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Nursing 101: Test #1 > Test #2 > Flashcards

Test #2 Flashcards

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1
Q

Describe Jean Watson’s theory of caring how it relates to GSC philosophy.

A

Individuals are unique and worthy of respect. Multi-dimensional (holistic) care = physiological, spiritual, psychological. Holistic care meets needs of diverse population across the lifespan.

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2
Q

Name 7 caring behaviors.

A
  1. Being with/doing for
  2. Touch
  3. Listening
  4. Know the patient.
  5. Spiritual care
  6. Relieving pain/suffering
  7. Family care
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3
Q

What are the four C’s of how to provide care?

A

Courtesy
Comfort
Connection
Confirmation

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4
Q

What is Kristin Swanson’s Theory of Caring?

A

Being with the patient and doing for the patient

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5
Q

What is primary purpose of patient records? Secondary purposes?

A 
Primary = communication
secondary = legal documentation, reimbursement, auditing/monitoring, education, research
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6
Q

What is the golden rule of documentation?

A

If it’s not documented, it has not been done.

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7
Q

Describe TJC-NPSG #2. Give examples

A

Improve effectiveness of communication among caregivers. (do not use list, complete nursing care data.

Trx of info (reporting, change-pf-shift hand off, nursing rounds, pt trx)

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8
Q

What are the 6guidelines/essentials for clinical documentation?

A
  1. Complete
  2. Legible
  3. Organized
  4. Current
  5. Factual
  6. Accurate
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9
Q

What does DARP stand for? Explain what each one stands for.

A

Data - assessment data
Action - nursing intervention
Response - pt’s response to intervention
Plan - future

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10
Q

What does SBAR stand for?

A

Situation, background, assessment, recommendation

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11
Q

What are guidelines for reporting?

A
  1. Essential pt info
  2. Assessment finding/related info
  3. Request/recommendation
  4. Pt’s response to care administered
  5. Identify priorities for next shift.
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12
Q

What are the. steps of the nursing process?

A
  1. Assessment - establish baseline data and rapport/trust with patient
  2. Analysis - identify issues/CC
  3. Planning - create plan of care/establish goals
  4. Implementation
  5. Evaluation
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13
Q

What are the 5 components of critical thinking? KECAS

A 
Knowledge base
Experience
Competencies
Attitude
Standards
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14
Q

What are the 3 levels of critical thinking?

A

Level 1 = Basic
Level 2 = Complex
Level 3 = Commitment

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15
Q

What are the competencies for clinical decision making?

A 
Critical thinking
Problem Solving
Inference
Nursing Process
Diagnostic Reasoning
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16
Q

What is the difference between nursing diagnoses and medical diagnoses?

A

Nursing dx = resp to health alteration/disease and is focused on pt’s health perception.

Medical dx = disease process and focuses on pathophysiology

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17
Q

What are the types of nursing diagnoses?

A 
Actual = impaired tissue integrity (w/signs and symptoms)
Potential = risk for impaired tissue integrity (w/no signs/symptoms)
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18
Q

What does etiology mean?

A

The cause of the diagnosis, where it stems from (“as evidenced by”)

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19
Q

What does SMART stand for? Related to an outcome

A 
Specific
Measurable
Attainable
Realistic
Timely
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20
Q

What are the 7 steps of evidence based practice?

A
  1. Cultivate spirit of inquiry
  2. Ask clinical question (PICOT)
  3. Search for relevant evidence
  4. Critically appraise evidence gathered.
  5. Integrate. evidence with expertise, pt preferences/values to make best clinical decision
  6. Evaluate outcomes of practice change based on evidence
  7. Communicate outcomes of EBP decisions/changes
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21
Q

What does PICOT stand for?

A 
Patient population of interest
Intervention/area of interest
Comparison intervention
Outcome
Time frame
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22
Q

Name the normal breath sounds by name, location, and sound on auscultation.

A
  1. Tracheal
  2. Vesicular
  3. Bronchovesicular
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23
Q

Name the different adventitious breath sounds.

A
  1. Crackles (rales): wet popping
  2. Wheeze: high-pitched moving through small airway
  3. Rhonchi: continuous low-pitched snore
  4. Stridor: high-pitched crowing - airway obstruction
  5. Pleural Friction Rub: low-pitched due to inflammation
24
Q

Name the normal breath sounds by name, location, and sound on auscultation.

A
  1. Tracheal/Bronchial: expiration longer than inspiration
  2. Vesicular: inspiration longer than expiration
  3. Bronchovesicular: equal inspiration/expiration
25
Q

Name the normal breath sounds by name, location, and sound on auscultation.

A
  1. Tracheal/Bronchial: expiration longer than inspiration
  2. Vesicular: inspiration longer than expiration
  3. Bronchovesicular: equal, inspiration/expiration
26
Q

Describe the location and origin of vesicular breath sounds.

