferring facilities?

A

Older adults

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94
Q

What does MBAR stand for and when is it used?

A 
Used during transfer reports
Stands for...
Medication
Background
Assessment
Recommendation
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95
Q

What does SBAR-R stand for and when is it used?

A

It’s SBAR with a read-back component and its used when taking verbal or telephone orders from a physician

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96
Q

In what situations would a telephone order be acceptable?

A

Sudden change in patient condition
Emergency
Primary doctor not at hospital
Doctor doesn’t have access to internet to put in order

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97
Q

What should the nurse include when recording a verbal order?

A

Date, time, written text or electronic entry of the order. Indicate “VO” with the physicians name and your name

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98
Q

What are the legal and ethical responsibilities of the nurse as pertains to physicians orders?

A

If you believe it is inappropriate or unsafe, you are legally/ethically required to question it.
you are allowed to refuse orders if uncomfortable — just report up the chain of command

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99
Q

What are some key elements to teamwork?

A 
Clearly defined roles
Respect for one another
Good communication
Decision-making procedures are clear
Non-punitive environment
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100
Q

Nurses feeling free to speak and voice concerns has been proven to lead to…

A

Better patient outcomes

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101
Q

What are some barriers to effective interdisciplinary communication?

A 
Personalities
Differing values
Hierarchy
Cultural differences
Generational differences
Gender differences
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102
Q

What are the benefits of nurses participating in patient rounding?

A

Nurse can provide input

Improves nurse/doctor relationships and professional satisfaction

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103
Q

What is CUBAN used for?

A

Used as a guideline for how report should be given

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104
Q

What does CUBAN stand for?

A 
Confidential
Uninterrupted
Brief
Accurate
Named nurse
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105
Q

How should the nurse always end an oral report?

A

Ask if receiving nurse has any questions

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106
Q

What are some guidelines for receiving telephone orders?

A

Have another nurse listen to verify accuracy
Only do it if you heard it firsthand
Spell back medications and say numbers as individual digits
Repeat back the order

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107
Q

What does “TO” stand for?

A

Telephone order

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108
Q

What does “VO” stand for?

A

Verbal order

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109
Q

How quickly must a telephone or verbal order be signed by practitioner?

A

Within 24 hours

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110
Q

What is the difference between a handoff report and a transfer report?

A

Transfer report is more detailed

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111
Q

What should be included in a transfer report?

A

Patient name, demographics, diagnoses, reason for transfer
Family contacts
Summary of care
Current status (medications, treatments, tubes, times for meds)
Wounds/open areas
Special directives
Code status, intensity of care, isolation
Your contact information

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112
Q

What are morals?

A

Beliefs or convictions of an individual or a group that are learned and developed across the lifespan

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113
Q

What are ethics?

A

A formal process for deciding right and wrong conduct in situations where issues of values/morals arise. Process for making consistent moral decisions

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114
Q

What does nursing ethics refer to?

A

Ethical questions that arise out of nursing practice

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115
Q

What is ethical agency?

A

Ability to make ethical choices and be responsible for one’s ethical actions. Being able to follow through on ethical decisions

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116
Q

What is moral distress?

A

The inability to carry out moral decisions. Difficulty choosing between options because of morals

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117
Q

Identifying incompetent, unethical, or illegal factors in a work situation and bringing it to the attention of someone who may have the power to stop it is called…

A

Whistleblowing

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118
Q

What are four factors that contribute to the frequency of nurses ethical problems?

A

Technological advances
Multicultural population
Cost containment in healthcare
Increasing consumer awareness

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119
Q

What are some factors that affect someone’s ethical decision making?

A

Developmental stage
Values
Ethical framework/principles
Professional guidelines

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120
Q

Mental dispositions towards a person, object, or idea are…

A

Attitudes

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121
Q

Something that one accepts as true is a…

A

Belief

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122
Q

A belief about the worth of something is a…

A

Value

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123
Q

How are values transmitted?

A

Social interaction

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124
Q

What is meant by value neutrality?

A

We know our own values regarding issues and know when to put them aside to become non-judgmental

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125
Q

What are six important ethical principles?

A 
Autonomy
Nonmaleficence 
Beneficence 
Fidelity
Veracity
Justice
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126
Q

Autonomy

A

A person’s right to choose and act on that choice

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127
Q

Non-maleficence

A

Doing no harm

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128
Q

Beneficence

A

Doing good

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129
Q

Fidelity

A

Duty to keep promises

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130
Q

Veracity

A

Duty to tell truth

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131
Q

Justice

A

Obligation or duty to be fair

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132
Q

What do consequentialist theories state?

A

The rightness or wrongness of an action depends on the consequences of that action

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133
Q

What does the principle of utility state about “good”?

A

Good acts produce the greatest good for the greatest number of people

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134
Q

What is believed under deontological theory?

A

An action is objectively right or wrong, regardless of the outcome

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135
Q

What is focused on by feminist ethics?

A

Individual stories
Social issues
Virtues like love and caring

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136
Q

What is the focus of an ethics-of-care?

A

Patients specific needs in a specific situation

Feelings emphasized, but not at the expense of ethical principles

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137
Q

What are some trustworthy standards for nursing ethical guidance?

A

Professional codes of ethics
Standards of practice
Patient care partnership

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138
Q

Which ethical principle underlies informed consent?

A

Autonomy

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139
Q

What is values clarification?

A

Becoming conscious of and naming ones values

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140
Q

What is an ethical dilemma?

A

A moral problem in which a decision must be made between two equally undesirable outcomes with no clear right or wrong choices

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141
Q

What is the MORAL acronym used for?

A

Working through an ethical dilemma

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142
Q

What does MORAL stand for?

A 
Massage the dilemma
Outline the options
Resolve the dilemma
Act on chosen option
Look back and evaluate
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143
Q

What will a good compromise do in an ethical situation?

A

Preserve the integrity of all parties

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144
Q

What are four reasons of why nurses should be patient advocates?

A
  1. The role requires it
  2. They have special knowledge that the patient doesnt have
  3. They have a special relationship with patients
  4. They have an obligation to defend patients autonomous decisions
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145
Q

How is bioethics defined?

A

The application of ethics to healthcare

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146
Q

Altruism

A

Concern for the well-being of others

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147
Q

Human dignity

A

The worth, uniqueness, and value of people

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148
Q

Integrity

A

Acting within a code of ethics

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149
Q

Social justice

A

Upholding moral, legal, and humanistic principles for the greater interest of groups and populations

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150
Q

What are the ethical principles involved in a given ethical situation?

A 
Autonomy
Non-maleficence 
Beneficence 
Fidelity
Veracity
Justice
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151
Q

What are the nurses obligations in an ethical decision?

A 
Be sensitive to the issue
Take responsibility for moral actions
Work as a team member
Support patient
Support decisions
ADVOCATE
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152
Q

What is moral outrage?

