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NUR120 > Ultimate Stack™ > Flashcards

Ultimate Stack™ Flashcards

1
Q

*What are some types (6) of elder abuse?

A
  • physical (trauma, bruises, alert: may see multiple providers!!)
  • emotional (do they have outside support network?)
  • financial (ask who controls finances?)
  • neglect (unkempt appearance)
  • sexual
  • abandonment

***first intervention is to ensure client safety, THEN duty to report abuse

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2
Q

*What are some things to keep in mind when communicating with clients with cognitive deficits? (4)

A
  • use simple sentences
  • avoid vague comments
  • repeat words back exactly
  • understand that the client’s reality is distorted
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3
Q

*What are common health problems among older adults? (6)

A
  • heart disease
  • cancer
  • stroke
  • lower respiratory disease
  • diabetes
  • Alzheimer’s/dementia
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4
Q

*What are common challenges for older adults? (3)

A
  • polypharmacy (lots of meds)
  • social isolation
  • adjusting to chronic health problems, loss of independence
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5
Q

*What are the benefits of sleep? (4)

A
  • regulates metabolism
  • improves learning/adaptation
  • reduces stress/anxiety
  • improves immune system
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6
Q

*NREM vs REM sleep?

A

NREM:

  • restful phases (I,II, III)
  • muscles relax
  • body temp and BP decreases
  • delta waves present in phase III

REM:

  • mental&emotional restoration
  • dreaming

***all but NREM I are repeated about 4x/night

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7
Q

*What factors affect sleep? (4)

A
  • Age (older are more prone to sleep disturbances)
  • Lifestyle Factors (exercise, diet high sat fat interferes; animal and dairy products help, caffeine, nicotine, alcohol)
  • Illness (fever, pain, SOB interfere; anxiety)
  • Environmental (light, noise)
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8
Q

*What are the components of good sleep hygiene? (8)

A
  • good sleep habits
  • regular routine
  • restful environment
  • relaxation techniques
  • no tv/computer/cell
  • avoid caffeine, alcohol, nicotine
  • avoid carbs (?)
  • avoid exercise before bed
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9
Q

*What are some common sleep disorders? (8)

A
  • insomnia
  • restless leg syndrome (RLS)
  • sleep apnea
  • narcolepsy
  • parasomnias- sleep walking/talking
  • night terrors
  • bruxism (clenching)
  • nocturnal enuresis (bed wetting)
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10
Q

*What are 3 nonprescription sleep meds?

A
  • melatonin
  • lavender
  • chamomile
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11
Q

*What are nursing responsibilities regarding safe med administration? (5)

A
  • nurses hold full legal responsibility for safe med administration; so abide by institutional policies, state laws, and federal laws
  • practice 3 checks
  • practice 10 rights
  • narcotics must be double locked
  • need witness for “waste”
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12
Q

*What is stress? (definition)

A
  • any disturbance in a person’s balanced state

- a stimulus that the person perceives as a challenge or as physical or emotional stress

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13
Q

*What are the types of stress? (5)

A
  • distress/eustress- threat to health/good stress
  • external/internal- death of family member/anxiety
  • developmental- predictable, middle adults adjust to health changes
  • situational- unpredictable, car accident
  • anticipatory- upcoming exam
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14
Q

*How do people respond to stress?

A

**GAS (General Adaptation Syndrome)- fight or flight stage, adaptation, exhaustion or recovery

**LAS (Local Adaptation Syndrome)- localized body response, inflammatory response, pain response

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15
Q

*What is culture? (definition)

A

-a collection of learned, adaptive, and socially transmitted behaviors, values, beliefs that form the context from which a group interprets the human experience

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16
Q

*What is acculturation? (definition)

A
  • immigrants assume the characteristics of that culture through acculturation
  • a person who is acculturated accepts both their own and their new culture
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17
Q

*What is assimilation? (definition)

A
  • new members gradually learn and take on the essential values, beliefs, and behaviors of the dominant culture
  • complete when the newcomer is fully merged into the dominant cultural group
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18
Q

*How do we provide culturally competent care? (3)

A
  • incorporate beliefs and practices from various cultures into your care and education
  • encourage helpful cultural practices and discourage those that are harmful (suggest alternatives)
  • accommodate cultural dietary practices as possible
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19
Q

*What is cultural awareness? (definition)

A

-ability to objectively examine own beliefs, values, and practices

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20
Q

*Inductive vs Deductive reasoning?

A

Inductive- gathering pieces of info, see pattern, and form generalization

Deductive- general premise and moves to a specific deduction

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21
Q

*What are the essential parts of nursing theory? (4)

A
  • PERSON (needs, fears, etc)
  • (good) ENVIRONMENT
  • (improving) HEALTH
  • NURSING (care I provide)
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22
Q

*Who are some of the important theorists in nursing?

A
  • Florence Nightingale (clean environment)
  • Virginia Henderson (first to define nursing, 14 basic needs)
  • Hildegard Peplau (theorized that communication with the patient helps outcomes)
  • Patricia Benner (primacy of caring theory, novice-expert theory)
  • Madeleine Leininger (cultural competence)
  • Jean Watson (caring theory, interpersonal process)
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23
Q

*What are the rights of research participants? (6)

A
  • informed consent
  • right to not be harmed
  • right to full disclosure
  • right to self-determination
  • right to privacy/confidentiality
  • institutional review boards
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24
Q

*What do experienced nurses strive for?

