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Nursing I Final Exam

QuestionAnswer
3 phases of nurse-patient interaction 1) Orientation-One to one relationship, assessment is made here with mutual agreement. This can be minutes to weeks 2) Working- The longest phase 3) Termination-the end
Inductive Reasoning Going from specific to general
Deductive Reasoning Going from general to specific
Six Rights of Medications 1) Right patient 2) Right medication 3) Right route 4) Right time 5) Right dose 6) Right documentation
Infiltration of an IV 1) Swelling 2) Cooling 3) Leakage
Phlebitis 1) Redness 2) Heat 3) Pain 4) Swelling
What local signs indicate something is wrong with the IV? 1) Redness 2) Pus 3) Warmth 4) Induration 5) Pain
What systemic signs indicate something is wrong with the IV? 1) Chills 2) Fever 3) Tachycardia 4) Hypertension 5) WBC elevated
Compensation A person overcoming a perceived weakness by emphasizing it in a more desirable trait
Denial A person refuse to acknowledge the presence of something
Displacement A person transfers an emotional reaction from one object
Introjection A person incorporates values onto another person ex. Older sibling taking parent role and advising younger sibling
Projection A person's thought or impulses are attributed to another person
Rationalization A person giving a logical or socially acceptable explanation "Behavior justification"
Reaction Formation A person develops conscious attitudes and behaviors that are opposite from what they want to believe or do
Vital Signs Temperature, Pulse, Respiration, Blood Pressure
What are 4 ways heat loss happens? 1) Convection- Pushing away the heat from them ex. Fan 2) Evaporation- When the body is wet, it evaporates to make cooler 3) Conduction- Body heat is transferred to another object 4) Radiation
Factors affecting body heat? 1) Circadian Rhythm- Lowest temperature in the morning and highest in the evening 2) Age- Increases as older you get 3) Gender- Women tend to have high temperature than men 4) Environmental
Normal Body Temperature 37 C or 98.6 F
What are the different elevation of body temperature? 1) Fever 2) Hyperthermia 3) Neurogenic Fever 4) Fever of Unknown Origin (FUO)
What are the methods to reduce fever? 1) Antibiotics- If evidence of infection 2) Antipyretics- Ibuprofen and acetaminophen 3) Other methods- cool blankets and bath or shower
What is decreased body temperature? Hypothermia
Pulse Waves produced in the wall of an artery with each beat of the heart
Apical Pulse May be listened over the apex of the heart as the heart beats
Peripheral Pulse Throbbing sensation that can be palpated (felt) wherever the artery passes a solid structure
What are the pulse characteristics? 1) Rate- Number of pulsation in 1 minute 2) Rhythm- Regular or irregular 3) Quality- Strong or weak 4) Stroke Volume
Cardiac Output The amount of blood pumped per minute
Normal Pulse Rate 60-100 beats/min
Tachycardia A rapid heart beat 100-180 beats/min
Bradycardia A slow heart beat Below 60 beats/min
Pulse Amplitude 0-absent pulse 1+-thready pulse 2+-weak pulse 3+-strong pulse 4+-bounding pulse
Dysrhythmia Irregular pattern of heartbeat
Respiration 1) Ventilation- Movement of gas in and out of the lungs 2) Inspiration- Breathing in 3) Expiration- Breathing out 4) Disfusion (external)- Exchange of oxygen and CO2 in the lungs and circulatory 4) Perfusion(internal)- the same tissue
Normal Respiration Rate 12-20 breaths per minute
Abnormal Respiration 1) Tachypnea-rapid rate 2) Bradypnea-slow rate
Apnea Periods of no breathing
Dyspnea Difficult or labored breathing
Orthopnea A condition in which breathing is better in an upright position
Cheyne-Stroke Respiration Deep, fast breathing alternating with periods of apnea
Kussmaul Breathing Deep, repetitive, gasping pattern
Blood Pressure The force of the moving blood against the arterial wall Systolic pressure/dialostic pressure 120/80
Systolic Pressure Highest pressure exerted during contraction
Dialostic Pressure Lowest pressure exerted during relaxation
High and low blood pressure High blood pressure is hypertension and low is hypotension
LPN A 1 year vocational program and take the exam
RN Either a three year program or associates degree or bachelors degree program and take exam for licence
What are the four components of informed consent? 1) Explained proposed treatment 2) Comprehension 3) Competence 4) Voluntary
What is the difference between malpractice and negligence? Negligence is unintentional harm while malpractice is negligent acts with professional training and education
What do you need to prove malpractice? 1) A duty to the client 2) A breach in the duty 3) Damage 4) Cause and effect relationship