A

Belief that others are acting immorally and feeling powerless to do anything about it

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153
Q

Before whistleblowing, one should…

A

Have the facts
Go up the chain of command
Think about possible consequences

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154
Q

A binding practice, rule, or code of conduct that guides a community or society and is enforced by authority is…

A

Law

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155
Q

Where does the right of privacy come from?

A

The Bill of Rights

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156
Q

What is a durable power of attorney?

A

A person who will make decisions for a patient if the patient becomes unable to do so

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157
Q

What are some state laws that affect nursing practice?

A

Mandatory reporting laws
Good Samaritan laws
Safe harbor laws
Nurse practice acts

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158
Q

What is outlined by the ANA code of ethics?

A

Standards of professional responsibility for nurses

What ethical and acceptable behavior looks like

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159
Q

What is outlined in the ANA Bill of Rights?

A

Rights nurses should expect from their workplace and work environment in order to practice as a professional

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160
Q

What is a primary thing that encourages competence and adherence to standards of practice in healthcare providers?

A

Medical malpractice system

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161
Q

What do standards of practice say?

A

What a reasonable and prudent nurse would do in the same or similar situations

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162
Q

What is established by state boards of nursing to govern nursing practice?

A

Nurse practice acts

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163
Q

What are nurses mandated to report?

A

Suspected or actual abuse
Impaired health professionals
Communicable diseases

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164
Q

What are state boards of nursing allowed to do?

A

Approve pre-licensure nursing education programs
Set licensure criteria
Define nursing practice
Establish grounds for disciplinary actions

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165
Q

What does HIPAA do for patients?

A

Ensure privacy and confidentiality of medical records
Protect coverage for people with pre-existing conditions
Establish privacy standards

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166
Q

Which act established the guidelines for living wills and durable power of attorney?

A

Patient Self-Determination Act

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167
Q

What else does the Patient Self-Determination Act allow patients to do?

A

Make their own medical decisions after being fully informed about benefits and risks

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168
Q

When acting under Good Samaritan laws, what should a nurse do?

A

Don’t leave the patient
Call 911
Give patient to EMS as soon as they arrive

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169
Q

Can a nurse be punished for violating ANA Standards of Care?

A

Yes

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170
Q

What is an intentional tort?

A

Action with intent to harm

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171
Q

What is an unintentional tort?

A

Action that causes harm but was not meant to do so

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172
Q

What are some common malpractice claims?

A

Failure to assess and diagnose
Failure to implement plan of care
Failure to evaluate

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173
Q

What are some strategies to minimize liability in nursing practice?

A 
CHART EVERYTHING 
Report errors quickly 
Assess/diagnose properly
Delegate properly
Evaluate 
Check meds
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174
Q

What is fraud?

A

False representation of facts

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175
Q

Laws made by judges or courts

A

Common law

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176
Q

Laws dealing with wrongs or offenses against society

A

Criminal law

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177
Q

Felony

A

Crime punishable by more than one year in jail

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178
Q

Law involving disputes between two entities

A

Civil law

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179
Q

What is assault?

A

Patient placed in fear of immediate harm (words of intent included)

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180
Q

What is battery?

A

Harmful physical contact or unauthorized touching

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181
Q

Is doing a procedure without consent assault or battery?

A

It is both

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182
Q

Restraining someone without legal authority is…

A

False imprisonment

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183
Q

What is spoken or verbal defamation of character?

A

Slander

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184
Q

What is written defamation of character?

A

Libel

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185
Q

What is defamation?

A

False communication about someone to a third person

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186
Q

What kind of torts are slander and libel?

A

Quasi-intentional torts

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187
Q

What is negligence?

A

Failure to provide orderly and reasonable care

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188
Q

What is malpractice?

A

Negligence in a professional setting

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189
Q

Can a nurse back out of a staffing assignment once she has received report?

A

No

If the situation is unreasonable or unsafe, she cannot accept it and then back out/leave

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190
Q

What elements are necessary to collect damages?

A

Existence of duty
Breach of duty
Causation
Damages

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191
Q

What are the three basic functions of the neurological system?

A

Sensory
Integration
Motor

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192
Q

What are the reflexes that are present at birth but disappear during infancy?

A 
Rooting
Sucking
Palmar grasp
Tonic neck reflex
Moro
Stepping reflex
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193
Q

What would it indicate if the reflexes present at birth Either doesnt disappear or does reappear in a later developmental stage?

A

Stroke
Trauma
Severe neurological problems

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194
Q

What is the normal neurological screening test used on young children?

A

The Denver Developmental Screening Tool (Denver II)

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195
Q

What does the Denver II examine?

A

Motor, language, and coordination skills in young children

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196
Q

What ages is the Denver II designed for?

A

Ages 0-6

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197
Q

What does the Denver II consist of and how does it generally work?

A

125 tasks in four developmental areas

Children are only tested on tasks pertinent to their age and previous ages

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198
Q

What are commonly observed neurological changes in older adults?

A

Slower reaction time
Slower problem solving
Slower voluntary movement

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199
Q

What changes are not associated with normal aging?

A

Decreased intelligence, memory, and discrimination

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200
Q

What are the usual causes of neurological deficits in older adults?

A 
Medication
Poor nutrition
Cardiovascular changes
Diabetes
Degenerative neurological conditions
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201
Q

What is the first sign of neurological deterioration?

A

Decreased LOC

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202
Q

What are the two assessment tools associated with level of consciousness?

A

Glasgow Coma Scale

Full Outline of UnResponsiveness

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203
Q

What three things are monitored with the GCS?

A

Eye, motor, and verbal responses

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204
Q

The GCS helps to monitor…

A

Neurological decline

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205
Q

What are the drawbacks of the GCS?

A

Cannot be used on patients with an endotrachial tube because it requires verbal response

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206
Q

What GCS score is considered good?

A

15 and above

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207
Q

What GCS scores indicate a serious problem/need for intervention?

A

8 or below

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208
Q

How does the FOUR differ from the GCS?

A

It is more comprehensive and looks at eye response, motor response, brainstem reflexes, and respiration’s

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209
Q

What is the main advantage of the FOUR over the GCS?

A

Can be used on patients with an endotrach tube because it does not rely on verbal responses

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210
Q

A decreasing FOUR score indicates…

A

Worsening neuro function

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211
Q

What are the aspects of assessing orientation?

A

Person, place, and time

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212
Q

What items are assessed when looking at mental status and cognitive function?

A 
Behavior 
Appearance
Response to stimuli
Speech
Memory
Communication
Judgment
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213
Q

When assessing cognitive function, the nurse wants to know…

A

The patient’s baseline

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214
Q

What are deep tendon reflexes?

A

Automatic responses that don’t require brain input

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215
Q

What is the grading scale for deep tendon reflexes?