A

Empowerment!

  • power to solve problems
  • power to take initiatives
  • power to exercise autonomy
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25
Q

*What are necessary leadership skills for nurses? (5)

A
  • schedule
  • identify goals
  • set priorities
  • organize work
  • delegate
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26
Q

*What are (4) leadership styles?

A
  • laizzez-faire (gives followers control in the decision-making process)
  • autocratic (gives direction, final decisions, bears responsibility of outcomes)
  • democratic (shares planning, decision making, and responsibility for outcomes. Guidence > control)
  • scientific (?)
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27
Q

*What are some religions and their practices? (4)

A
  • Christianity
  • Islam
  • Roman Catholicism (may wish for anointing the sick by a priest, deacon, or minister)
  • Jehovah’s Witnesses (refuse blood transfusion)
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28
Q

*What are barriers to spiritual care? (6)

A
  • lack of awareness of spirituality
  • lack of awareness of your own spiritual belief system
  • differences between nurse and patient
  • trying to be all things to all people
  • fear that your knowledge base is insufficient
  • fear of where spiritual discussions may lead
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29
Q

*What nursing diagnosis’ can be applied to spirituality? (7)

A
  • moral distress
  • impaired religiosity
  • readiness for enhanced religiosity
  • readiness for enhanced spiritual well-being
  • risk for spiritual distress
  • risk for impaired religiosity
  • spiritual distress
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30
Q

*What are categories of loss? (6)

A
  • actual (death)
  • perceived (perceived only by the person experiencing)
  • physical (injury, loss of function)
  • psychological (loss of hope, faith, or dreams)
  • external (loss of object)
  • environmental (loss of familiar)
  • loss of significant relationships (death or divorce)
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31
Q

*What is end-of-life care? (7)

A
  • support of family/caregiver
  • ensuring continuity of care
  • ensuring respect for person
  • ensuring informed decision making
  • attending to emotional and spiritual concerns
  • supporting function
  • managing symptoms
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32
Q

*What are the (2) key premises of hospice care?

A
  • the quality of life is as important as the length

- those who are terminally ill should be allowed to face death with dignity

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33
Q

*What are the legal and ethical concerns related to death?

A
  • advance directives
  • DNR/AND
  • Assisted suicide (ANA prohibits)
  • Euthanasia (ANA prohibits)
  • Autopsy (signed permission)
  • Organ Donation
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34
Q

*What are some interventions for family members coping with a loved one’s death? (6)

A
  • have family help with care
  • encourage questions
  • provide FU for referrals
  • encourage talk with clergy
  • provide anticipatory guidance
  • acknowledge feelings of the family
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35
Q

What are the four assessment techniques and which order are they in for most assessments?

A
  • inspection
  • auscultation
  • palpation
  • percussion
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36
Q

What is the acronym SPICES used for?

A 
Common problems in older adults:
S- sleep disorders
P- Problems with eating/feeding
I- Incontinence
C- Confusion
E- Evidence of falls
S- Skin Breakdown
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37
Q

During a comprehensive assessment what info do you gather during your general survey?

A
  • vital signs
  • height/weight
  • appearance/behavior
  • dressing/grooming/hygiene
  • body type/posture
  • speech
  • mental state
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38
Q

What are each of the cranial nerves? How to test?

A

I- olfactory- smell- cotton ball

II- optic- visual acuity, pupillary reaction to light- PERRLA

III- oculomotor- EOMS- follow penlight

IV- trochlear- EOMS- follow penlight

V- trigeminal- facial sensation, jaw movement- clench teeth, touch with cotton ball

VI- abducens- EOMS- follow penlight

VII- facial movement, taste- smile for symmetrical movement

VIII- auditory- hearing, equilibrium- whisper test

IX- glossopharyngeal- swallowing, gag reflex, tongue movement, taste, saliva- ahhh

X- vagus- sensation of pharynx/larynx, swallowing, vocal cords, cardiac/respiratory reflexes, peristalsis, digestive secretions- ahhh

XI- spinal accessory- head and shoulder movement, speaking- shrug test

XII- hypoglossal- tongue movement- light tight dynamite

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39
Q

Bronchial vs Bronchovesicular vs Vesicular breath sounds?

A

Bronchial- loud, high, longer expiration, over trachea

Bronchovesicular- medium, equal in/out, over 1st/2nd ICS adjacent to sternum

Vesicular- soft, low, breezy longer inspiration, over lung fields

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40
Q

What is the order of assessment of the abdomen?

A
  • inspect
  • auscultate
  • percuss
  • palpate
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41
Q

What tool can be used to assess level of consciousness?

A

Glasgow Coma Scale

  • evaluates eye opening, motor responses, and verbal responses
  • it does not evaluate brainstem reflexes
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42
Q

What is a normal BMI? Overweight? Obesity classes 1-3?

A 
normal- 18.5-24.9
overweight- 25-30
obesity (1)- 30-35
obesity (2)- 35-40
obesity (3)- 40+
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43
Q

What are the cervical lymph nodes? (12)

A
  • posterior auricular
  • occipital
  • superficial
  • posterior cervical
  • posterior triangle
  • superclavicular
  • deep mandibular
  • preauricular
  • tonsillar
  • submental
  • anterior triangle
  • submandibular
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44
Q

What are the (5) general health assessment components?

