Week 3 Flashcards

Question 1

Q

What is the nursing process

Answer

A

intellectual process of reasoning 
 
 Assessment > diagnosis > planning > implementation > evaluation 
 
 These steps are not linear to one another and are subject to change (you could go from evaluation back to diagnosis)

Question 2

Q

What is the assessment phase ?

Answer

A

collection of pertinent data to the client’s health status or situation.
 
 Nurses begin their assessment by documenting a comprehensive
 nursing health history, a detailed database that allows them to plan
 and carry out nursing care to meet clients’ needs

Question 3

Q

What is the diagnosis phase ?

Answer

A

the nurse analyzes the assessment data in order to determine key issues and make
clinical judgements in the form of a nursing diagnosis.

Question 4

Q

What is the planning phase:

Answer

A

e creation of a formal plan that prescribes
 strategies and alternatives to attain the expected outcomes

Question 5

Q

What is the implementation phase:

Answer

A

Then carries out implementation of the plan. This may occur by coordinating care delivery, providing health teaching and health promotion activities to the client, consulting with other health care providers, or providing medications or other therapies within the scope of practice of the registered nurse

Question 6

Q

What is the evaluation phase ?

Answer

A

the nurse conducts an evaluation of the client’s response to the selected interventions and determines whether the interventions were effective.

Question 7

Q

what is subjective data ?

Answer

A

are clients’ verbal descriptions of their health concerns.
 Subjective data are obtained through the health history and the nurse’s
 questions and the explanation the client provides
 
 include feelings, perceptions, and self-report of symptoms

Question 8

Q

what is objective data

Answer

A

observations or measurements of a client’s
 health status. Inspection of the condition of a wound, description of
 an observed behaviour, and measurement of blood pressure are examples of objective data.
 
 Objective data may be considered a normal
 or abnormal finding

Question 9

Q

What are the sources of data ?

Answer

A

Nurses obtain data from a variety of sources. Each source of data provides information about the client’s level of wellness, strengths, anticipated prognosis, risk factors, health practices and goals, and patterns of health and illness. Primary source: The only primary source of data is the client Secondary source: clients chart/ nurses notes/ charting / physician progress notes/ or family members (this type of source is anything outside the client itself) Tertiary source: literature or nurses experiences

Question 10

Q

Methods of data collection ?

Answer

A

Interview: is an organized conversation with the client. The initial formal interview involves obtaining the client’s health history and information about the current illness
 
 Nurse has the opportunity to:
 -Introduce him- or herself to the client, explain the nurse’s role, and explain the role of other health care providers during care.
 - Establish a caring therapeutic relationship with the client.
 - Obtain insight about the client’s concerns and worries.
 - Determine the client’s goals and expectations of the health care system.
 - Obtain cues about which parts of the data collection phase necessitate further in-depth investigation

Question 11

Q

What is the orientation phase of the interview ?

Answer

A

the nurse introduces him- or herself, describes the nurse’s position, and explains the purpose of the interview.
 
 It is imperative that nurses explain to clients why they are collecting data (e.g., for a nursing history or for a focused assessment) and assure them that any information obtained will remain confidential and will be used only by
 health care providers

Question 12

Q

What is the working phase of the interview ?

Answer

A

In the working phase of the interview, nurses gather information about the client’s health status. 
 
 The nurse does this by focused questioning and other communication strategies such as active listening, paraphrasing, and summarizing to promote a clear interaction. 
 
 Open ended questions and closed ended questions are also utilized

Question 13

Q

Open ended questions are ?

Answer

A

Nurses use open-ended questions whenever they want to explore broader issues and have clients describe their history in their own words
 
 example: tell me how you are feeling ?
 
 your discomfort affects your ability to get around in that way ?

Question 14

Q

Close-ended questions are ?

Answer

A

can all be answered by “yes” or “no” (or a choice of answers that the nurse provides); these should be limited to issues in which the
 nurse does not need additional information from the client
 
 examples:
 do you feel as if the medication is helping you ?
 
 who is the person that helps you at home ?

Question 15

Q

What is the termination phase:

Answer

A

The nurse provides the client clues that the interview is coming to an end. "we will be finished in 2 min" this helps the client maintain direct attention without being distracted by wondering when the interview will end.

Question 16

Q

What is cultural considerations in assessment ?

Answer

A

As a nurse, it is important
 to conduct any assessment with cultural competence and cultural safety.
 
 Good communication techniques are important
 when assessing a client whose culture is different from your own.

Question 17

Q

what is the family history ?

Answer

A

The purpose of collecting the family history is to obtain data about immediate and blood relatives. The objectives are to determine whether the client is at risk for illnesses of a genetic or familial nature and to identify areas of health promotion and illness prevention

Question 18

Q

what is the physical examination ?