Asepsis A condition of being free from infection
What is the purpose of asepsis? 1) To prevent infection 2) To prevent cross-infection 3) To prevent reinfection
What are the types of asepsis? 1) Medical asepsis- Clean 2) Surgical asepsis- Sterile
Maslow Biological-Safety and Security-Love and Belonging-Self-esteem-Self-actualization
Normal Range on Pulse Oximetry 90-100%
What factors can affect a pulse oximetry reading? 1) Nail polish 2) Excessive motion 3) Poor circulation
IBW Ideal body weight Females: 100 for 5' then 5 for each inch Males: 106 for 5' then 6 for each inch
Macronutrients Fats, proteins and carbohydrates
Micronutrients Vitamins, minerals and water
What are the positive signs you are pregnant? 1) Fetal heartbeat 2) Fetal movement palpable by the examiner 3) Visualization of the fetus through ultrasound
What are the probable sign you are pregnant? 1) Pregnancy test 2) Changes in pelvic organs (vagina,cervix,uterus) 3) Enlargement of abdomen 4) Ballottement 5) Braxton Hicks Contractions (false labors)
What are the presumptive signs of pregnancy? 1) Amenorrhea 2) Morning sickness 3) Excessive fatigue 4) Urinary frequency 5) Breast changes 6) Quickening
Naegle's Rule 1st day of last menstrual period-3 months+7 days+1 year=EDD
What are the 3 germ layers? 1) Ectoderm (responsible for nervous system) 2) Mesoderm (responsible for muscular/skeletal system) 3) Endoderm (responsible for digestive/gland and everything else)
What does the umbilical cord contain? 1) 1 vein (Carries rich oxygenated blood from placenta to the fetus) 2) 2 Arteries (Carries blood containing waste from the fetus to the placenta)
What is the purpose of amniotic fluid? 1) Protection 2) Aids in muscular development
What are the amniotic membranes? 1) Chorionic membrane: Outermost fetal membrane and it forms the sac and holds the amniotic fluid 2) Amniotic membrane- form beneath the chorion and adheres to it and produces the amniotic fluid
Union if the sperm and the egg depend on these 3 factors? 1) Equal maturation of the egg and the sperm 2) Ability of the sperm to reach 3) Ability of the sperm to penetrate
What are the 3 stages of fetal development? 1) Pre-embryonic- first 2 weeks 2) Embryonic stage- Week 3 to 8 3) Fetal Stage- Week 9 to birth
What are the leading cause of death in middle aged adults? 1) Motor vehicle accidents 2) Occupational injuries 3) Suicide 4) Chronic disease
Erikson Seventh Stage- Middle-aged adults Generativity VS. Stagnation
Erikson Sixth Stage- Young Adults Intimacy VS. Isolation
What are some conflicts with hospitalization? 1) Separated from friends 2) Modesty 3) Exercise 4) Independence 5) Appearance 6) Smoking/drugs
What are health concerns with teens? 1) Obesity 2) Anorexia 3) Bulimia 4) Pregnancy 5) STD's/Aids 6) Dysmenorrhea (pain with period) 7) Choking games/Huffing 8) Accidents 9) Drug/alcohol 10) Suicide/Homicide 11) Piercings/Tattoos
What are the teens issues? 1) Puberty (capable of reproduction) 2) Masturbation 3) Acne (most common skin disorder) 4) Inactivity (less real exercise)
What are the sexual development in females? 1) Hair 2) Breast enlargement 3) Menses begin
What are the sexual development in males? 1) Enlargement of testes, scrotum and penis 2) Pubic hair
What are the developmental tasks for adolescents? 1) Accepting changing body 2) Developing a sastifying male or female role 3) Achieving more adult relationship 4) Preparing for independence 5) Developing workable set of values and ideas 6) Desiring and achieving socially responsible behavior
Erikson Fifth Stage- Adolescents Identity VS. Role Confusion
ADHD Attention Deficit Hyperactivity Disorder characterized by inability to focus, attention, lack of impulsive control and hyperactivity
What are the healthcare issues concerning school age children? 1) Privacy and modesty 2) Security/family 3) Separation from peers 4) Industry 5) Regression
What are the developmental tasks to be learned by school-age children? 1) Learning academic skills 2) Expanding social boundaries 3) Developing sensitivity and respect for others
Erikson Fourth Stage- School-Age Industry VS. Inferiority
How would hospitalization affect the basic needs and developmental tasks of a toddler and preschool child? 1) Separation anxiety-especially from parents 2) Lack of routine-disruption of schedule 3)Eating habits 4) Fear of unknown 5) Confinement 6) Pain
What are the developmental tasks to be learned by preschoolers? 1) Learning sex differences and developing sex modesty 2) Begin to interact with age mates 3) Learning to identify with male-female roles 4) Learning to give and share affection 5) Learning to distinguish right from wrong