A

0-4+

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216
Q

What further assessment should nurse do if patient has altered sensation in an area?

A

Systematically assess the area to determine the border of the changed area

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217
Q

What does the cerebellum do?

A

Coordinate muscle movement
Regulate muscle tone
Maintain posture and equilibrium
Proprioception

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218
Q

How would a disorder of motor and cerebellar function manifest?

A

Pain and problems with movement, gait, and posture

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219
Q

When is a Romberg test most often used practically?

A

By police to look for intoxication

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220
Q

In the medical field, what does a Romberg test look for?

A

Cerebellar or vestibular disorder

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221
Q

How is a Romberg test done?

A

Patient stands with feet together and eyes closed and provider checks for excessive swaying

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222
Q

What characterizes a positive Romberg?

A

Swaying and moving

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223
Q

A positive Romberg means…

A

The issue is most likely sensory

224
Q

A negative Romberg most likely means…

A

The issue is cerebellar

225
Q

What are some possible causes of abnormal LOC?

A

Trauma
Neurological disorder
Hypoxia
Chemical substances

226
Q

What is one of the earliest indicators of increased intracranial pressure?

A

Change in level of arousal

227
Q

When determining orientation, which measure remains intact the longest?

A

The year

228
Q

In a hospital setting, what might impact a patient’s orientation?

A

Medication
Stress
Constant lights, noise, and people
Altered sleep schedule

229
Q

A hospitalized patient not getting enough sleep can lead to…

A

Hospital psychosis and delirium

230
Q

Hospital delirium is considered…

A

A medical emergency

231
Q

What are some prevention measures for hospital delirium?

A

Constantly reorient patient to time and situation

Try to maintain sleep/wake cycle

232
Q

What are anticipated versus abnormal findings in older adult memory?

A

Loss of immediate short term memory is more common (though not “normal”). Loss of long term memory is abnormal and may indicate neurological problems

233
Q

What could abnormal findings in thought process, abstract thinking, or judgment indicate?

A 
Dementia 
Psychosis
Alcohol 
Drugs
Delirium
Mental retardation
234
Q

Describe reflexes in older adults

A

Might not be as strong or fast, but should still be present

235
Q

What five deep tendon reflexes are assessed?

A 
Biceps
Triceps
Brachioradialis
Patellar
Achilles
236
Q

How would nurse assess tonic neck reflex and what would a normal finding in an infant be?

A

Turn the head to one side

The body on that side should extend, and flex on the other side

237
Q

How does a nurse test for babinski refllex?

A

Stroke the sole of the foot in an arc from the lateral heel across the ball of the foot

238
Q

What is a positive babinski?

A

Toes unfurling/fanning

239
Q

Where would one expect to get a positive babinski?

A

Children under the age of two

240
Q

What could a positive babinski indicate in someone over the age of two?

A

Intoxication

Upper motor neuron disease

241
Q

What did Piaget term the infancy stage? Why?

A

Sensorimotor stage

Infant is developing coordination and solves problems by sensory systems

242
Q

What is a key attribute of those in the preoperational stage?

A

Egocentricism

243
Q

What did Piaget term the stage from 2-7 years old?

A

Preoperational stage

244
Q

What is one main cognitive connection/skill learned by those in the preoperational stage?

A

Object permanence

245
Q

What did Piaget term the stage between 7 and 11 years of age?

A

Formal operations stage

246
Q

What cognitive processes begin in the formal operations stage?

A

Introspection
Idealism
Reemergence of egocentricism
groundwork being laid for abstract thinking

247
Q

What did Piaget term the stage that begins at 12 and continues through adulthood?

A

Concrete operations stage

248
Q

What characterizes the concrete operations stage?

A

Being able to think realistically and objectively

Being able to analyze all aspects of a situation and form a hypothesis

249
Q

What are some possible causes of cognitive problems in older adults

A

Electrolyte imbalance
Diabetic ketoacidosis
Hypoxia

250
Q

What are the symptoms of dementia?

A

Language difficulty
Problems with language
Problems with object recognition
Problems with planning

251
Q

What does PERRLA stand for?

A 
Pupils
Equal
Round
Reactive to
Light
Accommodation
252
Q

What will a focused neuro exam look at?

A 
Level of consciousness 
Sensation
Pain
Strength 
**only assess problem areas/complaints, don’t over assess**
253
Q

Solute

A

Solid substance that dissolves in fluid

254
Q

Electrolyte

A

Substance that develops an electrical charge when dissolved in water

255
Q

ICF

A

Intracellular fluid, fluid found in cells

256
Q

ECF

A

Extracellular fluid: fluid found outside of cells (either interstitial or intravascular)

257
Q

Cation

A

Positively charged electrolyte

258
Q

Anion

A

Negatively charged electrolyte

259
Q

What are the major electrolytes in the ICF?

A

Potassium and magnesium

260
Q

What are the major electrolytes in the ECF?

A

Sodium, chloride, bicarbonate, and albumin

261
Q

Osmosis

A

Movement of water from an area of higher concentration to an area of lower concentration

262
Q

Diffusion

A

Movement of molecules from an area of higher concentration to lower

263
Q

Filtration

A

Water and particles moving together from an area of higher pressure to an area of lower pressure

264
Q

Active transport

A

Movement of water and/or particles against a concentration gradient (requires energy)

265
Q

What are the major functions of sodium?

A

Maintenance of BP and blood volume
Transmission of nerve impulses
Fluid balance

266
Q

What are the functions of potassium in the body?

A

Normal function of nerves and muscles, especially the heart

Cellular metabolism

267
Q

How does potassium relate to blood pressure?

A

Potassium deficiency may be linked to higher BP

268
Q

What is the function of calcium in the body?

A

Bone health
Neuromuscular and cardiac function
Blood clotting

269
Q

What does magnesium do in the body?

A

Aids in over 300 biochemical reactions
Bone strength
Nerve and muscle function

270
Q

What is the function of chloride in the body?

A

Helps maintain fluid balance between ICF and ECF

271
Q

What is the most abundant ECF anion?

A

Chloride

272
Q

What is the function of phosphate in the body?

A

Bone and teeth formation

Bone and teeth health

273
Q

What is the function of bicarbonate in the body?

A

Maintain acid/base balance

274
Q

What are the risks with not consuming enough potassium?

A

Higher BP
Kidney stones
Risk of bone turnover

275
Q

How long can renal mechanisms take to take effect in the body for balancing pH?

A

Up to three days

276
Q

Define deficient fluid volume

A

Proportional loss of fluid and electrolytes from the extracellular space

277
Q

Define excess fluid volume

A

Excessive retention of sodium and water in the extracellular space

278
Q

How much of a loss of body fluid must occur to be considered significant?

A

5% loss of body weight in fluid

279
Q

Losing how much body weight as fluids is usually fatal?