A
  • physical
  • mental
  • spiritual
  • socioeconomic
  • cultural
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45
Q

What are the (2) components of a comprehensive physical examination?

A

Interview

Head-to-Toe assessment

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46
Q

Subjective vs Objective data? Primary vs secondary?

A

PRIMARY
Subjective- what the client tells you
Objective- data that you obtain about the client through observation and examination

SECONDARY
Subjective- what others tell the nurse about client
Objective- data the nurse collects from other sources (family, caregivers, med records)

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47
Q

What types of things should we avoid when using therapeutic communication? (4)

A
  • medical jargon
  • giving advice or opinions
  • ignoring feelings
  • offering false reassurances
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48
Q

What are some good techniques of therapeutic communication? (6)

A
  • open-ended questions
  • clarifying- specific details
  • back channeling “tell me more” “go on’
  • probing “what else would you like to add to that”
  • closed-ended questions
  • summarizing
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49
Q

What is self-knowledge?

A

-knowing your own skill and having a willingness to seek help when needed

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50
Q

Diaphragm vs Bell of stethoscope?

A

Diaphragm- high sounds (heat, lung, bowel)

Bell- low sounds (unexpected heart sounds, bruits)

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51
Q

What are adventitious breath sounds and what do they sound like?

A

Crackles/Rales- fine bubbly sounds not cleared with coughing

Wheezes- high pitched musical sounds

Rhonchi- corse, loud, low pitched, can be cleared with coughing

Pleural Friction Rub- dry, grating, rubbing sound

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52
Q

How do we grade pulse strength?

A 
0 absent
1+ diminished, weaker
2+ brisk, expected
3+ increased, strong
4+ bounding
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53
Q

What is the expected pulse range?

A

60-100 bpm

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54
Q

What is a pulse deficit?

A
  • the difference between radial and apical pulses
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55
Q

What is ventilation?

A

-the exchange of oxygen and carbon dioxide

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56
Q

What is ventilation?

A

-movement of air air into and out of lungs

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57
Q

What are Cheyne-Stokes respirations?

A

shallow breaths lead to normal breaths lead to increased rate leads to slowing back down leads to apnea period

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58
Q

What are Kussmaul respirations?

A

increased rate, abnormally deep

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59
Q

What is the expected range for pulse oximetry?

A

95-100%

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60
Q

What is the expected range for blood pressure?

A

normal- 120/80
stage I HTN- 130/80
stage II HTN- 140/90

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61
Q

What is the pulse pressure?

A

difference between systolic and diastolic readings

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62
Q

How does cuff size affect BP?

A
  • too large- falsely low
  • too small- falsely high
  • cuff width=40% of arm circumference
  • cuff bladder=80% of arm circumference
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63
Q

During two-step BP reading how much higher do we go when the pulse is no longer felt?

A

30 mmHg higher

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64
Q

What is a DASH diet?

A

Dietary Approach to Sop Hypertension

  • restrict sodium
  • get enough K, Ca, and Mg
  • restrict cholesterol and sat fat intake
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65
Q

*What is the edema rating scale?

A

1+ trace- 2mm (rapid refill)
2+ mild- 4mm (10-15 sec)
3+ moderate- 6mm (prolonged)
4+ severe- 8mm (prolonged)

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66
Q

What is the ABCD system used for?

A 
used to detect possible skin cancer
A- asymmetry
B- border irregularity
C- color variation
D- diameter >6mm
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67
Q

What are the terms to describe joint movement?

A

Flexion- movement that decreases angle between two bones

Extension- movement that increases the angle between two bones

Hyperextension- movement of a body part beyond its normal extended position

Supination- movement of a body part so that the ventral surface is up

Pronation- movement of a body part so that the ventral surface is down

Abduction- movement of an extremity away from midline

Adduction- movement of an extremity towards midline

Dorsiflexion- foot and toes up

Plantarflexion- foot and toes down

Eversion- turning body part away from midline

Inversion- turning body part toward midline

External rotation- rotating a joint outward

Internal rotation- rotating a joint inward

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68
Q

Unexpected spinal curvatures?

A

Kyphosis- curvature of the thoracic spine

Lordosis- curvature of the lumbar spine

Scoliosis- exaggerated lateral curvature

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69
Q

What are some words we can use to describe a patients level of conciousness?

A

alert- person, place, time
lethargic- can open eyes and respond, drowsy
obtunded- responds to shaking, confused, slow
stuporous- responds to painful stimuli only
comatose- no response

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70
Q

Stereognosis vs Graphesthesia?

A

Stereognosis- familiar object in hand and identify

Graphesthesia- trace a number on palm and identify

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71
Q

What are the (3) stages of wound healing?

A

Inflammatory
-1-5 days, vasoconstriction, platelets aggregate

Proliferative
-5-21 days, granulation, fibroblasts make collagen

Maturation
-2-3 weeks (or more), old collagen is broken down an remodeled

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72
Q

What are the (3) healing intentions?

