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VN 15 FUNDS OF NURSING > VN 15 TEST 1-DONE > Flashcards

VN 15 TEST 1-DONE Flashcards

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1
Q

NEGLIGENCE

A

A harm that results because a person did not act reasonably

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2
Q

4 COMPONENTS NECESSARY TO PROVE NEGLIGENCE

A
  1. Duty of care
  2. Breach of Duty
  3. Causation
  4. Damages
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3
Q

Do nurses need personal liability insurance? Is it mandatory?

A

Nurses should get personal liability insurance because if a nurse is involved in a lawsuit they will have a separate attorney working on nurses behalf.

Personal liability insurance is not mandatory.

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4
Q

FIDELITY

A

Being faithful to work related commitments & obligations

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5
Q

VERACITY

A

Being honest & avoid deceiving or misleading a client

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6
Q

AUTONOMY

A

A competent person’s right to make his or her own choices w/out intimidation or influence

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7
Q

BENEFICENCE

A

Doing good or acting for another’s benefit

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8
Q

WHEN CAN RESTRAINTS BE USED

A

To prevent client from self harm or harming others or when patient is interfering w/treatment. Repositioning or fall risk

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9
Q

LIST OF COMPLICATIONS OF IMMOBILITY

A

Loss of muscle mass/tissues (atrophy), strength, range of motion in joints(contractures). Decreased heart health. Balance issues, depression, weight gain,clot formation, pneumonia, pressure ulcers, urinary stasis.

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10
Q

STEPS FOR A 4 POINT GAIT W/CRUTCHES

A

Right Crutch, Left Foot, Left crutch, Right foot

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11
Q

CLIENT EDUCATION FOR PROSTHESIS USE

A
  1. Cleanse stump skin & wash the socket every evening only, rinse soap off & dry it well.
  2. Uses small brush to clean the valve on a prosthesis w/a suction socket.
  3. Keep a supply of clean stump socks to facilitate a daily change and a nylon sheath if one is used.
  4. Store clean wool stump socks for several days before use. Wash a nylon sheath in soapy lukewarm water, rinse well, and stretch it lengthwise before air-drying; never remove water by twisting the sheath.

Advise the client with a new prosthesis to wear it for short periods initially and then increase the wearing time each day

Encourage client to lie supine or prone periodically during the day. Client should avoid crossing the legs.Keeping the natural knee flexed for a prolonged period.

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12
Q

Measuring for knee- high anti embolic stockings?

A
  1. Measure the calf @the widest point

2. Measure from the bend of the knee to the base of the heel. Stocking should go right below the knee cap.

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13
Q

Steps to taking Tympanic Temperature?

A

Perform hand hygiene,Pull ear up & back for an adult and for a child you pull down & back.

Aim the probe toward the anterior inferior third of the ear canal.( insert & twist the odometer into ear so it fits right in the ear canal)

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14
Q

How long does the VN count the apical pulse?

A

For a minute

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15
Q

What is the order to assess bowel sounds in the head to toe?

A
  1. Inspection
  2. Auscultation
  3. Percussion
  4. Palpation
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16
Q

How & why does the VN assess muscles & muscle strength in head to toe assessment?

A

Strength can be measured by having client push up or against VN’s hands with one set of extremities at a time.

To assess function & screen for abnormalities

17
Q

WOUND

A

A break in the skin

18
Q

ULCER

A

Open,crater-like area

19
Q

ABRASION

A

An area that has been rubbed away by friction

20
Q

LACERATION

A

Torn or jagged wound

21
Q

FISSURE

A

A crack in the skin, especially in or near mucous membranes

22
Q

SCAR

A

A mark left by the healing of a wound or lesion

23
Q

HOW AND WHY DOES THE VN CHECK FOR SKIN TURGOR IN THE HEAD TO TOE?

