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nur 111 final
final exam
| Question | Answer |
|---|---|
| maslow's hierarchy of needs | 1: physiological 2. safety 3. love/belonging 4. esteem 5. self-actualization |
| trust vs. mistrust | infant, dependence on mother, need body & sensory stimulation, have a routine, attend to needs promptly |
| autonomy vs. shame & doubt | toddler, mastery of body and environment, stress of separation from mother, |
| initiative vs. guilt | preschool, beginning of peer involvement, accept child as they are, allow independence |
| industry vs. inferiority | school age,competitiveness, puberty, provide intellect stimulation |
| identity vs. role confusion | adolescence, independence from family, choosing life goals, peer pressure to conform |
| intimacy vs. isolation | young adult, carrying out life plans, choosing work & mate, depression over interruption of plans |
| generativity vs. stagnation | middle aged adult, ideas for next generation, carrying out life goals, assessment of life |
| integrity vs. despair | older adult, life review, dec. physical function, unhappiness due to dec. independence |
| types of abuse | physical, emotional, sexual, financial, violation of rights |
| barriers to obtaining help from elder abuse | fear of reprisals, question of injury occurred, cultural traditions make it difficult to determine abuse |
| ANA code of ethics | pt dignity & advocate, commitment to pt, nurse responsibility for own practice, character & professional growth, quality health care, collaboration with other health care professionals, maintain nurse values |
| primary healthcare | health promotion and illness prevention |
| secondary healthcare | diagnosis and treatment |
| tertiary healthcare | rehabilitation and health restoration |
| AIDET | acknowledge, introduce, duration, explanation, thank |
| QSEN | pt centered care, team work, evidence based practice, quality improvement, informatics, safety |
| TEAMSteps | from military, pt safety, promote team leadership, situation monitoring, support communication |
| TCAB | transforming care at the bedside |
| HIPPA | protected & kept private, allows pt access & the ability to amend their health info, pt has right to refuse or approve release of health info, pt has right to view info unless MD feels it is harmful, info may be revealed to friend/family identified by pt |
| payment sources | medicare, medicaid, SSI, private, canada, cobra, military/va |
| 5 steps to the nursing process | 1. assessment 2. nursing diagnosis 3. planning 4. implementation 5. evaluation |
| characteristics of a GOAL | realistic, measurable, time frame, pt centered, positively stated |
| purpose of documentation | communication, education, assessments & planning, research, auditing, legal documentation, agency accreditation, reimbursement |
| source orientated medical records | each person or department makes notation in a separate section or sections of clients chart |
| problem orientated medical records | data is arranged according to problems the pt rather than source of the info |
| charting by exception | only abnormal or significant findings or exceptions to norms are recorded |
| computerized charting | use computers to stare pt database, add new data, create and revise care plans and document pt progress |
| info found in Kardex | medical diagnosis, MD orders, plan of care, nursing orders, test & procedures, diet/activity, safety precautions, written in pencil |
| 4 factors influencing response to stress | 1. nature of stress 2. # of stressors to be coped with at one time 3. duration of exposure to stressor 4. past experiences with comparable stressor |
| negative stress | rejection, guilt, negative body image, embarrassment, breaking off relationship |
| nursing diagnosis for stress | hopelessness, ineffective coping |
| anxiety | response to unobservable internal danger, source not identifiable, r/t future or anticipated event, vague, psychological/ emotional conflict |
| fear | response to observable external danger in proportion to danger, source in identifiable, r/t present event/happening, definite & clear, result of direct or psychological entity |
| 4 levels of anxiety | mild, moderate, severe, panic |
| nursing intervention with angry patient | recognize pt is angry, ask direct questions, accept anger for what it is, assist pt to recognize they are angry, encourage pt to verbalize anger and their feelings, allow time to relax |