A

15%

280
Q

What are the signs and symptoms of deficient fluid volume?

A 
Thirst
Increased heart rate
Weak and rapid pulse
Orthostatic hypotension
Dry skin/decreased turgor
Flat neck veins
Decreased urine
Increased temperature
281
Q

What are the signs and symptoms of excess fluid volume?

A 
High BP 
Edema
Bounding pulse
Lung crackles
Distended neck veins
282
Q

What are some physical assessment components that can be used to monitor fluids, electrolytes, and acid/base balance?

A 
Skin
Mucous membranes
Cardiovascular changes 
Respiratory changes
Vital signs
Daily weights 
Intake and output
Capillary refill
283
Q

What are some things that should be evaluated when doing a nursing history focused on fluids and electrolytes?

A 
Medical history 
Current concerns
Food/fluid intake
Elimination
Medications
Lifestyle
284
Q

What are some laboratory tests to monitor fluid, electrolyte, and acid/base balance?

A 
CBC
Serum electrolytes 
Serum osmolality
Urine osmolality
Urinalysis
285
Q

What are some strategies to prevent fluid and electrolyte imbalance?

A

Limit sodium and increase potassium and calcium in diet
Give electrolyte supplements if necessary
Facilitate fluid intake and restriction as needed
Give paraenteral replacement of fluid and electrolytes as needed
Identify meds causing imbalances

286
Q

What is an electrolyte related risk with the diuretic Lasix?

A

It removes potassium as well

287
Q

How much of body weight does ICF account for?

A

40%

288
Q

How much of body weight does ECF account for?

A

20%

289
Q

Which electrolyte has an inverse relationship with calcium?

A

Phosphorus

290
Q

What are general recommendations for total fluid intake for men and women?

A

Men: 3700 mL/day
Women: 2700 mL/day

291
Q

Bicarbonate is regulated by…

A

The kidneys

292
Q

What is the principle buffer system in the body?

A

The carbonic acid and sodium bicarbonate system

293
Q

How does a buffer system work?

A

A weak acid and a weak base absorbing or releasing hydrogen ions from strong acids and bases as necessary. They do this to keep the strong acids and bases from altering body pH

294
Q

How do the lungs compensate when serum pH is too acidic?

A

Rapid, deep breathing (to get CO2 out of body)

295
Q

When the serum pH is too alkaline, how do the lungs compensate?

A

Shallow respirations (to conserve CO2)

296
Q

What is third spacing?

A

Shifting of fluid from the intravascular to the interstitial space

297
Q

What are some risk factors for fluid imbalance?

A 
Depression
Burns
Confusion
Fever
Hyperventilation
Diarrhea
Pneumonia
Medical processes
298
Q

What happens with SIADH?

A

Too much ADH is produced, leading to over hydration and possible hyponatremia (because water will outweigh the salt)

299
Q

What are normal serum sodium values?

A

Between 135 and 145 mEq/L

300
Q

What are normal serum magnesium values?

A

Between 1.5 and 2.5 mEq/L

301
Q

What are normal serum potassium values?

A

Between 3.5 and 5.0 mEq/L

302
Q

NG suctioning puts a patient at risk for what fluid and electrolyte issues?

A

Dehydration and hypomagnesia

303
Q

When a COPD patient is having difficulty breathing, a nurse should…

A

Have them do pursed lip breathing

DO NOT increase 02, this makes it harder for them!

304
Q

What are normal serum bicarbonate levels?

A

20-28 mEq/L

305
Q

What are some vulnerable subcultures we will be treating in nursing?

A 
Homeless
Elderly
Mentally ill
Poor
Physical disabilities
306
Q

Vulnerable populations have lack of access to what?

A

Healthcare

307
Q

What are some examples of non-race based minorities?

A

Groups like male nurses, single mothers, etc

308
Q

Define culture

A

What people have in common. It is all encompassing and provides identity for those in the culture. It is learned, taught, and shared

309
Q

Define ethnicity

A

Has members who share the same social and cultural heritage that is passed on from generation to generation

310
Q

How is race different from ethnicity?

A

Race is solely based on biological similarities, not on social and cultural factors

311
Q

Give examples of different “races”

A

Korean
Northern European
African American

312
Q

Give examples of different ethnic groups?

A

Latinos

Hmong

313
Q

Define socialization

A

How one learns to be a member of their society

314
Q

Define acculturation

A

Assuming the characteristics of the culture

315
Q

Define cultural assimilation

A

Taking the essential values, beliefs, and practices of dominant culture

316
Q

Define cultural conflict

A

Conflict between guest of a different culture and the culture they are in

317
Q

Define culture shock

A

Cultural misunderstanding or surprise, with interpersonal conflict due to highly different methods of doing things

318
Q

In what ways does culture provide an identity for an individual?

A

Provides framework for beliefs, habits, food choices, values, and actions

319
Q

What is an archetype?

A

Example of a person or a thing that has its basis in facts

320
Q

What is a stereotype?

A

A widely held but oversimplified and unsubstantiated belief about all people in a certain cultural or ethnic group

321
Q

What are six cultural specifics (things particular to a culture) that can affect health and the view on it?

A 
Communication
Personal space
Time orientation
Social organization
Beliefs about amount of environmental control
Biological variations
322
Q

How can a nurse use cultural specifics to provide better care?

A

I can use it to better understand clients beliefs about healthcare and the expected outcomes of healthcare, making care more culturally competent

323
Q

What types of alternative healthcare are delivered by formally trained practitioners in healthcare settings?

A

Diet therapy
Reflexology
Chiropractic

324
Q

What are magico-religious belief systems?

A

Religious systems that believe in mystical supernatural forces

325
Q

What are efficacious healthcare practices and how does the nurse respond to them?

A

Cultural health practices that are helpful to the client, so the nurse can support the patient integrating those practices into their care

326
Q

What is folk medicine?

A

Certain beliefs and practices that cultural members follow when sick

327
Q

Give examples of folk medicine practices

A 
Using herbs
Drinking tea
Rituals when sick
Taking vitamin C
Drinking chicken soup
328
Q

Define cultural competence

A

Becoming more aware of and sympathetic to other cultures and being able to use that in practice

329
Q

How does ethnocentric is impede nursing care?

A

Prevents the nurse from seeing and understanding the patient’s point of view. Also instills a lack of respect for the patient into the nurse-patient relationship

330
Q

How is discrimination different from prejudice?

A

Prejudice is the attitude, discrimination is the behavior that results from the prejudice

331
Q

What does the BALI acronym stand for? (Pertains to cultural competence)

A

Be aware of your cultural heritage
Appreciate the uniqueness of your client
Learn about the clients culture
Incorporate clients culture and values into care

332
Q

The most critical aspect to providing culturally competent nursing care is…

A

Communication

333
Q

Culturally sensitive nurses have what trait?