A

Primary Intention
-no tissue loss, approximated edges, little scarring

Secondary Intention
-loss of tissue, unapproximated edges, risk for infection, most scarring

Tertiary Intention
-deep and unapproximated, closed when free of infection, less scarring than 2ndary

73
Q

What are the types of drainage seen from wounds? (5)

A

Serous- clear, straw colored

Sanguineous- blood, red

Serosanguineous- pink, serous and blood

Purulent- thick, foul odor, yellow tan green or brown

Purosanguienous- pus and blood

74
Q

What are the (3) depths of wounds?

A

Superficial- epidermal

Partial-thickness- through epidermis not dermis

Full-thickness- through subcutaneous and beyond

75
Q

*What are the six risk factors related to skin integrity that the Braden scale focuses on? What does it NOT include?

A 
sensory perception
moisture
activity
mobility
nutrition
friction/sheer
**does NOT include cognition
76
Q

How do we irrigate a wound?

A

ideal irrigation pressure is 4-15 psi. More than 15 psi has a risk of driving bacteria deeper

77
Q

What are the different types of dressings (5) and what types of wounds to use them on?

A

Gauze- absorbs exudate

Transparent film- IV site or small superficial wounds

Hydrocolloid- prevents evaporation, maintains a granulating wound bed (stage 2 pressure)

Hydrogel- gel promotes autolytic debridement and cooling for infected or deep wounds (not for heavy drainage)

Alginates- non-adherent, absorb exudate, maintains a moist wound bed, packs

Collagen- helps stop bleeding and promotes healing

78
Q

What are the stages of pressure injuries?

A

Stage 1- nonblanchable erythema, intact skin

Stage 2- partial thickness skin loss, red-pink wound bed no granulation

Stage 3- full-thickness skin loss, visible adipose, possible undermining

Stage 4- full-thickness skin and tissue loss, bone or tendon visible, undermining is common

Unstageable- eschar or slough obscures the wound bed

79
Q

What are the (7) types of therapeutic diets commonly prescribed? Special recommendations for diabetics and folks with dysphagia?

A

NPO- nothing by mouth

Clear liquid- water, juice, broth, jello

Full liquid- clear plus liquid dairy

Pureed- clear and full plus pureed meat, fruit, eggs

Mechanical soft- clear and full plus diced/ground food

Low-residue- dairy products, eggs, ripe bananas

High-fiber- whole grain, raw and dried fruits

  • Diabetic- 1,800 cal/day, watch macros
  • Dysphagia- pureed and thickened liquids
80
Q

What are the fat-soluble vitamins and what are they used for in the body?

A

A- immune, skin/mucus mem, visual acuity in dim light

D- calcium and phosphorous absorption (strong bones)

E- antioxidant that fights toxins

K- synthesis of proteins for clotting and bone development (leafy greens, veg, fish, liver, meat, eggs, cereals)

81
Q

What are the water soluble vitamins and what are they used for in the body?

A

C- immune, wound healing (citrus, tomatoes, potatoes)

B- essential

82
Q

What are the (2) most commonly monitored minerals?

A

Iron- beans/lentils, leafy greens, cereals, whole grains, tofu, cashews

Calcium- dairy, leafy greens, breads with fortified flour

83
Q

*What are the normal ranges for electrolytes? (6)

A

*Sodium- 135-145
*Potassium- 3.5-5.0
*Calcium- 8.5-10.5
Magnesium- 1.6-2.6
Chloride- 95-105
Phosphorous- 3-4.5

84
Q

What are normal BUN and creatinine levels?

A

BUN- 10-25

creatinine- 0.5-1.2

85
Q

*What are normal BUN and creatinine levels?

A

BUN- 10-25

creatinine- 0.5-1.2

86
Q

What is the range for urine specific gravity?

A

1.001-1.029

87
Q

What labs to check if client is experiencing hypovolemia? Hypervolemia?

A

Hypovolemia- urinalysis, CBC, and electrolytes

Hypervolemia- ABGs, SaO2, CBC, and chest xray

88
Q

*What are some methods for collecting a urine sample?

A

Freshly voided- same method as for Intake and Output

Clean catch- cleanse genitals, catch midstream

Sterile- insert a urinary catheter and withdraw from the bladder

24-hour- void in morning and record the time, collect everything thereafter

89
Q

*What does urinalysis test? (6)

A
  • pH
  • specific gravity
  • protein
  • glucose
  • ketones
  • occult blood
90
Q

*What are some of the nursing diagnosis’ used to describe incontinence? (5)

A
  • urge incontinence- (involuntary loss of urine with strong urge to void)
  • stress incontinence (pressure from a sneeze, laugh, cough causes bladder to leak)
  • overflow incontinence (leakage of urine with distended bladder)
  • functional incontinence (all GU components work but the person cannot make it to the restroom)
  • urinary retention (unable to start urination, or if able to start, cannot fully empty)
  • urinary frequency (need to go many times a day of either a lot or a little urine)
91
Q

*Define the -urias (5)

A

anuria- no urine (>100ml/24hrs)

hematuria- blood in urine (trauma, kidney stone)

dysuria- painful/difficult urination (infection, retention)

oliguria- small amounts of urine (>400ml/24 hrs)

polyuria- large amounts of urine (diabetes, high fluid intake)

92
Q

How much urine is expected from healthy kidneys?

A

~50-60ml/hour

1.5L per day

93
Q

*What does CVAT tenderness indicate?

A

kidney infection

94
Q

What is respiration?