Answer

A

is an investigation of the body to determine its
 state of health. A physical examination involves use of the techniques of inspection, palpation, percussion, auscultation, and smell.
 
 A complete examination includes measurements of a client’s height, weight, and vital signs and a head-to-toe examination of all body systems

Question 19

Q

what does the clients Behaviour tell you during an examination ?

Answer

A

it is important for nurses to observe a client’s verbal and nonverbal behaviours closely in order to enhance their objective database.

Question 20

Q

What is data validation ?

Answer

A

Before nurses begin analyzing and interpreting data, they need to validate the collected information they have, to avoid making incorrect inferences. 
 
 Validation of assessment data is the comparison of data with another source to determine data accuracy.

Question 21

Q

what is analysis and interpretation of data.

Answer

A

After the nurse collects extensive information about a client, the nurse analyzes and interprets the data.
 
 The nurse begins analysis by organizing the information into meaningful and usable clusters, keeping in mind the client’s response to illness.

Question 22

Q

What are data clusters ?

Answer

A

is a set of signs or symptoms that are grouped together in a logical way. During data clustering, the nurse will organize data and focus attention on client functions to determine which
 support or assistance for recovery is needed

Question 23

Q

what is data analysis ?

Answer

A

involves recognizing patterns or trends in the clustered data, comparing them with standards, and then establishing a reasoned conclusion about the client’s responses to a health problem.

Question 24

Q

What is data documentation ?

Answer

A

last part of complete assessment. Necessary data obtained from client are recorded.

Question 25

Q

what is concept mapping ?

Answer

A

A concept map is a visual representation that show the connections between a client’s health problems.

It fosters a holistic view of the client and identifies linkages between the multiple variables affecting the 
 client’s health.
 
 Constructing concept maps demonstrates and promotes critical thinking through the use of reflection, creativity, and insight

Question 26

Q

what is a medical diagnosis ?

Answer

A

is is the identification of a disease condition on the basis of a specific evaluation of physical signs, symptoms, the client’s medical history, and the results of diagnostic tests and procedures.

Question 27

Q

what is nursing diagnosis ?

Answer

A

determines health problems within the domain of nursing. The term diagnose means “distinguish” or “know.”
 
 A nursing diagnosis is a clinical judgement about individual, family, or community responses to actual and potential health problems or life processes that is within the domain of nursing

Question 28

Q

what is a collaborative problem ?

Answer

A

is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a client’s status.
 
 When collaborative problems develop, nurses intervene in collaboration with personnel from other health care disciplines. Nurses manage collaborative problems such as hemorrhage, infection, and cardiac dysrhythmia by
 using both physician-prescribed and nursing-prescribed interventions to minimize complications

Question 29

Q

what is diagnostic reasoning ?

Answer

A

is a process of using assessment data about a client to logically explain a clinical judgement—in this case, a nursing diagnosis. The diagnostic includes decision-making steps.
These steps include data clustering, identifying client needs, and formulating the diagnosis or problem

Question 30

Q

what is the clinical criteria ?

Answer

A

are objective or subjective
 signs and symptoms, clusters of signs and symptoms, or risk factors that lead to a diagnostic conclusion. A specific set of defining characteristics helps confirm identification of each NANDA International– approved nursing diagnosis

Question 31

Q

What are the 4 formulations of the nursing diagnosis ?

Answer

A

Actual nursing diagnosis: describes responses to health conditions or life processes that exist in an individual, family, or community. Defining characteristics (manifestations, signs, and symptoms) that cluster in patterns of related cues or inferences support this diagnostic judgement
Risk nursing diagnosis: describes human responses to health conditions or life processes that will possibly develop in a vulnerable individual, family, or community. ( ex physiological factors that can increase the clients vulnerability to develop a condition)
health promotion: to increase well-being and actualize human health potential, as expressed in their readiness to enhance specific health behaviours, such as those related to nutrition and exercise.
Wellness nursing diagnosis: describes levels of wellness in an individual, family, or community that can be enhanced

Question 32

Q

what are the components of nursing diagnosis ?

Answer

A

The nursing diagnosis results from the assessment and diagnostic process.
 
 It is this two-part format that provides a diagnosis meaning and relevance for a particular client.

Question 33

Q

what is a diagnostic label ?

Answer

A

is the name of the nursing diagnosis as approved by NANDA International.
 
 It describes the essence of a client’s response to health conditions in as few words as possible.
 
 Diagnostic labels include descriptors used to give additional meaning to the diagnosis. For example, the diagnosis impaired physical mobility includes the descriptor impaired to describe the nature or change in mobility that best describes the client’s response

Question 34

Q

what is related factors ?

