Nursing Exam 1B

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Nursing Exam 1B
2011-09-13 21:12:34
vital signs nursing process etc

Exam 1B
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  1. Describe thermoregulation in the body
    the hypothalamus controls body temp
  2. Explain why it is so important to take a patients vital sign pattern rather than relying on a single reading:
    • to create a baseline
    • then to check for accuracy
  3. What is the normal oral temperature range for adults?
  4. Explain the physiological mechanisms of fever:
    • abn high body temp ( >100.4oF or 38o C)
    • occurs b/c of pyrogens (bacteria)
  5. What is the method of finding a peripheral pulse & an apical pulse?
    • use 2-3 fingers (no thumbs)
    • apical - 60 sec
    • peripheral -30 sec x 2
    • apical - 5th intercostal space mid-clavicular line
    • peripheral - carotid, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial
  6. What are the abnormal findings for a pt given their age, pulse rate, rhythms, quality & symmetry?
    • bradycardia: rate <60bpm
    • tachycardia: rate >100bpm
    • quality: bounding (easy to feel) thready (hard to feel)
  7. What is a normal pulse rate for healthy adults?
    • 60-100 bpm
    • avg: 70-80 bpm
  8. How are respirations regulated in the body?
    exchange of oxygen & carbon dioxide in the body
  9. Define: arterial oxygen saturation
    amt of oxygen in your blood
  10. Define: hypoxia
    inadequate cellular oxygenation
  11. Define: hyperventilation
    rapid & deep breathing resulting in excess loss of CO2
  12. Define: hypoventilation
    rate & depth of respirations are decreased & CO2 is retained
  13. What are the abnormal findings of a pt given their age, respiratory rate, depth. rhythm, chest movement, & associated clinical signs?
    • apnea: cessation of breathing
    • bradypnea: abnormally slow 1-12
    • tachypnea: abnormally fast > 12
    • deep/shallow
    • reg/irreg rhythm
    • dyspnea: labored breathing
    • hypoxia
  14. What is the normal respiratory rate for adults?
  15. Describe the physiology of blood pressure:
    • pressure of blood as its forced against arterial walls during cardiac contraction
    • measured in millimeter of mercury (mm Hg)
    • pulse pressure: the difference between systolic & diastolic pressures
  16. Describe the process for taking a brachial blood pressure reading:
    • apply BP cuff
    • find radial pulse
    • pump cuff up till can't feel radial pulse, release cuff, then add 30 to your #
    • apply steth diaphram to brachial pulse, put in ears
    • pump up to your number
    • slowly release listening for the systolic(first sound) and diastolic (last sound)
    • remove cuff
    • chart findings
  17. What is the importance of cuff size when obtaining a blood pressure reading?
    • should be 2/3 length of upper arm or 40% of arm
    • wrong size cuff could result in measurement error
  18. Define: hypotension
    systolic blood pressure <100 mm Hg
  19. Define: hypertension
    • systolic bp >140 mm Hg OR
    • diastolic bp >90 mm Hg on 2 or more seperate occasions
  20. Define: essential hypertension
    diagnosed when there is no known cause for the increase in bp
  21. Define: secondary hypertension
    when there is a clearly identified cause for the persistent rise in bp
  22. What is the nursing process when interpreting vital signs results?
    taking vital signs as part as the assessment data
  23. What is the rapid response team?
    called for respiratory distress , chest pain etc
  24. What is code blue?
    called when someone is breathless, &/or pulseless (respiratory/cardiac arrest)
  25. What are the basic elements of airway management including placement of oral and nasal airways:
    • endotrachial airways are pliable tubes inserted into the trachea through:
    • oral: in mouth to trachea
    • nasal: in nose to trachea
  26. Define: Pain
    unpleasant sensory/emotional experience
  27. Classify pain according to origin:
    • cutaneous or superficial pain (near surface)
    • visceral pain (deeper pain)
    • deep somatic pain (body, ligaments, bones)
    • radiating pain (from one spot and branches out)
    • referred pain (pain diff location from where actually is)
    • phantom pain ( amputee's)
    • psychogenic pain (np physical cause)
  28. Classify pain according to cause:
    • nociceptive pain (aching) (muscles/joints, organs)
    • neuropathic pain (burning, numbness, itching, & "pins & needles")
  29. Classify pain according to duration:
    • acute pain: brief duration
    • chronic pain: longer than 6 months
    • intractable pain: chronic & highly resistant to relief
  30. Classify pain according to quality:
    • sharp or dull
    • throbbing
    • stabbing
    • burning (nerve)
    • ripping
    • searing (nerve)
    • tingling (nerve)