A

Respect for the cultures and ethnicities of the patients they are caring for

334
Q

True/false: you can ask the patient which cultural group and racial affiliation they identify with?

A

True! It is culturally competent to not assume that you know automatically and much better to ask

335
Q

REMEMBER EVERY PERSON IS CULTURALLY UNIQUE

A

And developing cultural competence is the responsibility of EVERY nurse

336
Q

Education is the number one way to overcome cultural incompetence!

A

Ask questions, admit you dont know everything, and provide a safe environment for the patient!

337
Q

Which cultural theorist had the goal of guiding research to help nurses provide culturally congruent care?

A

Madeline Leninger

338
Q

What are the three modes of nursing care actions in Madeline Leninger’s culture theory?

A

Accommodation
Negotiation
Repatterning/restructuring

339
Q

What does negotiation mean in leningers theory?

A

Acknowledging gaps in perspectives on care, and negotiating care to be safe for the patient

340
Q

When might a nurse need to negotiate culturally?

A

When traditional or folk practices that a patient has could be harmful to the patient

341
Q

What is restructuring and repatterning in Leninger’s theory?

A

Attempting to change my actions or the lifestyle of the client

342
Q

How can a nurse support a patient trying to repattern their behavior?

A

Encourage the new healthy behaviors while respecting cultural beliefs and values

343
Q

Which culture theorists said that cultural competence is gained through teamwork, knowledge, ability, and skills?

A

Purnell and Paulanka

344
Q

Which nursing theorists said that becoming culturally competent requires skills, awareness, knowledge, and desire?

A

Campinha and Bacote

345
Q

The best way to make sure a patient of another culture understood your teaching is…

A

Have them do a return demonstration/display of what was taught

346
Q

What are three methods for determining whether hydration is adequate and urine output is within normal limits?

A

Specific gravity
Color
Volume measurement of urine

347
Q

What are common medications to increase the amount of urine voided?

A

Thiazide
Potassium-sparing
Loop-acting

348
Q

What types of medications are associated with urinary retention?

A

Antihistamines
Anticholinergics
Antispasmodics
Tricyclic antidepressants

349
Q

What are some conditions associated with a high incidence of altered urination?

A 
Being a child or older adult
Anxiety and stress
Hydration level
Activity level
Medications 
Anesthetics
Surgeries in the reproductive, urinary, pubic area, vagina, or rectum
350
Q

What are the key elements of a physical assessment for a client with urination problems?

A

Examination of kidneys, bladder, urethra, skin around genitals

351
Q

How does one catch a clean-catch urine specimen?

A

Clean around urinary meatus
Have patient begin voiding and then start catching mid-stream
Collect 30-60 mL
Remove cup and have patient to finish

352
Q

What are some nursing activities that promote normal urination patterns?

A 
Provide privacy 
Assist with positioning
Facilitate routines
Promotes hydration
Assist with hygiene
353
Q

What is a straight catheter and when is it used?

A

Single lumen catheter

Used to drain bladder and then is removed immediately

354
Q

What is a Foley catheter and when is it used?

A

Double or triple lumen catheter that stays in the patients long term

355
Q

Why is intermittent catheterization preferred for long term catheterization?

A

It has a lower infection risk than an indwelling catheter

356
Q

How often should the urine collection bag be emptied?

A

At least every 8 hours or sooner if needed

357
Q

What are some factors that affect bowel elimination?

A 
Developmental stage
Personal/cultural factors (such as stress, privacy, or more pressing needs to attend to)
Nutrition
Hydration
Medication
Activity levels
Surgeries
Pregnancy
Bowel diversions
358
Q

What are some factors associated with constipation?

A

Pregnancy
Stress
Low fiber diet
Being bedridden

359
Q

What are some factors associated with diarrhea?

A

Allergies/intolerances
Some medications
Coffee sometimes

360
Q

What causes gas?

A

Bacteria fermenting food in the colon

361
Q

What should you discuss with a patient when performing a nursing history focused on elimination?

A

Normal elimination pattern and appearance
Medications
Any info about bowel diversions, if applicable

362
Q

What are some laboratory studies done on feces?

A

fecal fat
Occult blood
Ova/parasites

363
Q

What are some things that can give a false positive in occult blood tests?

A

Diet high in red meat

High vitamin c levels

364
Q

What physical assessments would you perform on a constipated client?

A

Abdomen, anus, rectum
Examine stool
Listen for bowel sounds
Look at size/shape/contour of abdomen

365
Q

What are some independent nursing actions that can promote regular elimination?

A

Provide privacy
Assist with positioning (as normal a position as possible)
Support healthy food/high fiber and fluid intake
Encourage exercise or do range of motion with bedridden clients
Give laxatives if other interventions fail

366
Q

What are the different types of enemas?

A

Cleansing
Retention
Return flow

367
Q

What does a cleansing enema do?

A

Promotes removal of feces from the colon with either a hypertonic or hypotonic solution

368
Q

What is a retention enema?

A

Enema that is inserted and retained to soften stool and promote elimination

369
Q

What specifically does an oil retention enema do?

A

Soften stool

370
Q

What is a return flow enema?

A

Saline is instilled and drained several times to relieve distended abdomen

371
Q

What is a return flow enema also known as?

A

A Harris Flush

372
Q

How can the nurse make the patient more comfortable when receiving an enema?

A 
Position patient correctly
Assist as needed 
Help to toilet if possible
Explain procedure thoroughly
Talk to/distract patient during procedure
373
Q

What are the major patient care concerns associated with bowel incontinence?

A

Impaired skin integrity
Embarrassment
Dehydration

374
Q

What are the elements of a bowel training program?

A 
Plan it with the patient
Gradually increase fiber and monitor stool
Increase fluid
Initiate times for defecation 
Provide privacy and ample time
Have plan if constipation develops
375
Q

What does a healthy stoma look like?

A

Deep pink to brick red, shiny, and moist

376
Q

How can you help a patient adjust to living with a bowel diversion?

A

Teach about diet modification
Teach about ongoing ostomy care
Help them adjust to its presence

377
Q

Why is skin care around a stoma so important?

A

Because skin breakdown can lead to infection, pain, and leakage

378
Q

What effect do cathartics have on the GI tract?

A

Promote peristalsis and are stronger than laxatives

379
Q

What effect do narcotics have on the GI tract?

A

Decrease GI activity (depress CNS) leading to constipation

380
Q

What are some common cathartics?

A

Dulcolax
Ex-lax
Senna

381
Q

What are some dangers of chronic use of cathartics?

A

Decrease muscle tone in large intestine and decrease responsiveness to laxatives

382
Q

What are some common laxatives?

A

Docusate
Milk of magnesia
Mineral oil

383
Q

How do laxatives work?

A

Soften stool by drawing fluids into the bowel

384
Q

What can overuse of laxatives cause?