Answer

A

is a condition or etiology (cause/ origin) identified from the client’s assessment data

It is associated with the client’s actual or potential response to the health problem and can be changed through the use of nursing interventions.

Question 35

Q

what are risk factors ?

Answer

A

Risk factors are environmental, physiological,
 psychological, genetic, or chemical elements that increase the vulnerability of an individual, family, or community to an unhealthful event

Question 36

Q

what are some errors that can occur within the clinical setting ?

Answer

A

errors in data collection: its vital to check for inaccurate or missing data and to collect data in an organized way.
errors in interpretation and analysis of data: Data are reviewed to confirm that measurable objective physical findings support subjective data. (ex trouble breathing, matching finding on x-ray or listening to sound)
Errors in data clustering: Errors in data clustering occur when data are clustered prematurely or incorrectly or are not clustered at all. (Premature closure of clustering occurs when nurses make the nursing diagnosis before, grouping all data, incorrect clustering, occurs when nurses try to make the nursing diagnosis fit the signs and symptoms obtained)

Question 37

Q

what is the planning phase ?

Answer

A

Planning requires critical thinking, applied through deliberate decision making and problem solving, to set priorities for a client.

Successful planning requires the nurse to collaborate with the client and family, consult with other members of the health care team, and review related literature

Question 38

Q

what is priority setting ? and what are the 3 levels of priorities ?

Answer

A

is the ranking of nursing diagnoses or client problems, through the use of principles such as urgency or importance, to establish a preferential order for nursing actions<

highest priorities: conditionals that when left untreated could result in hard to the client or others.

Intermediate priorities: y nursing diagnoses involve the nonemergency, non–life-threatening needs of the client

low priorities: y nursing diagnoses are not always directly related to a specific illness or prognosis but affect the client’s future well-being. Many low-priority diagnoses focus on the client’s long-term health care needs.

Question 39

Q

What are the 3 phases of planning

Answer

A

initial > ongoing > discharge.
 
 initial planning: involves the development of preliminary plan of after assessment and diagnosis.
 
 ongoing: continuous update of clients plan of care
 
 discharge: involves the anticipation and preparation for meeting the client’s needs after discharge.

Question 40

Q

what are goals and expected outcomes ?

Answer

A

are specific client behaviour or physiological responses that nurses set to achieve through nursing diagnosis or collaborative problem resolution

Question 41

Q

what is a client centered goal ?

Answer

A

is a specific and measurable behavioural response
 that reflects a client’s highest possible level of wellness and independence in function

Question 42

Q

what is a short term goal ?

Answer

A

is an objective behaviour or response that a client is expected to achieve in a short time, usually less than a week.
 
 
 In an acute care setting, goals are set for over a course of just a few hours

Question 43

Q

what is a long term goal ?

Answer

A

is an objective behaviour or response that a client is expected to achieve over a longer period, usually over several days, weeks, or months: for example, “Client will be tobacco-free
 within 60 days.”

Question 44

Q

what are expected outcomes ?

Answer

A

a specific measurable change in a client’s status
 that is expected in response to nursing care.
 
 Expected outcomes provide a focus or direction for nursing care because they are the desired physiological, psychological, social, developmental, or spiritual
 
 Derived from both short- and long-term goals, outcomes determine when a specific client-centred goal has been met.

Question 45

Q

what are the 7 guidelines for writing goals and expected outcomes ?

Answer

A

client goal or outcome: the nurse should write a goal to reflect client behaviour not to reflect goals or intervention.
singular goal or outcome: should be precise in evaluating a clients response to nursing action.
observable goal or outcome: need to be able to observe whether change in a client’s status occurs. Changes in physiological findings and in the client’s knowledge, perceptions, and behaviour are observable.
measurable goal or outcome: It is imperative to learn to write goals and expected outcomes that set standards against which to measure the client’s response to nursing care. Examples such as “Body temperature will remain between the normal range of 36.5 and 37.5°C”
time limited goal or outcome: The time frame for each goal and expected outcome indicates when the expected response should ccur. Time frames assist in determining progress toward goals and outcomes.
mutual goal outcome: Mutually set goals and expected outcomes ensure that the client and nurse agree on the direction and time limits of care. Mutual goal setting increases clients’ motivation and cooperation.
realistic goal or outcome: It is important to set goals and expected outcomes that are achievable. Clients are then more likely to have a sense of empowerment that increases motivation and cooperation. In order to establish realistic goals, the nurse needs to assess the resources of the client, the family, the health care facility, and the community

Question 46

Q

kardex card filling system

Answer

A

allows quick reference to the needs of the client for
 certain aspects of nursing care

Question 47

Q

what are computerized care plans ?

Answer

A

a majority of health care facilities now have some type of electronic record (EHR).
 