A

exchange of O2 and CO2 in the lungs

95
Q

What are some upper respiratory infections and some lower respiratory infections? (3 for each)

A

Upper:
cold, flu, rhinosinusitis, pharyngitis

Lower:
respiratory syncytial virus, acute bronchitis, tuberculosis

96
Q

What is saO2 vs pO2?

A

saO2- percentage of hemoglobin carrying O2

pO2- amount of O2 available to combine with hemoglobin

97
Q

What is saO2 vs pO2 vs FiO2?

A

saO2- percentage of hemoglobin carrying O2

pO2- amount of O2 available to combine with hemoglobin

FiO2- percentage of oxygen that the client receives

98
Q

Who is incentive spirometry used for? (3)

A
  • risk for pneumonia and atelectasis
  • abdominal, chest, or pelvic surgery
  • prolonged bedrest
99
Q

What are the early signs of hypoxia? (6)

A
  • tachypnea
  • tachycardia
  • restlessness, anxiety, confusion
  • pale skin, mucous membranes
  • elevated blood pressure
  • use of accessory muscles
100
Q

What are some low-flow oxygen delivery systems? (4)

A
  • nasal cannula- FiO2 24-44% at a rate of 1-6L/min
  • simple face mask- FiO2 35-50% at a rate of 6-12L/min
  • partial rebreather mask- FiO2 60-75% at a rate of 6-11L/min
  • non-rebreather mask- FiO2 80-95% at a rate of 10-15L/min delivers highest flow of O2 except for intubation
101
Q

What are some high-flow oxygen delivery systems?

A
  • venturi mask- FiO2 24-50% at flow rate of 4-12L/min most precise
  • aerosol mask- FiO2 24-100% at a rate of 10L/min
102
Q

Safety measure to take when using oxygen?

A
  • no smoking
  • cotton clothing not wool
  • electrical things should be grounded
  • no alcohol or acetone use
103
Q

What is the best way to obtain a sputum sample?

A
  • in morning
  • rinse mouth
  • breath deeply
  • cough, dont spit
104
Q

What is a fecal occult blood test used for and what can create a false positive?

A
  • used to detect occult blood in stool

- red meat, chicken, raw veg, ASA, and warfarin can create a false positive

105
Q

What is a fecal occult blood test used for and what can create a false positive?

A
  • used to detect occult blood in stool
  • collect fecal sample 3x from 3 diff defecations
  • blue color indicates blood
  • red meat, chicken, raw veg, ASA, and warfarin can create a false positive
106
Q

What is the daily amount of fiber recommended?

107
Q

What types of enemas are there? (6) How far to insert? How high to hold bag?

A
  • insert 3-4in for adults
  • 12-18in above anus

tap water (hypotonic)- do not use more than once

soapsuds- castile soap irritates and stimulates, be careful with older adults

normal saline- safest and volume stimulates

low-volume hypotonic- commercially prepared for pts who cannot tolerate high- volume

oil-retention- lubricates

medicated enema- contains meds to retain for 1-3 hrs

108
Q

What are the (4) components of body mechanics?

A
  • body alignment
  • balance
  • coordination
  • joint mobility
109
Q

List (8) ways to move your body without causing injury?

A
  • proper alignment
  • wide base of support
  • avoid bending and twisting
  • squat to lift
  • keep objects close
  • raise beds
  • push versus lift
  • get help
110
Q

isometric vs isotonic vs isokinetic exercises

A

isometric- muscle contraction without motion

isotonic- movement of a joint during muscle contraction

isokinetic- use of equipment to move a joint during muscle contraction

111
Q

aerobic vs anaerobic exercise

A

aerobic- oxygen taken in meets needs

anaerobic- oxygen taken in does not meet needs

112
Q

What are the s/s of heat exhaustion vs hypothermia?

A

heat exhaustion- fatigue, loss of concentration, dizzy, nausea, increased RR, abdominal cramps, elevated temp with cold clammy skin

hypothermia- fatigue, loss of coordination, confusion

113
Q

*What effects does immobility have on the body?

A
  • joint contractures
  • muscle atrophy
  • kidney stones
  • UTIs
  • upper respiratory infections (URIs)
114
Q

*What is paresis vs paralysis?

A

paresis- muscle weakness caused by nerve damage (partial paralysis)

paralysis- loss of the ability to move

115
Q

*What are contractures?

A

ROM of a joint becomes compromised due to muscle, tendon, or ligament tightening

116
Q

How to teach proper cane use?

A
  • cane on strong side of the body
  • move cane forward 6-10in
  • move weaker side forward toward the cane
  • advance strong leg past the cane
117
Q

How to teach proper crutch use?

A
  • elbows flexed 20-30 degrees
  • 6 in in front of and 15cm from center
  • hold crutches together when sitting or rising from a chair
118
Q

What is resistance training vs flexibility training?

A

resistance- for muscle strength and endurance

flexibility- maintain mobility

119
Q

How to teach a patient to go up or down stairs?

A
  • lead with the strong leg going up the stairs

- lead with the weak leg coming down the stairs

120
Q

What are the effects of heat vs cold therapy?

