Week 8

Question 1

Examples of role-relationships NANDA dx

Answer 1

Risk for impaired attachments

Caregiver role strain

Grieving

Interrupted family process

Social isolation

Question 2

spiritual well being

Answer 2

Faith: cultural or institutional religion, belief in something, enables action

Religion: Specific system of practices assoc. w/ form of worship

Question 3

Spiritual problems

Answer 3

Acute illness

Chronic illness

Terminal illness

Near-death experience

Question 4

Spiritual interventions

Answer 4

Health promotion: establish presence, trust, support

Acute care: identify support system, diet therapy, supportive rituals

Restorative care and continuing care: prayer/meditation

Question 5

Spiritual evaluation

Answer 5

Success=increased/restored sense of connectedness

Question 6

Conditions that affect air movement

Answer 6

Eupnea
Tachypnea
Bradypnea
Apnea
Hypercarbnia/capnia

Question 7

Conditions that affect diffusion

Answer 7

Hypoxemia
Hypoxia
Cyanosis

Question 8

Biots respirations

Answer 8

4-5 irregular breaths then a period of apnea

Question 9

Complete vs partial respiratory function

alteration

Answer 9

complete: No chest movement, unable to speak

Partial: low snoring, retractions, inspiratory stridor, restlessness, dyspnea

Question 10

Throat culture collection

Answer 10

Collect culture before antibiotics

Depress tongue, swab posterior wall of throat

Avoid antiseptic mouthwash before

Avoid touching any other mouth area

Two swabs preferred

Question 11

Nursing respiratory diagnoses

Answer 11

Ineffective airway clearance

Inffective breathing pattern

Impaired gas exchange

Activity intolerance

Question 12

Respiratory planning

Answer 12

Maintain patent airway

Improve ease of breathing

Maintain ability to take part in activities

Prevent risks associated with O2 problems

Question 13

Nursing positioning interventions respiratory

Answer 13

Positioning: semi or high fowlers

Orthopenic/tripod position

Turn every two hours, sit up/out of bed

Ambulation

Question 14

Nursing hydration/medication interventions respiratory

Answer 14

Humidifiers

Bronchodilators

anti-inflammatory

Leukotriene modifiers

Expectorant

Cough suppressant

Question 15

Pursed lip breathing used for

Answer 15

COPD

Question 16

does O2 therapy need order

Answer 16

yes

Question 17

partial rebreather vs nonrebreather

Answer 17

Partial: 6-10L/min, 45-60% FIO2

Nonrebreather:
95-100%FIO2
10-15L/min

Question 18

Venturi mask

Answer 18

24-50%FIO2

Question 19

Face tent

Answer 19

4-8L/min

30-50%FIO2

not as closed up, reduces claustrophobia

Allows for emesis to exit mask and not just stay there

Question 20

COPD symptoms

Answer 20

Easily fatigued
Freq. resp. infections

Labored breathing

Thin

Cor Pulmonale

Wheezing

Pursed lip

Respiratory acidosis

Question 21

oropharyngeal artificial airways

Answer 21

Stop tongue from blocking airway

Question 22

tracheostomy stuff

Answer 22

Suction only when withdrawing

suction when client not able to cough

Sterile technique for lower airways

Provide O2 before and after suctioning

Question 23

Chest tubes

Answer 23

Drain blood or air from pleural space