 In many facilities, the format is for
 standardized care plans that list generalized nursing diagnoses, goals,
 outcome criteria, and interventions for specific clients. The nurse adds
 or deletes information by making selections from menus on the standardized form to individualize it for a client’s need

Question 48

Q

what is the definition of critical pathways ?

Answer

A

treatment plans that outline treatments or interventions that clients may require for treatment of a condition.

Most pathways are based on medical rather than nursing diagnoses, but they incorporate related nursing diagnoses and associated nursing interventions.

A critical pathway maps out, day to day or even hour to hour, the recommended interventions and expected outcomes

Question 49

Q

What is the implementation step of the nursing process?

Answer

A

initiates or completes
 planned actions or nursing interventions.
 
 This may include organizing and managing planned care, aiding with activities of daily living.

Question 50

Q

what is a nursing intervention ?

Answer

A

is any treatment, based on clinical judgement and knowledge, to enhance client outcomes
 
 Ideally, interventions are evidence informed providing the most current up to date and effective approaches addressing the clients problems, this includes direct/indirect care

Question 51

Q

what is direct care interventions ?

Answer

A

are treatments performed through interactions with clients.

Question 52

Q

what are indirect nursing intervention ?

Answer

A

are treatments performed away from the client but on behalf of the client
 
 ex. environment safety and infection control

Question 53

Q

what are the 3 categories of nursing interventions ?

Answer

A

1. nurse initiated
 2. physician initiated
 3. collaborative

Question 54

Q

what are independent nursing interventions ?

Answer

A

nurse initiated interventions are a type of independent nursing intervention
 
 these dont require directions from other health care providers
 
 these actions must be evidence informed decision

Question 55

Q

what are dependent nursing interventions ?

Answer

A

physician initiated interventions are a type of dependent nursing intervention
 
 These require direct orders or directions from the physician
 
 this intervention is directed towards treating or managing a medical diagnosis

Question 56

Q

what are collaborative interventions

Answer

A

Interdependent nursing interventions, or collaborative interventions, are therapies that require the combined knowledge, skill, and expertise of numerous health care providers.
 
 Typically, when a nurse plans care for a client, the nurse reviews the necessary interventions
 and determines whether the collaboration is necessary

Question 57

Q

what are the 6 factors a nurse must consider before making an intervention

Answer

A

1. the nursing diagnosis
 2. goal and expected outcomes
 3. evidence base
 4. feasibility
 5. acceptability to the client
 6. the nurse competence

Question 58

Q

Nursing intervention classification (NIC)

Answer

A

developed a set of nursing interventions that provide a level of standardization, which enhance communication of nursing care across all health care settings and enable health care providers to compare outcomes.

Question 59

Q

what is the clinical practice guideline and protocols ?

Answer

A

is a document that guides decisions and interventions for specific health care problems.

Question 60

Q

what are medical directive or standing orders ?

Answer

A

is a statement of orders for the conduct of routine therapies, monitoring guidelines, or diagnostic procedures of a combination of these for a specific client with a problem

Question 61

Q

what is the implementation process

Answer

A

Preparation for implementation ensures efficient, safe, and effective nursing care.
 
 Preparatory activities include reassessing the client, reviewing and revising the existing nursing care plan, organizing resources and care delivery, anticipating and preventing complications, and implementing nursing interventions.

Question 62

Q

what is the reassessment of a client and why is it important ?

Answer

A

Assessment is a continuous process that occurs each time the nurse interacts with a client. As new data are collected and client needs change or resolve, nurses modify the plan of care.
 
 Reassessment helps the nurse decide whether the proposed nursing action continues to be appropriate for the client’s level of wellness

Question 63

Q

Why is reviewing and revising the existing nursing care plan important ?

Answer

A

After reassessing a client, the nurse reviews the care plan, compares assessment data in order to validate the nursing diagnoses, and determines whether the nursing interventions remain the most appropriate ones for the client’s situation.
 
 if the clients status has changed and the current intervention is not appropriate, then the nursing care plan is modified.

Question 64

Q

what resources should be organized to make efficient client care ?

Answer

A

1. equipment: Most nursing procedures require some equipment or supplies. Nurses must identify which
 supplies are required for an intervention, determine whether they are available, and ensure that equipment is in working order
 
 2. personal: Nurses are responsible for determining whether to perform an intervention or to delegate it to another member of the nursing team.
 
 3. environment: Nurses must anticipate circumstances that place clients at risk and must create a culture of client safety
 
 4. Client: Before providing care, the nurse needs to ensure that the client is as physically and psychologically comfortable as possible.

