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Quiz 1 (wk.3)
professionalism, assessment (cognition, mobility, comfort, sensory)
| Question | Answer |
|---|---|
| Autonomy | The authority to make decisions related to nursing practice. |
| Knowledge | The synthesis of theory, evidence, and practical application. |
| Competence | The knowledge, skills, and abilities necessary for the practice setting. |
| Professionhood | The development of professional nursing, preparing for nursing practice. |
| Accountability | The assuming of responsibility for one’s own nursing practice. |
| Advocacy | The support and defense of the healthcare participant. |
| Collaborative Practice | The integration of nursing with other disciplines to provide holistic care. |
| Commitment | The altruistic dedication to all aspects of the nursing profession. |
| professional nurse behaviors | -teaching and learning -accountability -collaboration -advocacy -caring interventions -ethics |
| unprofessional behaviors | any behavior that makes members of the healthcare team or patients feel uncomfortable, hurt, threatened, or targeted |
| types of commitment: affective | Identification with and involvement in profession - develops when involvement in profession produces a satisfying experience |
| types of commitment: normative | Feeling of obligation to continue in profession - develops as a result of having received benefits, positive experiences through engagement in the profession |
| types of commitment: continuance | Awareness of costs associated with leaving profession - develops when negative consequences of leaving are reasons for remaining (ex. job security or loss of money) |
| 5 stages of developement | -Exploratory (exploring profession) -Testing (willingness to deal w/ negative elements) -Passionate (synthesis of + and - elements) -Quiet and bored (settling in) -Integrated (commitment created by + and -'s) |
| neuro assessment steps | 1. pupil assessment 2. orientation (mental stat) 3. motor assessment 4. sensory assessment |
| pupil assessment | inspect: size, symmetry, and shape |
| pupil light reflex | shine light in each eye and check for: -direct constriction: constriction in illuminated eye -consensual constriction: simultaneous constriction in non-illuminated eye |
| pupil documentation (PERRL) | pupils: equal, round, reactive to light and accomodation |
| orientation questions | -Person: “What is your name?” -Place: “Where are you right now?” -Time: “What is today’s date/month/year?” -Purpose/Situation: “Do you know why you are here?” |
| levels of consciousness | alert, drowsy, lethargic, etc |
| motor assessment: Hand grips | Patient squeezes examiner’s hands → compare strength bilaterally -place your dominant hand on pts dominant hand |
| motor assessment: Foot pushes/pulls | Patient pushes down (plantar flexion) and pulls up (dorsiflexion) against resistance |
| motor assessment: Biceps | Patient flexes elbow against resistance |
| motor assessment: Triceps | Patient extends elbow against resistance |
| motor assessment: Quadriceps | Patient extends knee against resistance |
| motor assessment: Hamstrings | Patient flexes knee against resistance |
| sensory assessment (light touch) | -Instruct patient to close their eyes. -Lightly touch specific body areas w/ a cotton ball and ask: “Where am I touching you?” |
| where should you touch during a sensory assessment? | - Chin - Cheek - Upper left arm - Lower right leg - Foot |
| glasgow coma scale | - Eye response (1-4) - Motor response (1-5) - Verbal response (1-6) |
| glasgow coma scale: level of consciousness | 15 points = alert and oriented 8 or less = comatose |
| body mechanics for nurses | 1. Feet Positioning: stand w/ feet apart and 1 foot slightly forward 2. Bend at the Knees to lift 3. Use Large Muscles to lift 4. Close Proximity to pt or object 5. Avoid Twisting your back |
| Prone Position | Patient lies on their stomach. It's used to improve respiratory function and prevent pressure ulcers on the back. |
| Supine Position | Patient lies flat on their back. It is often used for surgeries or when a neutral alignment is needed. |
| Lateral Position (Side-lying) | Patient rests on either side. This helps relieve pressure from the back and enhances ventilation. |
| Trendelenburg Position | Head of the bed is lowered while feet are elevated. Used to promote venous return and assist with certain medical procedures like percussion |
| Reverse Trendelenburg Position | Head of the bed raised while feet lowered. Ideal for patients with gastric conditions to prevent esophageal reflux. |
| Mechanical Lift | Ideal for patients who cannot assist in the transfer, this device uses a sling to lift and move the patient safely. |
| Gait/Transfer Belt | This belt is placed snugly around the patient's waist to provide support during the transfer. |
| Sliding Board | Useful for patients with upper body strength, it allows them to slide from bed to chair independently. |
| Wheelchair | Positioned close to the bed, it provides a stable destination for the patient during transfer. |
| Anesthesia | loss of sensation |
| hyperesthesia | more than normal sensation |
| hypoesthesia | less than normal sensation |
| Parasthesia | abnormal sensation (burning, pain,etc) |
| reflex ratings: | 0 No reflex response 1+ Minimal activity (hypoactive) 2+ Normal response 3+ More active than normal (hyperactive) 4+ Maximal activity with clonus (spasm) |
| Normal Walking Gait | Patients are expected to have an upright posture with a steady gait and opposing arm swings. They should be able to walk unaided, maintaining balance without any visible difficulties. |
| Deviations from Normal | abnormalities associated with neuro issues -poor posture, -unsteady or irregular gait, -wide stance, -rigid or no arm movements |
| Romberg Test | Assesses balance by asking patients to stand with feet together and eyes closed. A positive test means the inability to maintain stance |
| Heel–Toe Walking | Evaluates coordination and balance by requiring the patient to walk heel-to-toe along a straight line. A wider foot gait indicates potential imbalance issues. |
| adult pain scales | -descriptor (none, mild, moderate, severe) -numeric (1-10) |
| during a pupil assessment what is important to document | if a pt wear glasses or has poor vision |
Created by:
tabithaj23