  31. What are the physiological changes of pain?
    • transduction
    • transmission
    • perception
    • modulation
  32. What are some factors that influence pain?
    • emotions
    • developmental stage
    • sociocultural factors
    • communication impairments
    • cognitive impairments
    • vital signs
  33. What are some nonpharmacological pain relief measures?
    • relaxation/imagery
    • meditation
    • distraction/laughter
    • heat/cold
    • massage
    • TENS
    • acupressure/acupuncture
    • therapeutic touch
    • biofeedback
  34. What are pharmacological measures for pain including opiod analgesics?
    • used to treat moderate to severe pain
    • ex: oxycodone
  35. What are pharmacological measures for pain including nonopioid analgesics?
    • NSAIDS, centrally acting agents or acetaminophen
    • used for mild to moderate pain
    • Ex: advil, tylenol
  36. What are pharmacological measures for pain including adjuvant analgesics?
    • used to treat chronic pain that is neuropathic in nature
    • ex: fentanyl
  37. Why should pain be considered a 5th vital sign?
    pain management is essential for quality patient care
  38. What is the nursing process in the care of a patient with pain?
    assess for pain then diagnosis
  39. How is critical thinking used in the nursing process?
    • for nurses to apply knowledge to provide holistic care
    • theoretical
    • practical
    • personal
    • ethical
  40. What are the 6 steps of the nursing process?
    • assessment: data gathering
    • diagnosis: identify pt health needs by analyzing data
    • planning: -outcomes: pt focused goals -interventions: nurse focused goals
    • implementation: carry out planned actions
    • evaluation: determine if interventions were effective
  41. Describe the relationship of assessment to the other steps in the nursing process
    • diagnosis: helps identify pt actual/potential health problems & strengths
    • planning outcomes & interventions: helps formulate realistic goals, helps choose interventions most acceptable & effective for client
    • implementation: conti to gather assessment data by observing clients response as you implement interventions
    • evaluation: indicate whether or not goals have been met
  42. What is subjective data?
    what the pt (or family) tells you
  43. What is objective data?
    • what nurse sees, hears, smells, feels or another nurse
    • observation
  44. What is primary data?
    • obtained from client
    • your own assessment
  45. What is secondary data?
    • "second hand"
    • medical record
  46. What are 3 circumstances you would validate data?
    • subjective/objective data do not agree or make sense
    • clients statements differ at different times in the interview
    • data are far outside normal range
  47. What is the difference between cue and inference?
    • cue: what the pt says & what you observe
    • inference: judgements
  48. What is a nursing diagnosis?
    statement of client health status that nurses identify, prevent, or treat
  49. What is a medical diagnosis?
    focus on disease, illness, and injury
  50. What are collaborative problems?
    always a potential problem... if becomes "actual" now its a med diagnosis
  51. What are the 5 types of nursing diagnoses?
    • actual (prob is present, has signs & symptoms)
    • risk (prob may occur)
    • possible (prob may be present, not enough data to support diagnosis)
    • syndrome (several related prob are present)
    • wellness (no prob, in transition to higher lvl wellness, no cause or etiology)
  52. Why is etiology always an inference?
    b/c you can never really observe the link between etiology and problem
  53. How do you know which of the NANDA labels to use to describe a pt's problems?
    identify the topic that fits the your assessment data
  54. Clairfy the relationship between nursing diagnosis and outcomes/interventions:
    • the prob suggests the outcome/goal
    • the etiology suggests interventions
  55. State at least 5 criteria for judging the quality of a diagnostic statement:
    • incl. both problem & etiology
    • descriptive and specific
    • state the prob as a pt response
    • nonjudgemental lang
    • avoid legally questionable lang
  56. What is the importance of a written care plan?
    to help the nurse provide individualized goal-directed client centered care
  57. What is the difference between short and long term goals?
    • Short term- to be achieved in hours, days
    • long term -a week, month, or more
  58. Give an example of an outcome statement
    • Client will take part in self care activites such as personal hygiene daily.
    • Client will identify 2 resources available to help in giving care such as babysitters, husband switching roles, within 1 month after discharge.
  59. How is an outcome derived from a nursing diagnosis?
    based on what our desired result of care will be
  60. What does SMART stand for?
    • specific
    • measurable
    • attainable
    • realistic
    • timely

    make sure u write all these in the outcome that dont conflict w. the med diag.
  61. How do theories and research influence the choice of nursing interventions?
    • theories - how you define a prob
    • research - looking at studies, protocols
  62. Explain how nursing interventions are determined by problem status
    • goals met
    • goals part met
    • goals not met
  63. What must be on your nursing order?
    • date
    • subject ("the nurse")
    • action verb (tells nurse what action to take)
    • times and limits
    • signature
  64. What are "5 rights" of delegation?
    • think critically about:
