VN 15 TEST 1-DONE

Question 1

NEGLIGENCE

Answer 1

A harm that results because a person did not act reasonably

Question 2

4 COMPONENTS NECESSARY TO PROVE NEGLIGENCE

Answer 2

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

Question 3

Do nurses need personal liability insurance? Is it mandatory?

Answer 3

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.

Question 4

FIDELITY

Answer 4

Being faithful to work related commitments & obligations

Question 5

VERACITY

Answer 5

Being honest & avoid deceiving or misleading a client

Question 6

AUTONOMY

Answer 6

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

Question 7

BENEFICENCE

Answer 7

Doing good or acting for another’s benefit

Question 8

WHEN CAN RESTRAINTS BE USED

Answer 8

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

Question 9

LIST OF COMPLICATIONS OF IMMOBILITY

Answer 9

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.

Question 10

STEPS FOR A 4 POINT GAIT W/CRUTCHES

Answer 10

Right Crutch, Left Foot, Left crutch, Right foot

Question 11

CLIENT EDUCATION FOR PROSTHESIS USE

Answer 11

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.

Question 12

Measuring for knee- high anti embolic stockings?

Answer 12

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.

Question 13

Steps to taking Tympanic Temperature?

Answer 13

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)

Question 14

How long does the VN count the apical pulse?

Answer 14

For a minute

Question 15

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

Answer 15

1. Inspection
2. Auscultation
3. Percussion
4. Palpation

Question 16

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

Answer 16

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

Question 17

WOUND

Answer 17

A break in the skin

Question 18

ULCER

Answer 18

Open,crater-like area

Question 19

ABRASION

Answer 19

An area that has been rubbed away by friction

Question 20

LACERATION

Answer 20

Torn or jagged wound

Question 21

FISSURE

Answer 21

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

Question 22

SCAR

Answer 22

A mark left by the healing of a wound or lesion

Question 23

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

Answer 23

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

Question 24

DESCRIBE 4 DIFFERENT ABNORMAL LUNG SOUNDS

Answer 24

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

Question 25

DESCRIBE HEART SOUNDS S1, S2, S3, S4

Answer 25

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”

Question 26

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

Answer 26

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.

Question 27

RECOMMENDATIONS FOR CLIENT COMPLAINING OF ITCHING AFTER CAST INSTALLATION

Answer 27

Turn on hair dryer on cool setting& aim it under cast. | DO NOT stick items under cast to scratch skin

Question 28

NURSING ACTIONS FOLLOWING APPLICATION OF A PLASTER CAST

Answer 28

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

Question 29

NURSING INTERVENTIONS WHEN CARING FOR A CLIENT W/THOMAS SPLINT

Answer 29

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.

Question 30

STEPS FOR CANE USE

Answer 30

(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

Question 31

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

Answer 31

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

Question 32

SIGNS OF INFECTION AT THE PIN SITE OF TRACTION

Answer 32

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

Question 33

ABNORMAL FINDINGS WHEN ASSESSING INTEGUMENTARY SYSTEM

Answer 33

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

Question 34

CLIENT EDUCATION FOR WALKER USE

Answer 34

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

Question 35

CLIENT EDUCATION FOR CRUTCH USE

Answer 35

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.

Question 36

SKIN COLORS &POSSIBLE CAUSES

Answer 36

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

Question 37

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

Answer 37

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