Answer 65

A

concerns how certain interventions (e.g., pressure-relief devices, repositioning, or wound care) prevent or minimize complications, helps the nurse select the most useful preventive measures

Answer 66

A

a branch of of indirect care
 
 which is collaborative with a team of health care providers

Answer 67

A

cognitive skill: involves the application of critical thinking in the nursing process (to perform any intervention, nurse must use good judgments)
Interpersonal skill: the nurse must develop a trusting relationship.
psychomotor skills: require the integration of cognitive and motor activities. For example, when giving an injection, nurses need to understand anatomy, physiology, and pharmacology (cognitive skills) and use good coordination and precision to administer the injection correctly (motor skills)

Answer 68

A

are activities usually performed in the course of a normal day, including ambulation, eating, dressing, bathing, brushing the teeth, and grooming
 
 A client’s need for assistance with ADLs is
 temporary, permanent, or rehabilitative.

Answer 69

A

Direct care
 
 Illness or disability sometimes alters a client’s ability to be independent in society.
 
 IADLs include such skills as shopping, preparing meals, writing cheques, and taking medications. Nurses within the home care and community health care settings frequently assist clients in finding ways to accomplish IADLs.

Answer 70

A

Direct care
 
 Nurses routinely perform a variety of physical care techniques when caring for a client. Examples include turning and positioning, changing dressings, administering medications, and providing comfort measures.

Answer 71

A

Direct care
is a harmful effect of a medication, diagnostic test, or therapeutic intervention. Nurses are responsible for knowing the potential adverse reactions associated with nursing interventions as they provide client care

Answer 72

A

Direct care
 
 is a direct care method that helps the client use a
 problem-solving process to recognize and manage stress and to facilitate interpersonal relationships.
 
 Nurses may engage in emotional, intellectual, spiritual, and psychological support for the client.

Answer 73

A

direct care
 
 Teaching is an important nursing responsibility and is related to counselling.
 
 However, in counselling, the focus is on the development of new attitudes and feelings, whereas in teaching, the focus is on intellectual growth or the acquisition of new knowledge or psychomotor
 skills

Answer 74

A

direct care
 
 promote health and prevent illness in
 order to avoid the need for acute or rehabilitative health care. Prevention includes assessment and promotion of the client’s health potential, carrying out prescribed measures (e.g., immunizations), health teaching, and identification of risk factors for illness, trauma, or both

Answer 75

A

Nursing care is implemented to meet client-centred goals and outcomes.

Answer 76

A

valuation is the final step of the nursing process. Evaluation involves two components:
 1) an examination of a condition or situation and
 2) a judgement as to whether change has occurred.

Answer 77

A

1. identifying evaluative criteria and standards
 2. collecting data to determine whether the criteria or standards are met
 3. interoperating and summarizing findings
 4. documenting findings and any clinical judgments
 5. terminating, continuing or revising the care plan

Answer 78

A

is the minimum level of care acceptable to ensure high quality of care

Answer 79

A

are statements of progressive, step-by-step responses or behaviours that must be achieved in order to accomplish the goals of care

Answer 80

A

are assessment skills and techniques (e.g., auscultation of lung sounds, observation of a client’s skill performance, discussion of the client’s feelings, and inspection of the skin)

Answer 81

A

Nurses evaluate expected outcomes and determine whether the goals of care have been met. They then decide whether the plan of care needs to be adjusted. If goals are successfully met, that portion of the care
 plan can be discontinued. If goals are unmet or partially met, the intervention continues.

Answer 82

A

After a nurse determines that expected outcomes and goals have been met, he or she confirms this finding with the client, when possible. If the nurse and the client agree, that portion of the care plan is discontinued.

Answer 83

A

When nurses evaluate the effect of interventions, they are essentially performing another nursing assessment whereby they learn to recognize relevant evidence about a client’s condition.

Answer 84

A

When goals are not met, nurses identify the factors that interfere with goal achievement. A change in the client’s condition, needs, or abilities usually necessitates alteration of the care plan.

Answer 85

A

refers to the relationship of one body part to another body part along a horizontal or vertical line.
 
 Correct alignment involves positioning in such a way that no excessive strain is placed on a person’s joints, tendons, ligaments, or muscles, thereby maintaining adequate muscle tone and contributing to balance.

Answer 86

A

is the internal state of muscle tension within an individual muscle or muscle groups.

Answer 87

A

Body balance is achieved when a centre of gravity
 is balanced over a stable base of support and is enhanced using proper posture.