    • the task
    • the circumstance
    • the person
    • the direction or communication
    • supervision & evaluation
  65. How are standards and criteria used in evaluation?
    • RN evalu progress toward outcomes
    • documents results of evalu
    • uses ongoing assessment data to revise diagnosis
  66. What is ongoing evaluation?
    • immed after intervention
    • at ea pt contact
    • while implementing
  67. What is intermittent evaluation?
    • at specified times
    • goals should be designate times
  68. What is terminal evaluation?
    clients progress at time of discharge
  69. Describe a process for evaluating client health status (outcomes)?
    • review outcomes
    • collect reassessment data
    • determine progress towards goals
    • record evaluative statement
    • evaluate collaborative problems
  70. Describe a process for evaluating the effectiveness of a nursing care plan
    • relate outcomes to interventions
    • draw conclusions about problem status
  71. What is the definition of communication?
    process of sending and receiveing messages
  72. What are the 3 basic levels of communication?
    • intrapersonal- self talk
    • interpersonal- 2 or more people
    • group- public speaking
  73. What are the 5 components of the communication process?
    • encoder (sender)
    • message
    • channel (way you send msg)
    • decoder (receiver)
    • feedback
  74. What are some verbal communication characteristics?
    • use of spoken/written words to send a message
    • vocab & language
    • meaning
    • pace
    • tone of voice
    • clarity
    • timing
    • relevance
    • credibility
  75. What are some nonverbal communication characteristics?
    • body language
    • facial expression
    • posture
    • gait
    • personal appearance
    • gestures
    • touch
  76. What are some factors that influence the communication process?
    • environment
    • gender
    • devl lvl
    • age
    • personal space
    • roles & responsibilities
  77. How do relationships and roles influence communication?
    • rapport and trust established
    • effects all phases of therapeutic relationship
    • effectiveness determines quality of nurse-client relationship
  78. Describe the role of communication in each of the 4 phases of therapeutic relationship
    • stage 1: pre-interaction (no communication)
    • stage 2: orientation phase (client and nurse meet)
    • stage 3: working phase (nurse & client work together to meet clients needs)
    • stage 4: termination phase ( concl of relationship)
  79. Compare and contrast techniques that enhance communication to those that hinder communication.
    • enhance:
    • active listening
    • establish trust
    • be assertive
    • restate
    • clarify
    • validate
    • observe body language
    • explore issues
    • use silence

    • hinder:
    • asking too many ??
    • asking why
    • changing subj inapprop
    • failing to listen
    • offering advice
    • stereotyping
  80. What is the purpose of documentation?
    • communication
    • education
    • legal documentation
    • quality assurance
    • reimbursement
    • research
  81. What are the different types of documentation?
    • Narrative (chronological "story")
    • SOAP (subj, obj, assess, plan)
    • SOAPIE & SOAPIER (interv, eval, revision)
    • PIE (problem, interv, eval)
    • Focus (Data, Action, Response/Eval)
    • Charting by exception (streamlined doc)
  82. What are the 7 different charting forms & their purposes?
    • Admission Database (when pt enters HC system)
    • Flowsheets & Graphic Record (checklists: rout care,assess, VS, wound care, trtmt, IV flu adm)
    • Medication Admin Rec ( list of all ordered meds)
    • Kardex (brief summ pt POC)
    • Integrated IPOC (combo charting & car plan form)
    • Event report ( incident report)
    • Discharge Summary
  83. What are the key elements to include when giving an oral report about a client?
    progress, change of status, any tests given or will get, therapies, teaching
  84. How do you verify or question a medical order?
    • contact whomever wrote the order
    • if they dont change the order, you may refuse to carry it out
    • inform charge nurse
  85. What are federal laws regulating the nursing practice?
    • Bill of Rights
    • Emerg Medical Trtmt & Active Labor Act
    • Health Care Quality Improvement Act
    • American Disabilities Act
    • Pt Self-Determ Act
    • Newborns' & Mothers Health Prot Act
    • National Labor Relations Act
    • HIPAA
  86. What are state law regulating the nursing practice?
    • Mand. reporting laws
    • Good Samaratin Law
    • Nurse Practices Act (credentialing, licensing, discipline)
  87. What are some basic principles of criminal law controlling nursing practice?
    • offense against society
    • under jurisdiction of state & federal courts
    • lead to fine, imprisonment, or death
    • misdemeanor or felony
  88. What are some basic principles of civil law controlling nursing practice?
    • protect rights of indiv
    • pymt of monetary damages
    • plaintiff or defendant
    • Contract law (agreem btw indiv)
    • Tort Law ( breach of civil duty)
  89. What are the major legal issues that arise within nursing practice?
    • failure to assess & diagnose
    • failure to plan
    • failure to implement a plan of care
    • failure to evaluate
  90. What are some measures to take that would decrease the likelihood of committing nursing malpractice?
    • observe mand stand of care
    • use nursing process & follow prof stand
    • avoid med and trtmt errors
    • report & document accurately
    • obtain informed consent
    • maintain confidentiality
  91. What are the basic elements of informed consent?
    • completeness
    • clarity & comprehension
    • voluntariness
    • competence