| stages of dying | 1. denial and isolation 2. anger 3. bargaining 4. depression 5. acceptance |
| effect of dying process: senses | in sweating, impaired taste/smell, blurred vision, hearing is last to go |
| effect of dying process: skin | loss of sensation |
| effect of dying process: respiratory system | rapid, shallow, irregular, abnormal, gurgling, mouth breathing, dry mucous membranes |
| effect of dying process: CNS | mobility & reflexes dec., dec. muscle tone, changes in consciousness |
| effect of dying process: circulatory system | dec. circulation, dec. pulse, poor circulation=edema |
| effect of dying process: GI & GU system | dec. activity of GI tract, constipation, incontinence |
| signs of brain death | exclude hypothermia as cause of coma, rule out residual drug/alcohol, confirm absence of brain stem function |
| biological half life | time required for body's elimination process to reduce concentration by half life |
| peak drug level | highest blood or plasma concentration |
| what absorbs the drugs | kidneys |
| what breaks the drugs down | liver |
| onset of action | time after administration when body initially responds to drug feels effect of med |
| how do you check for placement of a g-tube | insert 5-10mls of air and listen for pop, aspirate content, check pH (normal range is < or equal to 5) |
| adverse reactions to medications | allergy, idiosyncracy, cumulative, iatrogenic, teratogenic |
| idiosyncracy | unexpected, individualized, under/over responsiveness to med, unexplainable |
| iatrogenic | disease caused unintentionally by med therapy |
| variables influencing drug action | age, gender, weight, illness/disease |
| how does heart diseases effect drug action | distribution problems |
| how does liver disease effect drug action | metabolism problems (accumulation of drug) |
| wound assessment | redness, edema, ecchymosis, drainage, approximation |
| contaminated wounds | pathogenic organism with no signs of infection |
| colonized wounds | body carries pathogen but no S/S of disease |
| infected wounds | S/S of disease are present |
| infection cycle | reservoir, portal of exit, common modes of transmission, portal of entry, host |
| microorganisms need... | warm, dark, moist, nutrients, oxygen, pH, immune response |
| local S/S of infection | redness, heat, edema, pain, drainage |
| systemic S/S of infection | fever, malaise, fatigue, anorexia, elevated wbc, diaphorsesis, irritability |
| 4 stages of infection | 1. incubation 2. prodromal 3. illness 4. convalescence |
| drives infection control practices | OSHA |
| sets standards and guidelines | CDC |
| mechanical debridement of wound | Surgical: cut away dead tissue Non-specific: pull off dead and healthy tissue |
| autolysis debridement of wound | let body own chemicals try to debride |
| transparent film and non-adherent | autolytic debridement, minimal drainage wound |
| hydrocolloid dressings | not infected wounds, autolytic debridement |
| hydrogel | absorbs small amount of exudate, autolytic debridement, partial/full thickness wounds, infected wounds |
| foam dressing | light to heavy drainage, not for dry eschar |
| what stage pressure ulcer is used for impaired SKIN integrity | stage 1 and 2 |
| what stage pressure ulcer is used for impaired TISSUE integrity | stage 3 and 4 |
| ___ blood glucose ___ rate of wound healing | increased; decrease |
| serosanguineous | serum and blood in drainage |
| sanguineous | bloody drainage |
| purulent | pus drainage |
| partial thickness wounds | involve only epidermis and dermis |
| full thickness wounds | involve complete destruction of the epidermis and dermis and extend into deeper tissues |
| human body regulates temperature by... | sweating, shivering, vasoconstriction, vasodialation, avoidance of external heat/cold |
| body's heat production is influenced by... | BMR, muscle activity, thyroxin, epi/norepinephrine, fever |
| pyrexia | fever |
| S/S of hypothermia | dec. body temp, shivering pale cold skin, dec. urine output, confusion, dec. muscle coordination |
| normal temperature ranges | oral: 97.6-99.6 Rectal: 98.6-100.6 Axillary: 97-98.6 |
| the most accurate measurement of frequency and rhythm of the heart | apical pulse |
| can radial pulse be > apical pulse | no |
| normal pulse range for older adult | 70(60-100) |
| respiration consist of what 3 interrelated procedures | 1. ventilation 2. diffusion 3. perfusion |
| normal respiratory range for older adult | 16(15-20) |
| eupnea | normal resp. rate |