A

heat- increase blood flow, increase tissue metabolism, relaxes muscles, eases joint stiffness and pain

cold- decreases inflammation, reduces bleeding, reduces fever, diminished muscle spasms, decreases pain

121
Q

*What types of pain are there? (6)

A

superficial- subcutaneous pain (burn, papercut)

deep somatic- ligaments, tendons, blood vessels, bone (arthritis, fracture)

visceral- deep (cramps, labor, bowel, organ cancer)

radiating- starts at origin and extends (heartburn all over thorax)

referred- arises from area distant to origin (MI pain in jaw or arm)

psychogenic- no known origin

122
Q

What is the physiological pain pathway? (4)

A

transduction- activation of nociceptors by stimuli (mechanical, thermal, chemical)

transmission- conduction of pain message to the spinal cord (via A-delta fibers-fast, via c fibers-slow)

pain perception- recognizing and defining pain in the cortex

pain modulation- occurs in the spinal cord causing muscles to contract reflexively away from stimuli

123
Q

*What are the characteristics we assess for of pain?

A
  • pain location
  • quality (sharp/dull, burning, stabbing, aching, throbbing, ripping, searing, tingling)
  • intensity (pain scale, mild, distracting, moderate, severe, intolerable)
  • aggravating/alleviating factors (what makes it better/worse)
  • periodicity (episodic, intermittent, constant)
124
Q

What are adjuvant analgesics?

A
  • reduce the amount of opioid needed
  • anticonvulsants, antidepressants, local anesthetics, topical agents, psychostimulants, muscle relaxants, neuroleptics, corticosteroids
125
Q

What are (3) models used to describe a person’s health?

A

Health-illness continuum: your position moves with physiological changes, lifestyle choices, results of tx

Dunn’s health grid: predicts the likelihood that a client will have a change in health status (environment/illness)

Neuman’s continuum: high energy is associated with wellness and vice versa

126
Q

**What (10) factors disrupt health?

A 
disease
physical injury
mental illness
pain
loss
impending death
competing demands
the unknown
imbalance
isolation
127
Q

What are the (5) stages of illness behavior?

A
  • experiencing symptoms
  • sick role behavior
  • seeking professional care
  • dependence on others
  • recovery
128
Q

*What is the difference between primary, secondary, and tertiary levels of prevention?

A

Primary- PREVENT disease (immunization, child car seat education, nutrition, fitness activities, health education in schools)

Secondary- SCREEN (communicable disease screening, early detection, treatment of diabetes, exercise programs for elderly adults)

Tertiary- sTOP disease progression (begins after an injury or illness, preventions of pressure ulcers, promoting independence after brain injury, referrals to support groups, rehabilitation)

129
Q

How does change occur in the Transtheoretical Model of Change?

A 
Precontemplation- no intent to change
Contemplation- decision to change
Preparation- baby steps
Action- implement plan
Maintenance- reinforce behavior
Termination- no danger of relapse
130
Q

What are the guidelines for screening? (7)

A

Comprehensive PE- q 3 years until age 40, then q year

Dental- q 6 mos

Visual- q 3-5yrs (q 2 yrs age 40-64, q 1 years age 65+)

Cholesterol- age 20+ q 5 yrs

Colon Cancer- beginning at age 50 FOBT or colonoscopy q 10 years OR sigmoidoscopy q 5 years

Cervical Cancer- pap q 3 yrs ages 21-65

Breast Cancer- mammogram offered at age 40, def start at age 50, at age 54 can be biannual

131
Q

*What are the three domains of learning?

A

Cognitive- storage and recall of information

Psychomotor- hands on skill

Affective- challenging feelings, beliefs, attitudes, and values

132
Q

What is self-efficacy?

A

a person’s perceived ability to successfully perform a task

133
Q

Passive vs Aggressive vs Assertive communication styles?

A

Passive- avoids conflict, lets others take the lead, apologetic

Aggressive- forces others to lose, bossy, manipulative

Assertive- “can do” attitude, “I” statements, use negative inquiry, compromises

134
Q

What are the (4) phases of the therapeutic realtionship?

A

Pre-interaction- gathering info prior to meeting

Orientation- build rapport

Working- nurse cares, client expresses theirselves

Termination- conclusion at end of shift or discharge

135
Q

*What are the (4) key characteristics of therapeutic communication?

A

Empathy- desire to be sensitive to the client

Genuineness- responding honestly

Concreteness- clear responses

Confrontation- getting clarification from client, being willing to be confronted if unclear

136
Q

What are some “interventions” to enhance therapeutic communication? (10)

A
  • address pt
  • listen actively
  • establish trust
  • be assertive
  • restate, clarify msg
  • interpret body language
  • explore issues
  • use silence
  • summarize convo
  • use recordings
137
Q

What are some barriers to therapeutic communication? (10)

A
  • asking too many questions
  • fire-hosing info
  • asking why
  • changing subject
  • failing to probe
  • expressing approval or disapproval
  • offering advice
  • false reassurance
  • stereotyping
  • using patronizing language
138
Q

What are the (4) components of self-concept?

A

Body image- cognitive understanding and sensory input affect mental image of self

*Role Performance- actions a person takes in fulfilling a role

Personal Identity- learned through socialization, doesn’t change very much, UNIQUE

Self-esteem- how well you like yourself. Difference between ideal self and actual

139
Q

*What is included in a sexual health history?

A
  • reproductive history
  • cancer screening
  • history of abuse
  • sexuality
  • activity/dysfunction
  • illness, meds
  • sexual self-concept
  • current relationship status
  • support systems
140
Q

What medications could affect sexual functioning?