Answer 88

A

is a force that occurs in a direction to oppose
 movement. It increases a patient’s risk for skin and tissue damage and potential pressure injuries

Answer 89

A

is physical activity for the purpose of conditioning the body, improving health, and maintaining fitness, or it may be used as a therapeutic measure

Answer 90

A

the amount of exercise or activity that the individual is able to perform

Answer 91

A

muscle contraction and changes in muscle length (Walking, swimming, dance aerobics, jogging, bicycling, and moving arms and legs with light resistance are examples of isotonic exercises

Answer 92

A

involve tightening or tensing muscles without
 moving body parts
 
 An example is quadriceps set exercises

Answer 93

A

are those in which the individual contracts the muscle while pushing against a stationary object or resisting
 the movement of an object
 
 plank (for abdominal strengthening) and the wall push-up (for chest, triceps, and shoulder strengthening).

Answer 94

A

The skeletal system or bones perform five functions in the body:
 
 support, protection, movement, mineral storage, and hematopoiesis (blood cell formation).

Answer 95

A

caused by weakened bone tissue
 
 patients with lowered decreased Ca regulation and metabolism are at risk for developing osteoporosis

Answer 96

A

permit strength and flexibility of the skeleton.
 
 Strength enables the skeletal system to support
 the body

Answer 97

A

Joints or articulations are the connections between bones.
 
 A person’s flexibility is demonstrated through range of motion (ROM), which is the range of normal movement for a joint.

Answer 98

A

bones are jointed by bones. No movement is associated with this type of joint, and the bony tissue that forms between the bones provides strength and stability.
 
 The classic example of this type of joint is the sacrum, in which vertebrae are joined

Answer 99

A

or synchondrodial joint, has little movement but is elastic and uses cartilage to unite body surfaces.
 
 
 Cartilaginous joints are found when bones are exposed to constant pressure, such as the costosternal joints between the sternum and ribs

Answer 100

A

or syndesmodial joint, is a joint in which two bony surfaces are united by a ligament or membrane.
The fibres of ligaments are flexible and stretch, permitting a limited amount of movement.
For example, the paired bones of the lower leg (tibia and fibula) are fibrous joints

Answer 101

A

is a freely movable joint in which contiguous bony surfaces are covered by articular cartilage and connected by ligaments lined with a synovial membrane.
 
 Joining of the humeral radius and ulna by cartilage and ligaments forms a pivotal joint.

Answer 102

A

are white, shiny, flexible bands of fibrous tissue that support the skeletal system.

Ligaments bind joints together and connect bones and cartilage, Ligaments are elastic and aid joint flexibility and support, also have protective function

Answer 103

A

are white, glistening, fibrous bands of tissue that connect muscle to bone.
 
 Tendons are strong, flexible, and inelastic

Answer 104

A

is nonvascular, supporting connective tissue with flexibility similar to that of firm plastic
 
 permits it to sustain weight
 
 it is a shock absorber

Answer 105

A

Muscles are made of fibres that contract when
 stimulated by an electrochemical impulse
 
 Contraction of skeletal muscles allows people to walk, talk, run, breathe, and participate in physical activity.

Answer 106

A

antagonistic, synergistic, and antigravity muscle groups are coordinated by the nervous system and maintain
 posture and initiate movement

Answer 107

A

movement at the joint.
 
 For example, during flexion of the arm, the active mover (the biceps brachii) contracts and its antagonist (the triceps brachii) relaxes

Answer 108

A

are two or more muscles that contract to accomplish the same movement.
When the arm is flexed, the strength of the contraction of the biceps brachii is increased by contraction of the synergistic muscle, the brachialis

Answer 109

A

work to stabilize joints.
 
 These muscles continuously oppose the effect of gravity on the body and permit a person to maintain an upright or sitting posture
 
 In an adult, the antigravity muscles are the extensors of the leg—the gluteus maximus, the quadriceps femoris, and the soleus muscles—and the muscles of the back.

Answer 110

A

Movement and posture are regulated by the nervous system

Answer 111

A

n is the awareness of the position of
 the body and its parts.

Answer 112

A

nervous system and requires proprioception and balance

Answer 113

A

Damage to any part of the central nervous system that regulates voluntary movement causes impaired body alignment and immobility

Answer 114

A

Musculoskeletal trauma often results in bruises, contusions, sprains, and fractures.

Answer 115

A

Osteoporosis, a well-publicized disorder of aging, results in the reduction of bone density or mass.
 
 The cause is uncertain, and theories vary from hormonal imbalances to insufficient intake of nutrients

Answer 116

A

1. infants through school ages children:
 
 2. adolescence: Adolescent growth is often sporadic and uneven. As a result, the adolescent may appear awkward and uncoordinated. Adolescent girls usually grow and develop earlier than boys do. In girls,
 hips widen and fat is deposited in the upper arms, thighs, and buttocks. The adolescent boy’s changes in shape are usually a result of long-bone
 growth and increased muscle mass
 
 3. young to middle age adults: A healthy adult also has the necessary musculoskeletal development and coordination to carry out ADLs
 
 4. older people: In older persons, a progressive loss of bone mass
 occurs as a result of decreased physical activity, hormonal changes, and increased osteoclastic activity (activity by cells responsible for bone
 tissue absorption).