A

Pinch gently the skin over the sternum or below the clavicle.
To check for dehydration

24
Q

DESCRIBE 4 DIFFERENT ABNORMAL LUNG SOUNDS

A

Crackles(crazy fluid): Pulmonary edema, HF (heart failure), Pneumonia
Wheezes(whistling): COPD, Asthma attacks
Pleural friction rub(2 pebbles rubbed together/snoring): Worsening Pneumonia
Stridor(serious squeak): chocking obstruction, croup in a child, Epiglottis (windpipe becomes inflammed) Medical Emergency

25
Q

DESCRIBE HEART SOUNDS S1, S2, S3, S4

A

S1 =“lub” sound & is louder at the apex or mitral area
S2= “dub” sound, can be heard in the mitral area but louder over aortic area
S3= “lub dub” sound or “ken-tuck-y”
S4= “lub lub dub” sound or “Ten-nes-see”

26
Q

What is the rationale for checking pupils in head-to-toe assessment?
What is it looking for?

A

It’s part of neurological assessment because pupils can provide vital diagnostic Information Looking for clear pupils,equal& between 3-7mm in diameter, round, reactive to light & accommodation of pupils when they dilate/constrict.

27
Q

RECOMMENDATIONS FOR CLIENT COMPLAINING OF ITCHING AFTER CAST INSTALLATION

A

Turn on hair dryer on cool setting& aim it under cast.

DO NOT stick items under cast to scratch skin

28
Q

NURSING ACTIONS FOLLOWING APPLICATION OF A PLASTER CAST

A

Every few hours assess skin integrity, assess for pain, assess neurovascular status(circulation/capillary refill), and assess cleanliness of cast

29
Q

NURSING INTERVENTIONS WHEN CARING FOR A CLIENT W/THOMAS SPLINT

A
  1. Make sure bandages around splint aren’t loose , apply padding. Check circulation.
  2. Provide skin care around splint.
  3. Encourage client to exercise the ankle/foot on affected leg.
30
Q

STEPS FOR CANE USE

A

(Top of cane should reach wrist, elbow slightly bent)
Maintain 2 points of support on the floor.
1.Place cane on side of leg that doesn’t need support
2.Move cane forward, then weaker extremity.
3.Move stronger extremity

31
Q

NURSING INTERVENTIONS WHEN CARING FOR A CLIENT IN A SKELETAL TRACTION FROM A FRACTURE

A
  1. Ensure that the traction weight bag is hanging freely( must not rest on bed or floor)
  2. Replace rope if it is worn or unraveled at the edge.
  3. Rope must be in the pulley tracks
  4. Ensure bandages are wrinkle free
  5. Tilt the bed to maintain counter traction
32
Q

SIGNS OF INFECTION AT THE PIN SITE OF TRACTION

A
  1. Skin redness, swelling or hardening
  2. Skin at site is warmer
  3. Increased pain at pin site
  4. Fever
  5. Yellow/green, thick or smelly drainage
33
Q

ABNORMAL FINDINGS WHEN ASSESSING INTEGUMENTARY SYSTEM

A

Clubbing nails, Alopecia, Poor turgor
Pale, yellow or bluish skin tones
Edema(swelling), lesions, skin odor

34
Q

CLIENT EDUCATION FOR WALKER USE

A

Place firm grip on both sides of the walker, then moved walker in front.
Step forward w/injured or weaker leg first, putting weight on palm of hands. Then step w/stronger leg

35
Q

CLIENT EDUCATION FOR CRUTCH USE

A

DO NOT alter crutches after fitting, follow the prescribed crutch gait.

  1. Begin in the tripod position, keep all your weight on your “good” (weight-bearing) foot.
  2. Advance both crutches and the affected foot/leg.
  3. Move the “good” weight-bearing foot/leg forward (beyond the crutches).
  4. Client should stand w/a straight back, hips, head and neck and shouldn’t place any weight on axillae.
36
Q

SKIN COLORS &POSSIBLE CAUSES

A

Pale >pallor = Anemia, blood loss
Red >Erythema= Superficial burns, local inflammation, carbon monoxide poisoning
Pink>flushed= Fever, hypertension
Purple>Ecchymosis= Trauma to soft tissue
Blue>Cyanosis=low tissue oxygenation
Yellow>Jaundice=Kidney/liver disease, destruction of red blood cells
Brown>Tan = Ethnic variation, sun exposure, addison disease

37
Q

HOW DO YOU DETERMINE INTERCRANIAL PRESSURE DURING HEAD TO TOE ASSESSMENTS?

A

During PERRLA: If eyes are sluggish to react to light or only one eye reacts.
3rd cranial nerve is assessment of pupils

VN 15 FUNDS OF NURSING (12 decks)

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