A

Diarrhea
Dehydration
Electrolyte depletion

385
Q

What is a risk of using mineral oil to relieve constipation?

A

Decreases the absorption of fat soluble vitamins

386
Q

What is a medication risk of using laxatives?

A

They may interfere with the effectiveness of other meds by altering the amount of time they’ll be in the GI tract to be absorbed

387
Q

How can aspirin change fecal appearance?

A

Can cause GI bleeding and make stool red or black

388
Q

How can NSAIDS affect fecal appearance?

A

Red or black stool (d/t bleeding from GI irritation)

389
Q

How does iron alter stool appearance?

A

Makes them black

390
Q

How do antibiotics change stool appearance and why?

A

They disrupt normal bacterial flora of the GI tract and make stool grey green (often as diarrhea)

391
Q

How do antacids change stool appearance?

A

They cause whitish discoloration/specks

392
Q

What are some diagnostic procedures for the GI tract?

A

Colonoscopy
Endoscopy
Sigmoidoscopy

393
Q

What does general anesthesia do to the GI tract?

A

Slows or stops peristalsis

394
Q

What is paralytic ileus?

A

Temporary (24-48 hour) cessation of GI peristalsis due to manipulation of intestines during surgery

395
Q

ASSESS FOR BOWEL SOUNDS POST OP

A

..

396
Q

How soon should newborns void after birth?

A

Within 24 hours

397
Q

How will the urine of newborns look? Why?

A

Light yellow or clear, because they cannot effectively concentrate it

398
Q

How common are UTIs in infants?

A

Very common (second most common infection in this age group)

399
Q

When does the elimination system reach maturity?

A

Between ages 5 and 10

400
Q

What is enuresis?

A

Involuntary passing of urine

401
Q

What percentage of 6 year olds struggle with enuresis?

A

10%

402
Q

When is nocturnal enuresis considered a problem?

A

When the child is older than 6 years old

403
Q

Which age group and gender experiences the most frequent UTIs?

A

Females from the ages of 15-24

404
Q

What does pregnancy do to the risk of UTIs?

A

Increases it

405
Q

Why do men over 50 have increased urination frequency?

A

Enlarged prostate gland

406
Q

By what percentage does total number of nephrons decrease by age 75?

A

30-50%

407
Q

How does bladder capacity change in older adults?

A

Decreases from around 500ml to 250 ml

408
Q

Which care professionals are allowed to change the ostomy bags?

A

Only the RN

409
Q

What are special considerations for 24 hour urine collections?

A

Must be kept on ice
Must get ALL urine for a 24 hour period
Upon initiation, pt must void, discard that urine, and then collect everything for 24 hours

410
Q

What are some common antidiarrheal medications?

A

Imodium

Lomotil

411
Q

How does the nurse manage fecal impaction?

A

PREVENTION is the optimal strategy
Determine presence of impaction
Can only do digital removal if presence is confirmed
Enema can be used to soften

412
Q

How much urine should an infant produce per day? How many diaper changes is this?

A

15-60 ml/kg

8-10 wet diapers per day

413
Q

What is stress incontinence?

A

Urine incontinence upon activities like laughing, sneezing, and coughing

414
Q

Where should the urine collection bag rest?

A

Below the level of the bladder but off the floor

415
Q

Is a doctors order needed for catheterization?

A

Yes

416
Q

Is a doctors order needed for a bladder scan?

A

No, nurse can decide to do independently

417
Q

What are Kegel exercises?

A

Pelvic floor muscle exercises

418
Q

How does the nurse assess fundal height/uterine placement in the mother postpartum?

A

Put one hand on top of the uterus and one hand below to support, and then you can assess placement

419
Q

How long does involution of the uterus take?

A

Around 6 weeks

420
Q

How much should the fundus go down ever day?

A

Between one and two cm

421
Q

What helps with the fundus descending back down?

A

Uterine contractions

422
Q

What do you do for a patient with a sub-involution?

A

Monitor fundal position, lochia, vital signs

Encourage client to breastfeed, ambulate, and void regularly

423
Q

Lochia rubra

A

Dark red, bloody, and heavy flow

First 1-3 days after birth

424
Q

Lochia serosa

A

Pinkish brown

4-10 days after birth

425
Q

Lochia alba

A

Yellowish white/creamy discharge

From 10 days to 3+ weeks after birth

426
Q

What level of discharge do you want before patient leaves hospital?

A

Scant or light (4” or less)

427
Q

What is one way to determine whether a discharged clot is dangerous or okay?

A

If it cuts easily, its okay. If its tough and membranous, it signals a problem

428
Q

What is the difference between a laceration and an episiotomy?

A

Laceration is a tear that occurs on its own during birth

Episiotomy is an incision made by the doctor during delivery

429
Q

What kind of education will you provide for someone with a laceration or episiotomy?

A

Cleanse the area after voiding
Blot the area
Clean from front to back

430
Q

What is one effective treatment for hemorrhoids?

A

Sitz baths

431
Q

Why is tearing preferred over an episiotomy?

A

Because it involves only soft tissue tear, which heals easier than the muscle incision of an episiotomy

432
Q

What happens to maternal glucose levels postpartum?

A

They decrease and return to normal

433
Q

What happens to estrogen and progesterone levels postpartum?

A

They decrease

434
Q

Why are hemorrhoids so common during pregnancy and postpartum?

A

Because the fetus puts pressure on the veins in the perineum, as does giving birth

435
Q

When will ovulation resume in lactating women? Non-lactating?

A

Lactating: approximately 6 months but it can happen sooner

Non-lactating: usually 7-9 weeks

436
Q

What should lactating and non-lactating women be taught regarding contraceptives?

A

Lactating women should start contraceptives after milk production is established (at around 6 weeks).
Non-lactating women should start them earlier, because ovulation can occur after just one month

437
Q

When does urinary function return to normal postpartum?

A

5-7 days but will take up to a month to be completely normal

438
Q

Why should a woman empty her bladder after delivery?

A

To prevent hemorrhage

439
Q

What happens if the bladder doesnt empty properly in a postpartum woman?

A

It can displace the uterus and prevent proper uterine involution

440
Q

Will milk still come in if a woman decides not to breastfeed?

A

Yes

441
Q

What are some interventions that can be done for the non-breastfeeding woman when her milk comes in?

A

Use breast binders, very supportive bras, and ice. Do not support/aid milk expression

442
Q

What is colostrum and for how long is it present?

A

It is the early milk-like substance that is produced until the milk comes in. Usually present until 72-96 hours after delivery

443
Q

What is engorgement and what are some comfort nursing interventions?

A

Fullness and pain in the breasts

Nurse can administer ice, teach breast care, and promote frequent feedings

444
Q

What are likely infection areas for postpartum mothers?

A

Uterus
Breasts
Urinary tract

445
Q

When is RhoGAM given?