Answer 117

A

is the manner or style of walking

Answer 118

A

ROM exercises
 
 In active ROM exercises, patients are able to move their joints independently.
 
 With passive ROM exercises, the nurse moves each joint in patients who are unable to perform these exercises themselves
 
 Walking also increases joint mobility

Answer 119

A

1. walkers
 2. canes
 3. crutches

Answer 120

A

are the coordinated efforts of the musculoskeletal and nervous systems to maintain balance, posture, and body alignment during lifting, bending, moving, and performing activities of daily living (ADLs).

Answer 121

A

congenital and acquired impairments, degenerative and episodic conditions, and diseases affecting virtually every body system

Answer 122

A

Congenital or acquired postural abnormalities affect the efficiency of the musculoskeletal system, as well as
 body alignment, balance, and appearance.
 
 during assessment nurse has to observe the ROM

Answer 123

A

Injury and disease can lead to numerous alterations in musculoskeletal function.
 
 For example, the muscular dystrophies are a group of familial disorders that cause degeneration of skeletal muscle fibres. They are the most prevalent of
 the muscle diseases in childhood

Answer 124

A

impaired body mobility.
 
 Trauma from a head injury, ischemia from a stroke or cerebrovascular accident (CVA), hemorrhage, tumour, or bacterial infection such as meningitis can damage
 the cerebellum or the motor strip in the cerebral cortex
 
 this causes problems with balance

Answer 125

A

muscle paralysis

Answer 126

A

muscle weakness

Answer 127

A

two limb paralysis

Answer 128

A

injury above the first thoracic vertebra

Answer 129

A

bruises,
 contusions,
 sprains
 fractures

Answer 130

A

is a disruption of bone tissue continuity.
 
 Fractures most commonly result from direct external trauma but can also occur as a consequence of some deformity of the bone

Answer 131

A

refers to the inability to move about freely

Answer 132

A

is an intervention that restricts patients to bed for therapeutic reasons. Although it is much less commonly used, health care providers often prescribe this intervention.
 
 the duration of the best rest depends on a variety of conditions

Answer 133

A

describes the tendency of cells and issue to reduce in size and function in response to prolonged inactivity resulting from bed rest, trauma, casting of a body part, or local nerve damage

Answer 134

A

can cause major physiological, psychological, and social effects.
 
 The greater the extent and the longer the duration of immobility, the more pronounced are the consequences.

Answer 135

A

endocrine metabolism, calcium resorption, and functioning of the gastrointestinal system.
 
 The endocrine system, made up of hormone-secreting glands, maintains and regulates vital functions such as
 
 (1) response to stress and injury;
 (2) growth and development;
 (3) reproduction;
 (4) maintenance of the internal environment; and
 (5) energy production, use, and storage

Answer 136

A

the endocrine system triggers a series of responses aimed at maintaining blood pressure and preserving life.
 
 The endocrine system is important in maintaining homeostasis.

Answer 137

A

Immobility disrupts normal metabolic functioning, decreasing the metabolic rate; altering the metabolism of carbohydrates, fats, and proteins; causing fluid, electrolyte, and calcium imbalances; and causing gastrointestinal disturbances such as decreased appetite and slowing of peristalsis

Answer 138

A

lack of movement and exercise places patients at higher risk for respiratory complications.
 
 Patients who are immobile are at a high risk of developing pulmonary complications such as atelectasis (collapse of alveoli) and hypostatic pneumonia (inflammation of the lung from stasis or pooling of secretions).

Answer 139

A

results in orthostatic hypotension, increased cardiac workload, and thrombus formation.

Answer 140

A

is a drop of blood pressure greater than 20 mm Hg in systolic blood pressure and of 10 mm Hg in diastolic
 blood pressure.
 
 Symptoms include dizziness, light-headedness, nausea, tachycardia, pallor, or fainting when the patient changes from a lying or sitting position to a standing position

Answer 141

A

Patients who are immobile are also at risk for thrombus formation. A thrombusis an accumulation of platelets, fibrin, clotting factors, and the cellular elements of the blood attached to the interior wall of a vein or artery, sometimes occluding the lumen of the vessel

Answer 142

A

a dislodged venous thrombus

Answer 143

A

Immobility affects the musculoskeletal system by causing temporary or permanent impairment or permanent disability.
 