Erikson Third Stage- Preschool Initiative VS. Guilt
What are the three developmental task for toddlers? 1) Learning to control large and small muscles 2) Learning to control elimination of bowel and bladder 3) Expanding verbal communication
Erikson Second Stage-Toddlers Autonomy VS. Shame and doubt
SIDs Sudden Infant Death Syndrome- Unexplained death of an infant usually 2-4 months so place the baby on their back
What are the concerns with propping bottles? 1) Infants is unable to push the bottle away 2) Leads to tooth decay 3) Decreased physical contact 4) CHOCKING
What are the ways parents can enhance trust in infants? 1) Predictable environment 2) Consistent caregiver 3) Responding consistently to needs 4) Rhythm to care
Erikson First Stage-Infancy Trust VS. Mistrust
Enuresis Bed wetting
What are the ways to measure sleep? 1) Polysomnographyy (PSG)- Sleep study 2) Eectroencephalogram (EEG)- Brain waves 3) Electro-oculogram (EOG)- Measures the eye 4) Electromyogram (EMG)- Record of resting and voluntary muscle activity 5) Wrist actigraph- Monitor activity
Bruxism Grinding of the teeth
Erikson Eight Stage-Older Adults Integrity VS. Despair
Parasomnia Patterns of waking behavior that occurs during sleep
Sleep Apnea Periodic breathing cessation for at least 10 seconds during sleep
Hypersomnia Excessive sleeping especially during the day time
Restless Leg Syndrome Uncontrollable movement of leg during sleep (has to do with the nervous system)
Circadian Disorders Abnormality of sleep/ wake times (rotating shifts and jet lag)
Insomnia Short term (it can last a month) or it can be chronic- this is the most common where inability to fall asleep or remain asleep
Why does environmental factor affect sleep? Temperature, light and noise can affect sleep
Why does illness affect sleep? Illness can lead to an increase of sleep needed in order to recoup
Why does lifestyle affect sleep? 1) Exercise increase sleep 2) Some food can help sleep (milk) 3) Caffeine is a CNS stimulant (no sleep) 4) Anxiety can disrupt sleep 5) Alcohol can disrupt sleep 6) Medications can go both ways
Why does age affect sleep? 1) Newborns and young children- Increased REM and they have sleep related problems (nightmare and bed wetting) 2) Adolescent- Sleep related problem 3) Young adult- All nighter, work, stress
Factors Affecting Sleep 1) Age 2) Lifestyle 3) Illness 4) Environmental factor
Dreams It can occur from stage 2 to REM and dreams are remembered in REM
REM rebound Continous deprivation of sleep eventually you will knock out
Stages of Sleep NREM 1- NREM 2- NREM 3- NREM 4- NREM 3- NREM 2-REM-brief waking
REM Vital signs start to go up and mental and emotional restoration happens
NREM 4 Deepest Sleep (heart rate drops) and physical restoration is restored
NREM 3 Deeper sleep (relaxed) no eye movement
NREM 2 Light sleep but the vital signs will start to lower
NREM 1 Starting to fall asleep
REM Rapid eye movement: Brain is high sctive in sleep and its difficult to awake in this stage
NREM Non rapid eye movement: Sleep produced by withdrawn neurotransmitter
Factors influencing the trend of increasing home care? 1) Cost 2) People like it better 3) Family not staying in the same region
What can a UAP do? 1) Feeding 2) Ambulating 3) Grooming 4) Transporting 5) Collecting data 6) Reporting
The five rights of delegation? 1) The right task (which tasks are appropiate) 2) The right circumstance 3) The right person (health care worker) 4) The right direction (communication is clear and concise) 5) The right supervision
Supervision 1) RN-to-RN delegation: No supervision involve 2) RN-to-LPN delegation: The LPN is under the guidance of RN 3) RN-to-UAP delegation: Supervision is needed by the RN
Who has liscensure? RN and the LPN
RN protected scope of practice- They can not delegate... 1) Assessment 2) Evaluation 3) Nursing Judgment 4) Initial client and family education 5) Care planning 6) Health counseling and therapeutic communication
LPN can generally do many care activities except: 1) Those items in the RN scope of practice 2) IV push drugs 3) IV meds and transfusion 4) Hanging and regulating medicated IV
Different Kind of Solution 1. Isotonic- the same concentration 2. Hypertonic- greater concentration 3. Hypotonic- lesser concentration
Major Anions in Body 1. Chloride 2. Bicarbonate 3. Phosphate
Major Cations in Body 1. Sodium 2. Potassium 3. Calcium 4. Hydrogen 5. Magnesium
Extracellular Fluid 1. Intravascular- in the vascular space (blood vessels) 2. Interstitial- outside the cell (between the cells) 3. Transcellular- Joint space (the fluid in spine and brain)