A

When an Rh- mother gives birth to an Rh+ baby, to prevent the mother from developing antibodies to Rh+ blood in future pregnancies

446
Q

How can the nurse promote mother-baby bonding?

A

Delay unnecessary procedures in the first hour after birth so mother and baby can have that time together
Encourage breastfeeding
Skin to skin contact

447
Q

What are benefits of breastfeeding for the baby?

A

Excellent source of all needed nutrients
Maternal antibodies
Reduced disease and obesity risk for breastfed children
Reduced infant mortality

448
Q

What are benefits of breastfeeding for the mother?

A

Reduced mortality
Decreased postpartum bleeding
Promotes healthy weight loss

449
Q

What does “baby friendly” hospital status mean?

A

It means the hospital meets a set of criteria to support breastfeeding and parent-child bonding

450
Q

How does a nurse assess LATCH?

A

Assess to see if infant’s mouth is over the nipple, areola, and breast with a seal between the mouth and the nipple

451
Q

What are the four most common breastfeeding holds?

A

Football
Modified cradle
Across lap
Side-lying

452
Q

What are feeding cues that a mother can watch for from her infant?

A

Firm tugging without pain
Audible swallowing
Round, non-dimpled cheeks
Jaw gliding smoothly

453
Q

What is a normal respiration rate for a newborn?

A

30-60 per minute

454
Q

What is a normal heart rate for a newborn?

A

110-160 BPM

455
Q

Where do you take a newborn’s temperature?

A

Axilla

456
Q

When doing newborn vitals, which should be assessed first?

A

Respiration and heart rate

457
Q

What is the normal range for blood pressure in newborns?

A

60-80 systolic

40-50 diastolic

458
Q

What is caput?

A

Swelling of the soft tissues of the scalp (filling up with non-blood fluid)

459
Q

What is cephalhematoma?

A

Blood between the periosteum and skull bones (medical emergency)

460
Q

What can newborns see at birth?

A

Things 8-12 inches from their face

461
Q

What can newborns hear?

A

Almost as much as adults

462
Q

What might it indicate if the infant’s nostrils are flaring with each breath?

A

Possible nasal blockage

463
Q

What are retractions? Why are they concerning?

A

The area between the ribs and the neck sinking in during infant’s inhalations.
Sign of difficulty breathing

464
Q

What is the normal vessel content of the umbilical cord?

A

2 arteries and one vein

465
Q

What is pseudomenses?

A

Blood tinged vaginal discharge seen in some newborn females due to estrogen levels (very normal)

466
Q

When should an infant’s first bowel movement occur?

A

12-24 hours after birth

467
Q

What does breast milk stool look like?

A

Yellow/golden and pasty, less smelly

468
Q

What does formula stool look like?

A

Yellow brown, with a firmer consistency and stronger smell

469
Q

What will stool with bilirubin present look like?

A

Brown (will be pale without)

470
Q

What is a normal voiding pattern for newborns?

A

2-6 times a day on the first and second days

6-8 times per day after that

471
Q

Lanugo

A

Fine downy hair

472
Q

Milia

A

White spots on newborn’s skin

473
Q

Vernix caseosa

A

Protective, thick, cheesy skin covering

474
Q

Will premature babies have more or less vernix?

A

More do not take off

475
Q

Stork bites

A

Flat pink or red marks on the neck or face (normal birthmarks)

476
Q

Erythema toxicum

A

Pink rash appearing in the first 3 weeks of life. Very mild allergic reaction that is fairly normal

477
Q

Mongolian spots

A

Spots of pigmentation on the back and butt that are very common on babies of color

478
Q

Port wine stains

A

Purple/red capillary angiomas common on infants faces. Not treatable and dont usually go away

479
Q

What are some health promotion activities for newborns?

A

Promote breastfeeding
Newborn screenings
Administer medications and vaccinations

480
Q

What are the normal newborn screenings?

A

Universal newborn screening
Hearing
Bilirubin
Congenital heart defect screening

481
Q

Why is erythromycin given to infants and in what form?

A

Given as eye drops to prevent conjunctivitis and blindness from potential bacteria encountered in birth canal

482
Q

What are the main nursing activities in the first three days postpartum?

A 
Prevent complications
Promote breastfeeding
Support comfort levels
Family bonding
Education about self care, infant care, and home care
483
Q

What is BUBBLE used for?

A

Postpartum assessment

484
Q

What does BUBBLE stand for?

A 
Breasts
Uterus
Bladder
Bowel
Lochia
Episiotomy/perineum
485
Q

What is the CE added on to BUBBLE?

A

Calves (for DVT)

Emotions

486
Q

How much extra fluid does the body gain during pregnancy?

A

1500 cc

487
Q

What are some common/good postpartum nursing interventions?

A 
Prevent bleeding and infection
Monitor vitals and labs
Monitor for bladder distension
Promote early ambulation and vaccination
Promote rest, comfort, breast care, exercise, and nutrition
488
Q

How big is a newborn baby’s stomach?

A

About the size of a walnut

489
Q

How much milk do newborns need at a feeding?

A

Only a teaspoon

490
Q

How often should breastfed newborns feed and for how long?

A

Every 2-3 hours for 10-20 minutes

491
Q

How often should bottle fed infants feed?

A

Every 3-4 hours

492
Q

Why do bottle fed infants have to be burped?

A

Because air gets in the stomach as well (no seal like with breastfeeding)

493
Q

What are common care tactics for episiotomys?

A

Sitz baths
Keep it dry
Use lidocaine gel if prescribed

494
Q

What is the usual time period for discharge from the hospital for mother and baby?

A

48 hours for a vaginal delivery

96 hours for a c-section

495
Q

What should be included in a newborn assessment history?

A 
Date/time of birth
Gestational age
Method of birth
Sex
Apgar scores
Void or stool issues during birth
496
Q

What five things are measured in APGAR scoring?

A 
Activity (muscle tone)
Pulse
Grimace (reflex)
Appearance (skin color)
Respirations
497
Q

What would get an infant a 2 in the pulse area?

A

HR over 100

498
Q

What would get the infant a 2 in respirations?

A

A strong, loud cry

499
Q

What is acrocyanosis?

A

Blue coloration of the extremities. Common in infants right after birth

500
Q

What are some contributing factors to jaundice?

A

Immature liver
Excessive hemoglobin in body
Not passing urine yet
Not feeding well

501
Q

Why is feeding a proper treatment for jaundiced infants? What does it prevent?

A

Bilirubin then binds to the protein of food and doesnt reach the brain and bind there, which can cause seizures

502
Q

What could it mean if the newborn does not have two arteries and one vein in the umbilical cord?

A

Kidney issues

503
Q

What might uneven gluteal folds or gluteal muscles indicate?

A

Dislocated hip

504
Q

Controlling thermoregulation in newborns prevents what two issues?