| cheyne strokes | rapid and shallow resp. with periods of apnea |
| 4 determinants of BP | 1. pumping action of heart 2. peripheral vascular resistance 3. blood volume 4. blood viscosity |
| orthostatic hypotension | BP falls when pt sits or stands with S/S of vertigo |
| pulse pressure | difference between systolic an diastolic pressure |
| hygiene nursing diagnosis | self care deficit |
| how are microorganisms are transmitted | direct, indirect, vector-borne, droplet, airborne |
| pressure ulcer risk factors | dec. mental status, dec. sensation, excess body heat, circulatory problems, older person |
| stage 1 pressure ulcer | intact skin, reddened area |
| stage 2 pressure ulcer | loss of epidermis, partial thickness, blister |
| stage 3 pressure ulcer | full thickness, tissue visible, may include undermining/tunneling |
| stage 4 stage ulcer | full thickness, exposure of bone/tendon/muscle |
| unstageable pressure ulcer | full thickness, base of ulcer covered by slough or eschar |
| squeezing on muscles that surround veins | dec. venous pooling, inc. venous return, inc. cardiac output, dec. dizziness |
| functional level 1 | requires equipment/device |
| functional level 2 | help from another person |
| functional level 3 | help from another person and equipment |
| functional level 4 | is dependent and doesn't participate in movement |
| nursing diagnosis for activity | impaired physical mobility |
| cataracts | buildup of protein in the lens that makes it cloudy, prevents light from passing clearly through the lens causing some loss of vision |
| glaucoma | damage to the optic nerve |
| 6 F's of distended abdomens | flatus, fetus, foreign matter, feces, flat, fluid |
| opioid | morphine, demerol, acts in CNS, moderate-severe pain |
| side effects of opioid (narcotic) | constipation, resp. depression therefore check respirations |
| non opioids-acetaminophen | Tylenol, mild-moderate pain, can cause hepatotoxicity |
| factors affecting pain experiences | fear, lack of knowledge, culture, ethnic values, environment, support, psychological |
| developmental consideration for older adults: pain | may not report due to dec. sensations or perceptions, seen as a weakness to admit pain |
| delirium | sudden, altered mental state caused by a disturbance in brain function |
| nursing intervention for delirium | remove causative agent, prevent further damage, mild sedation with MD order, hydrate, provide quite environment, measure I&O |
| symptoms of dementia | cognitive impairment, functional losses, behavior changes, anxiety, depression, hallucinations |
| nursing intervention for dementia | safe & structured environment, inc. sleep, proper nutrition, support family |
| drugs for dementia | cognex, namenda, aricept, haldol, depakote |
| NREM | non rapid eye movement, divided into 4 stages, 75% of sleep during night |
| meds affecting sleep | Lasix: inc. urination Beta-blockers: causes nightmares Bronchodilators: CNS stimulant |
| nursing diagnosis for sleep | sleep pattern disturbance |
| stages of sleep | Pre-sleep->NREM stage 1->NREM stage 2->NREM stage 3->NREM stage 4-> NREM stage 3-> NREM 2 |
| conduction | direct touch transfer of heat/cold |
| convection | loss of heat by air |
| diathermy | use of high frequency current to generate heat |
| nursing intervention for INEFFECTIVE TISSUE PERFUSION PERIPHERAL (arterial) | keep extremity below level of heart, eliminate pressure pointd, discourage leg crossing, assess SPO2 |
| nursing intervention for INEFFECTIVE TISSUE PERFUSION PERIPHERAL (venous) | assess for edema, remove venous pressure points, HT moving legs QH, do not massage leg, administer diuretics, apply antiembolism stockings |
| arterial assessment | pain, pallor, absent pulse, paresthesis, cold temp. |
| venous assessment | warm temp., edema |
| atelectasis | collapse of lung tissue, air sacs aren't completely filled |
| oxygen therapy assessment | 1. breathing 2. airway 3. circulation |
| incentive spirometer | measure how much pt can breath in with force, helps with lung expansion, improve ventilation, helps with collapsed aveoli |
| chronic hypoxia | fatigue, clubbing fingernails |
| hypoxia | dec. O2 in cells/body |
| 4 requirements essential for adequate ventilation | 1. adequate atmospheric O2 2. clear air passage 3. adequate stretch ability and recoil 4. intact CNS |
| 3 functions of resp. system | gas exchange, fluid balance, acid-base balance pH |
Created by:
kamia2010
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