Functions of Water 1. Transporting nutrient to cells and waste from cells 2. Transport hormones, blood 3. Facilitate cellular metabolism 4. Acts as a solvent 5. Help maintain body temperature 6. Facilitate digestion 7. Tissue lubricant
Four Levels of Anxiety 1. Mild 2. Moderate 3. Severe 4. Panic
Sympathetic Vs. Parasympathetic Sympathetic- Increase heart rate Para sympathetic- Slows heart rate
What is stress? A condition in which the human system respond in a normal state
12 Leading Health Indicators Were selected on the basis on their ability to promote action, the ability of data to measure progress, and their importance as public health issues
Tertiary Prevention Concerned with prevention of disease progression or re occurrence and rehab for no further complications
Secondary Prevention Focuses on early detection and prompt intervention to halt the progression- Screening activities and education for detection of early stages of illness
Primary Prevention Is concerned with health promotion and specific protection against the disease- Activities that are designed to prevent or slow the onset of disease
Levels of prevention 1. Primary 2. Secondary 3. Tertiary
Members of the Surgical Team 1. Patient 2. Circulating Nurse 3. Scrub Nurse 4. Surgeon 5. Anesthesiologist (captain of patient care) 6. Register Nurse First Assistant 7. Advanced Practice Nurse
Hypovolemic Vs. Hypervolemia Hypovolemic- Too little fluid Hypervolemia- Too much fluid
Goals of Post-Op Care 1. Maintain function 2. Promote recovery and healing 3. Facilitate coping with alterations and structure or function
Preparing the Patient Physically 1. Hygiene and skin prep 2. Elimination 3. Possible urinary catherization 4. Nutrition and fluid 5. Rest and sleep
Goals in Pre-Op Teaching 1. Promote lung ventilation and blood oxygenation 2. Promote deliberate body movement post-op to improve circulation 3. To assess and manage pain 4. Promote a sense of well-being
Moderate Sedation Conscious sedation- patient can respond verbally but amnesia can happen and they maintain their airways
Types of Anesthesia 1. General- IV or inhalation 2. Regional- Injected near a nerve or nerve pathway 3. Topical- Used on open skin surface, wounds and its spray on because if injected then its regional
Based on Purpose 1. Diagnostic-Confirm/determine diagnosis 2. Ablative-Take out diseased part 3. Reconstructive-help restore function 4. Transplantation-Take out old organ and put in new 5. Constructive-construct function that wasnt there 6. Palliative-help with sym
Degree of Risk Major or minor
Degree of Urgency 1. Emergency- Patient require immediate surgery within the hour (save organs) 2. Urgent- It has to be done within a day (appendix) 3. Required/Elective- should have surgery but in no hurry (back problem, hernia) 4. Optional- Cosmetic surgery, your choi
3 Categories of surgery 1. Degree of urgency 2. Degree of risk 3. Based on purpose
Reason for hot application 1. Inflammation 2. Contracture 3. Joint stiffness 4. Muscle spasm 5. Pain 6. Rewarm the body part 7. Hasten healing
Reason for cold application 1. Control bleeding 2. Prevent swelling 3. Cools the body 4. Relieves superficial pain 5. Muscle spasm
Cardinal response (local inflammation) 1. Swelling 2. Warmth 3. Pain 4. Redness 5. Decrease function in the affected area
Systemic response to inflammation 1. Fever 2. White Blood Cells 3. Maillase (genral discomfort) 4. Drowsiness and sluggish
Ways body resist infection 1. Intact skin and mucous membrane 2. Normal PH levels of gastric secretion 3. White Blood Cells within normal range 4. Good general health 5. Immunization 6. Stress at a healthy level 7. Other factors (age, race, heredity)
Factors required for infection to spread 1. The number of organism 2. The virulence of the organism (strength) 3. The weaken immmune system 4. The links and closeness of contact
Pathogen Pathogen can be in or out of the body. Pathogen is a disease producing microorganism.
Nursing Process A- Assessment D- Diagnosis P- Planning I- Implementation E- Evaluation
What are the consideration to be taken with fall risks? 1) Previous fall within the last 6 months 2) Person who takes 4 or more medications 3) People who are weak or dizzy from standing 4) People who forget their limits
What demographic are at risks for fall? 1) Age (increased age) 2) Gender (Females more at risk) 3) White (risks for fall)
SOAP S- Subjective (what the patient says) O- Objective (what is observed) A- Assessment P- Plan
What are the early signs and symptoms of alzheimers? 1) Forgetfulness 2) Mood changes 3) Impaired attention 4) Hygiene changes
What are the later signs and symptoms of alzheimers? 1) Gait disturbance 2) Lack of recognition 3) Incontinence 4) Sundowning (agitation and anxious)
Created by: nonelily