A

Diuretics- decrease vaginal lubrication, ED, and low libido

Antidepressants- ED and low libido

141
Q

*What are the five routes of med administration?

A
  • PO (oral)
  • enteral (NG tube, G tube, J tube)
  • parenteral (IV, injections)
  • sublingual (under tongue)
  • buccal (cheek) *used to absorb into mucous membranes rather than GI tract
  • topical (lotion, cream, ointment, transdermal patch, inhalations, eye, ear, nasal, rectum, vagina)
142
Q

*Pharmacokinetics vs Pharmacodynamics?

A

Pharmacokinetics- absorption, distribution, metabolism, and excretion

Pharmacodynamics- primary and secondary effects of the drug

143
Q

What are the (6) components of a med prescription?

A
  • full name
  • date and time
  • name of med
  • dosage size, freq, number of doses
  • route of admin
  • signature of provider
144
Q

*What are the three checks?

A
  • before you pour
  • after you prepare med
  • at the bedside
  • *checking against MAR
145
Q

*What are the (12) rights?

A
  • right patient
  • right drug
  • right dose
  • right route
  • right time
  • right documentation
  • right reason
  • right to know
  • right to refuse
146
Q

Where are ___ given? What are ___ used for? Angle of injection? (Intradermal, Subcutaneous, Intramuscular)

A

Intradermal:

  • nondominant forearm (or chest/upper back)
  • TB or allergy test
  • 5-15 degrees

Subcutaneous:

  • abdomen and triceps (fast absorption) anterior thigh and upper buttocks
  • insulin, immunization
  • not closer than 5cm to belly button, 45-90 degrees

Intramuscular:

  • deltoid, vastus lateralis, ventrogluteal (site of choice) **AVOID DORSOGLUTEAL
  • iron, anything really
  • 90 degrees
147
Q

*What factors affect absorption, distribution, metabolism, and excretion?

A

Absorption:

  • route of admin
  • drug solubility
  • PH ionization
  • blood flow

Distribution:

  • membrane permeability
  • protein binding capacity
  • local blood flow

Metabolism:

  • liver function
  • first pass effect
  • health/disease status

Excretion:
-kidney function

148
Q

What are the (6) ethical principles for client care?

A

Beneficence- do good

Nonmaleficience- do no harm

Autonomy- right to make one’s own decisions

Fidelity- fulfillment on promises

Justice- fairness

Veracity- tell the truth

149
Q

What are the (3) types of torts?

A

Unintentional:

  • negligence- failure to use safety measures for a fall risk patient
  • malpractice- med error resulting in death

Quasi-intentional:

  • breach of confidentiality
  • defamation of character

Intentional:

  • assault- threat
  • battery- physical
  • false imprisonment- restraining a client against their will
150
Q

What does the Patient Self-Determination Act stipulate?

A

staff must inform clients they admit of their right to refuse or accept care

151
Q

What is the chain of infection?

A

Infectious Agent- bacteria, virus, fungi, prion, parasite

Reservoir- human, animal, food, water, soil, insects, surfaces

Portal of Exit- respiratory tract, GI tract, transplacental

Mode of Transmission- contact, droplet, airborne, vector

Portal of Entry- break in skin, sexual contact

Susceptible Host- compromised immune system

152
Q

What are the (4) stages of infection?

A

Incubation- pathogen enters the body and first symptoms

Prodromal- symptoms rise

Illness- findings specific to the infection occur

Convalescence- symptoms disappear

153
Q

What (2) lab values would indicate an infection?

A

WBC- greater than 10.000

ESR- over 20mm/hr

154
Q

What are standard precautions?

A
  • applies for all patients
  • hand hygiene after contact with the client, after removing gloves
  • mask, eye protection, and face shields when their could be splashing or spraying of bodily fluid
155
Q

What are transmission precautions (4)?

A

Airborne:

  • measles, varicella, TB
  • private room
  • N95
  • negative pressure airflow exchange
  • client should wear a mask when outside of room

Droplet:

  • strep, pneumonia, flu, scarlet fever, rubella, pertussis, mumps
  • private room (or same dx)
  • masks for HCP and visitors
  • client should wear a mask when outside of room

Contact:

  • RSV, shigella, wound infections, herpes, impetigo, scabies, MDROs, cdif
  • private room (or same dx)
  • gloves and gown worn by HCP and visitors
  • disposal of infectious material in its own bag

Protective:

  • private room
  • positive airflow
  • HEPA filtration for incoming air
  • mask for client when out of the room
156
Q

What are the guidelines for use of restraints?

A
  • provider must assess client face-to-face
  • choose the restraint that is least restrictive
  • 4hrs max for an adult, can be renewed for up to 24 hours
  • signed consent from patient
  • assess restraints every 2 hours, should be able to fit 2 fingers under them

NEVER USE FOR:
convenience, punishment, clients who are extremely mentally of physically unstable

157
Q

What is the acronym RACE used for?

A 
Fire response:
R: rescue
A: alarm
C: contain
E: extinguish
158
Q

*What are some of the considerations for a Catholic patient?

A
  • clients may wish to anoint a client who is ill or near death
  • clients might fast during lent
  • might practice Holy Communion or have clergy come visit
159
Q

*What are some of the considerations for a Muslim patient?