 Restricted mobility may result in loss of endurance, strength, and muscle mass as well as decreased stability and balance

Answer 144

A

immobility can lead to joint contractures, in which jointed are fixed with one another
 
 ex of this is foot drop ( the foot is permanently fixed in a planter flexion)

Answer 145

A

immobility forces people to be in positioned in a flat position (harder for urine to move down due to gravitational forces)
 
 this cases urinary stasis which is an increase risk for infection and renal calculi (stones)

Answer 146

A

immobility a major risk factor for pressure injuries

Answer 147

A

is localized damage to the skin and/or underlying
 soft tissue as a result of prolonged ischemia (decreased blood supply in the tissues).

Answer 148

A

can contribute to decreased social interaction, social isolation, sensory deprivation, loss of independence, and role changes.

Answer 149

A

is the maximum amount of movement available at a joint in one of the four planes of the body:
 
 medial, sagittal, frontal, or transverse.

Answer 150

A

focuses on ROM, gait, exercise and activity tolerance, and body alignment.

Answer 151

A

Flexion is decreasing the angle between two
 adjoining bones (bending of the joint);
 
 extension is increasing the angle between two adjoining bones (extending the joint).

Answer 152

A

This is movement of a body part beyond its normal
 resting extended position.

Answer 153

A

Abduction is movement of an extremity away from the midline of the body;
 
 adduction is movement of an extremity towards the midline of the body

Answer 154

A

Eversion is the turning of a body part away from the midline;
 
 inversion is the turning of a body part toward the midline (e.g., feet).

Answer 155

A

Pronation is movement of a body part so that the front or ventral surface faces downward;
 
 supination is movement of a body part so that the front or ventral surface faces upward (e.g., hands, forearm).

Answer 156

A

Internal rotation is rotation of the joint inward; external rotation is rotation of the joint outward

Answer 157

A

This is the circular movement of a limb in a
 cone-shaped manner (e.g., shoulder).

Answer 158

A

to set a baseline measurment to determine the patients mobility status and later compare and evaluate whether loss in joint mobility has occured as a result of clinical changes and treatment

Answer 159

A

is the type and amount of exercise or work that a person can perform without injury

Answer 160

A

is done with the patient lying, sitting, or standing. This assessment has the
 following objectives:
 • Determining normal physiological changes in body alignment resulting from growth and development for each individual patient
 • Identifying deviations in body alignment caused by incorrect posture
 • Providing opportunities for patients to observe their posture
 • Identifying learning needs of patients for maintaining correct body alignment
 • Identifying trauma, muscle damage, or nerve dysfunction
 • Obtaining information about other factors contributing to poor alignment, such as fatigue, malnutrition, and psychological problem

Answer 161

A

When assessing metabolic functioning, nurses
 use anthropometric measurements (measures of height, weight, and skin fold thickness) to evaluate muscle atrophy)

Answer 162

A

A respiratory assessment is performed at least
 every 2 hours for patients with restricted activity. The nurse needs to inspect chest wall movements during the full inspiratory–expiratory cycle.

Answer 163

A

Cardiovascular assessment of the patient who is immobile includes blood pressure monitoring, evaluation of apical and peripheral pulses, and observation for signs of venous stasis (e.g., edema and poor wound healing)

Answer 164

A

Major musculoskeletal abnormalities to identify during nursing assessment include decreased muscle tone and strength, loss of muscle mass, reduced ROM, and contractures.

Answer 165

A

The patient’s skin must be continually assessed for breakdown and colour changes, such as pallor or redness.

Answer 166

A

To determine the effects of immobility on elimination, the patient’s total intake and output needs to be assessed each shift and every 24 hours.

Answer 167

A

Nurses should know proper positioning and transferring techniques to safely move patients

Answer 168

A

Patients with impaired function of the nervous, skeletal, or muscular system and with general weakness often require help to attain proper body alignment while in
bed or sitting.

Answer 169

A

pillows: Provide support, elevate body parts, and can splint incisional areas, reducing postoperative pain during activity or coughing and deep breathing.
wedge: : This is a triangular-shaped pillow made
of heavy foam used to maintain the legs in abduction after total hip replacement surgery
foot boot: Prevents footdrop by maintaining the feet in dorsiflexion
trochanter roll: Prevents external rotation of the hips when the patient is in a supine position
sand bag: These are sand-filled plastic tubes or bags that can be shaped to body contours. Sandbags can be used in place of or in addition to trochanter rolls. They immobilize an extremity or maintain body alignment.
hand wrist splints: These are individually moulded for the patient to maintain proper alignment of the thumb (slight adduction) and the wrist (slight extension).
trapeze bar: This is a triangular device that descends from a securely fastened overhead bar attached to the bed frame. A trapeze bar allows the patient to use his or her upper extremities to raise the trunk off the bed, to assist in transfer from the bed to a wheelchair, or to perform arm exercises

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Week 3 Flashcards

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