A

Cold stress and hypoglycemia

505
Q

What are some staples of umbilical cord area care?

A

Keep it dry
Wash with soap and water
Watch for infection

506
Q

What is the first period of reactivity in the infant?

A

The first hour after birth, infant is alert and responds to mother. Try to promote first breastfeeding in this time!

507
Q

What is the second period of transition/reactivity in the infant?

A

From 1-4 hours after birth. Infant is usually asleep

508
Q

When is the third period of transition/reactivity?

A

After the fifth hour, and will last for 2-8 hours

509
Q

What are the four components of the sensory experience?

A

Stimulus
Reception
Perception
Arousal mechanism

510
Q

What does a receptor do?

A

Converts a stimulus into a nerve impulse and transmits the impulse to the CNS via sensory neurons

511
Q

The process of receiving a stimuli is called

A

Reception

512
Q

The ability to interpret sensory impulses is

A

Perception

513
Q

What do nociceptors sense?

A

Pain

514
Q

What do chemoreceptors sense?

A

Chemical changes in the body

515
Q

How does perception relate to/impact our senses?

A

Perception allows us to use our senses and make sense of stimuli

516
Q

How much sensory information does the brain discard?

A

99%

517
Q

What is the RAS?

A

Reticular activating system

518
Q

What does the RAS do?

A

Controls consciousness and alertness

519
Q

How does the RAS control consciousness and alertness?

A

It coordinates brain regions to keep us awake, attentive, and observant. It keeps us sensing and responding to our environment

520
Q

When measuring levels/effectiveness of sedation, what is being looked at?

A

The RAS, and whether its currently active or not

521
Q

Is level of stimuli necessary to maintain arousal the same for everyone?

A

No it varies from person to person and can also vary for each person depending on the environment

522
Q

Response to a stimulus is influenced by what factors?

A

Intensity
Contrast to other stimuli
Adaptation
Previous experience

523
Q

What are some other factors that can influence how we do or don’t respond to stimuli?

A 
Illness
Injury
Medication 
Stress
Personality
Lifestyle
524
Q

What are some sensory/perceptual characteristics of newborns?

A 
Less acute vision
Very acute hearing at low frequencies
Reactive to odors
Prefer sweet to sour tastes
Very keen sense of touch
525
Q

What are some sensory/perceptual characteristics of infants?

A

Need sensory stimulation

Can discriminate sounds and observe light/color/contrast

526
Q

What are some sensory and perceptual characteristics and developments in children and adolescents?

A 
Improved vision
Full depth perception develops
Balance improves
Hearing fully developed
Increased sensory stimulation due to increased socializing
527
Q

What are some sensory/perceptual characteristics of older adults?

A

Slower reflexes
Less response to stimuli
Decreased vision/hearing
Decreased sense of touch

528
Q

How does culture impact sensory-perceptual status?

A

It affects how much stimulation one is comfortable with (example: eye contact, personal space, touch)

529
Q

What is sensoristasis?

A

A state of optimal sensory arousal

530
Q

What is sensory deprivation?

A

depression of the RAS due to lack of meaningful stimuli

531
Q

What does it mean to fill in the sensory gap?

A

Becoming overly sensitive/reactive to remaining stimuli when experiencing sensory deprivation

532
Q

What are some outcomes of filling in the sensory gap?

A

Distress

Problems with perception, cognition, and emotion

533
Q

What is the nurses main goal with sensory deprivation?

A

Prevention

534
Q

What increases the risk of sensory deprivation?

A 
Impaired sensory reception (sensory losses, neurological injury, dementia, etc)
Restricted mobility
Inability to transmit or process stimuli
Boring environment
Inability to interpret cultural cues
535
Q

What are some interventions for the patient with sensory deprivation?

A

Provide stimuli
Support senses
Continual orientation
Use of comforting touch

536
Q

What are signs ands symptoms of sensory deprivation?

A 
Irritation
Confusion
Reduced attention span
Drowsiness
Preoccupation with somatic complaints
Delusions
Hallucinations
Reduced problem solving
537
Q

What is sensory overload?

A

When environmental or internal stimuli are more than the patient can tolerate or effectively process

538
Q

What are some signs and symptoms of sensory overload?

A 
Irritability
Confusion
Poor attention span
Decreased problem solving
Muscle tension 
Anxiety
Difficulty concentrating
Restlessness
Disorientation
539
Q

What are some interventions for sensory overload?

A

Minimize stimuli
Provide rest
Infrequent visitors (especially for those with brain injuries)

540
Q

From what do sensory deficits stem?

A

Impaired reception, perception, or both

541
Q

Which sensory deficits are nurses most likely to encounter?

A

Impaired vision/hearing

542
Q

What area of the brain in closely associated with vision?

A

Occipital region

543
Q

Which area of the brain is most closely associated with hearing?

A

Occipital region

544
Q

What tastes can be detected by the tongue and which areas sense these tastes?

A

Sweet and salty (tip)
Sour (lateral)
Bitter (posterior and soft palate)

545
Q

What is one of the most common causes of impaired taste? What causes it?

A

Xerostomia, which is excessive dry mouth often caused by medications

546
Q

What are some results when someone loses the sense of smell?

A

Food wont taste the same, leading to potential nutritional deficits
Inability to smell rotten food or smells associated with danger

547
Q

How can a nurse make therapeutic use of a patients sense of smell?

A

Aromatherapy

548
Q

What is two point discrimination?

A

Ability to perceive two points of pressure that are close but not touching

549
Q

Where is two point discrimination the most sensitive? Least?

A

Most sensitive: lips and fingertips

Least sensitive: torso

550
Q

Where in the brain does conscious muscle sense stem from?

A

Parietal lobe

551
Q

Where in the brain does unconscious muscle sense stem from?

A

Cerebellum

552
Q

What is the connection between optimal sensory function and health screening?

A

Many sensory problems are related to other healthcare issues, and need to be identified and treated early to preserve sensory function

553
Q

What are some interventions the nurse can use for a patient with a visual impairment?

A 
Glasses
Sufficient light
Large print books
Keep important objects close
Evaluate and respect independence
554
Q

What are some interventions for a patient with impaired hearing?

A 
Hearing aid care
Closed caption TV
Promoting environmental safety
Assessing for isolation issues
Inspect ear canals 
Quiet areas for communication
555
Q

What are some interventions for the confused patient?

A 
Assess orientation and continually reorient them
Provide safe environment
Communicate clearly and slowly
Limit choices, but do give choices
Make them feel secure
556
Q

What are some interventions for the unconscious client?

A

Continually orient to reality
Safety measures
Attend to body systems and sensory needs just like you would if they were conscious

557
Q

Can the Glasgow coma scale help determine nursing actions/care for a patient with altered LOC?

A

Yes

Krystan: Semester One Nursing School (6 decks)

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