A

Inspiration longer than expiration. Created by air moving through smaller airways.
- soft, low pitched

27
Q

Describe the location and origin of bronchovesicular breath sounds.

A

Inspiration equal to expiration. Created by air moving through large airways.
- Medium pitched

28
Q

Describe the location and origin of tracheal/bronchial breath sounds.

A

Expiration longer than inspiration. Created by air moving through trachea close to chest wall.
- Loud and high pitched

29
Q

What is the term for absence of breath?

A

Apnea

30
Q

What is the term for higher than normal respirations?

A

Tachypnea

31
Q

What is the term for lower than normal respirations?

A

Bradypnea

32
Q

Describe crackles.

A

r/l lung bases

33
Q

What are the accessory muscles of breathing?

A

Sternocleidomastoid, trapezius, abdominal muscles. (Do not usually move with normal passive breathing)

34
Q

What is the correct gait sequence when using crutches going down stairs

A

Crutches forward first, then strong leg, then weak leg.

35
Q

How frequently should an immobile patient be turned and repositioned?

A

Every 2 hours

36
Q

Therapeutic position where head of bed is 45-60 degrees

A

Fowler’s

37
Q

Paralysis of the lower extremities

A

Paraplegia

38
Q

Positioning patient on side of bed w/legs in a dependent position

A

Dangle

39
Q

Abnormal drop in blood pressure when pt moves from bedrest to sitting/standing position

A

Orthostatic Hypotension

40
Q

Paralysis of one side of the body

A

Hemiplegia

41
Q

Weakness of one side of the body

A

Hemiparesis

42
Q

Permanent shortening of muscles/ligaments that restrict movement of a joint

A

Contracture

43
Q

Leg that goes first when ambulating a patient who has a walker and right leg weakness

A

Right leg

44
Q

Force exerted against skin while skin remains stationary but the boney structures move.

A

Shearing force

45
Q

What does manifestation mean in regards to analysis?

A

Manifestations = symptoms of actual problems

-Example = swollen right leg (fractured right femur)

46
Q

What do we inspect the thorax for during head-to-toe assessment?

A

Symmetry, configuration

- posterior thorax for bony prominences

47
Q

Which areas do you auscultate the lungs posteriorly?

A
  1. To the right/left of C7
  2. T3
  3. T4
  4. T10
  5. Sometimes T12 if patient is tall
48
Q

Which areas do you auscultate the lungs anteriorly?

A
  1. Both sides of trachea (bronchial)
  2. Apices (midclavicular line - distant bronchovesicular)
  3. 2nd ICS (btw 2/3 rib, midclavicular line - bronchovesicular)
  4. 4th ICS (btw 4/5 rib, midclavicular - vesicular)
  5. 6th ICS (btw 6/7 rib, midclavicular - vesicular)
  6. Midaxillary line @ 8th ICS
49
Q

What type of questions would you ask a patient before performing a chest/respiratory assessment?

A

Ask if they have any hx of COPD, asthma, pneumonia. Ask if they’re having SOB, smoke cigarettes chest pain, family hx.

50
Q

What are the different quadrants of the abdomen called? And which organs are located in each quadrant?

A

Lower right - secum, appendix,
Upper right - liver, gallbladder
Upper Left - stomach, spleen, pancreas, liver
Lower Left - sigmoid colon

51
Q

Which areas of the abdomen do you auscultate with the bell of your stethoscope? Where are they located? What sound are we looking for?

A
  1. Abdominal aorta - 2 inches above umbilicus
  2. Renal arteries - 2 inches above/to the right & left of umbilicus
  3. Iliac arteries - 2 inches below/to the right & left of umbilicus

**Looking for bruit sound. Should hear nothing if normal.

52
Q

What does “motility” mean?

A

How food is moved through GI tract through peristalsis.

53
Q

What are things to take note of when inspecting the abdomen?

A

Scars, bruises, lesions, stretch marks, bulging, visible masses, symmetry, distention, swelling/red or enlarged umbilicus.

54
Q

What is the normal range for bowel sounds?

A

5-30 times per minute

55
Q

What does hyperactive bowel sounds indicate?

A

Increased motility or peristalsis of the bowels. Could indicate diarrhea

56
Q

What does hypoactive bowel sounds indicate?

A

Decreased bowel sounds that occur less than 1 minute. Listen for bowel sounds for 5 minutes (1 min 15 sec each quadrant) to confirm absence of bowel sounds

57
Q

What is the purpose of palpating the abdomen?

A

Making sure patient doesn’t have any rebound tenderness, masses, rigidity, guarding,

Nursing 101: Test #1 (5 decks)

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