A
  • may avoid conversations about death
  • might withdraw life-support services but continue hydration and oral feedings
  • avoid organ transplantation
  • may decline porcine-derived-medications
  • fast during Ramadan
  • should be faced toward Mecca and pray 5x a day
160
Q

*What are some of the considerations for Jehovah’s Witness?

A
  • refuse blood transfusions

- dont observe holidays

161
Q

*What are some of the considerations for Judaism?

A
  • might refuse treatment on Sunday
  • life support may be discouraged
  • Kosher diet
  • death care is often performed by Jewish Burial Society and buried within 24 hours
162
Q

What is the Kubler-Ross Model?

A

Grief follows a pattern:

  • denial
  • anger
  • bargaining
  • depression
  • acceptance
163
Q

How to provide post-mortem care?

A
  • elevate the HOB
  • remove tubes
  • remove personal belongings
  • clean the body, keep dentures in
  • fresh linens
  • brush the client’s hair
  • remove supplies
  • apply ID tages post-viewing
  • if an autopsy is being performed tubes should stay in place
164
Q

*What should we do to promote teaching?

A
  • consider the patients learning style, language, education level
  • teach concepts simple to complex
165
Q

*How to obtain a sexual history?

A

-provide privacy

166
Q

*Rest vs Sleep?

A

Rest- the body is inactive and relaxed

Sleep- altered consciousness

167
Q

*What does a lack of REM sleep do to the body?

A
  • REM sleep is necessary for mental and emotional restoration
  • a person deprived of REM sleep for several nights in a row may experience REM rebound which means they will have more REM sleep on successive nights
  • sleep deprivation in general causes drowsiness, difficulty performing tasks, difficulty with cognitive functions, restlessness, perceptual disorders, slowed reaction time, irritability, reduced immune system defenses
168
Q

*What are the s/sx of fluid volume deficit and fluid volume overload?

A

FVD:

  • thirst
  • HR and BP up
  • hypovolemic shock: HR up, weak pulse, orthostatic hypotension, elevated temp, dry skin/turgor, fatigue, decreased urine output

FVO:

  • high BP
  • bounding pulse
  • increased shallow resp
  • cool, pale skin
  • distended neck veins
  • edema
169
Q

*What needs to be present in a nursing theory?

A
  • nurse
  • patient
  • environment
  • health
170
Q

*What are some interventions for altered sensory function?

A

Hearing loss:

  • sit and face client
  • hearing aids
  • speak slowly and clearly
  • short sentences
  • lower pitch before increasing volume
  • minimize background noise
  • do not shout

Vision loss:

  • call client by name when approaching, let them know when you leave
  • stay in client’s visual field if they have some vision
  • explain interventions before touching them
  • describe arrangement of food as if a clock

Aphasia (difficulty speaking or understanding speach):

  • call pt by name
  • clear and slow speech
  • pause between statements
  • check for comprehension
  • tell client when you do not understand them
  • ask Q’s that have simple A’s
  • picture chart may help
  • ackowldge frustration

Disoriented:

  • call client by name
  • maintain eye contact
  • brief simple sentences
  • one Q at a time
  • directions one step at a time
  • allow time to respond
171
Q

*What is SBAR?

A 
handoff report
S- Situation
B- Background
A- Assessment
R- Recommendation
172
Q

*What is Erikson’s theory?

A

Psychosocial Development Theory:

individuals must master 8 stages as they progress through life (may move back or forward based on life events)

173
Q

*What are some common myths about older adults that are not true?

A
  • that they are all incontinent
  • that they cant have sex
  • that they can’t learn new things
174
Q

*What are some common age-related changes?

A
  • decreased bladder capacity
  • dry skin, low skin turgor
  • increased BP
  • decreased muscle tone
  • decreased saliva production and GI motility
  • decreased sensation
  • vision or hearing changes
175
Q

*How to prevent a catheter associated urinary tract infection?

A
  • maintain a closed system
  • keep insertion site clean
  • empty bag every 8 hrs
  • dont let the bag touch the floor
176
Q

*What do you know about Tylenol (acetaminophen)?

A

Class: Antipyretic (fever reducer), non-opioid analgesic

Side Effects: SJS, TENecrolysis, fatigue, insomnia, anxiety, N&V, dyspnea, constipation

Contraindications: kidney or liver disease, taking with warfarin, NSAIDS, or alcohol

Client Education: avoid alcohol, check for rash, don’t take for longer than 10 days

177
Q

*What do you know about ibuprofen?

A

Class: Non-steroidal Anti-Inflammatory Agents

Side Effects: heart complications, exfoliative dermatitis, SJS, TENecrolysis, GI bleed, constipation, N&V, dizziness, drowsiness, burred vision, tinnitus, renal failure

Contraindications: ulcers, heart problems, renal problems, active GI bleed

Client Education: avoid driving, don’t take for more than 10 days, avoid alcohol, observe for rash or cardiac symptoms

178
Q

*What do you know about Oxycodone?

A

Class: opioid analgesics

Side Effects: confusion, sedation, respiratory depression, constipation, dizziness, blurred vision, headache

Contraindications: severe respiratory depression, asthma, paralytic ilieus

Client Education: avoid driving, protect med from theft, don’t crush ER tablets, avoid alcohol

NUR120 (17 decks)

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