NR 414

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tbemis
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195760
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NR 414
Updated:
2013-01-27 23:55:57
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Exam 1
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  1. When would you need surgical asepsis? 
    •During procedures that require intentional perforation of the client’s skin

    • •When the skin’s integrity is broken as a result
    • of trauma, surgical incision or burns

    -During procedures that involve insertion of catheters or surgical instruments into sterile body cavities
  2. What are the common shapes of lesions?
    • -Annular
    • -Confluent
    • -Discrete
    • -Grouped
    • -Gyrate
    • -Target, or Iris
    • -Linear
    • -Polycyclic
    • -Zosteriform
  3. What is the ABCDE rule of the self skin exam?
    • –A—asymmetry
    • –B—border
    • –C—color
    • –D—diameter
    • –E—elevation and enlargement
  4. What to do inspect when looking over someone's nails?
    • -Shape and Contour
    • -Profile Sign-clubbing?
    • -Consistency
    • -Color
    • -Capillary Refill Time (CRT)
  5. What are the functions of the skin?
    • 1. Protection: physical, chemical, thermal and light
    • 2. Prevents penetration & loss of fluids
    • 3. Perception: touch, pain, temperature, pressure
    • 4. Temperature regulation via sweat & adipose layer
    • 5. Identification
    • 6. Communication
    • 7. Wound repair
    • 8. Absorption and excretion
    • 9. Production of Vitamin D
  6. What are the symptoms of chronic pain? 
    • -—Continues for 6 months or longer
    • -Types are malignant (cancer related) and nonmalignant
    • -—Does not stop when injury heals
  7. What are symptoms of acute pain?
    • —-Short term
    • -—Self-limiting
    • -—Follows a predictable trajectory
    • -Dissipates after injury heals
  8. What are the sources of pain?
    • -Visceral pain
    • -Deep somatic pain
    • -Cutaneous pain
    • -Referred pain
  9. What is Neuropathic Pain?
    • -—Abnormal processing of pain message
    • -Most difficult type of pain to assess and treat
    • —-Damaged/dysfunctional/injured nerve fibers
  10. What are the typical changes to aging adult's? 
    • -—Temp:decrease fevers, increase risk hypo/hyperthermia, decrease sweating
    • -—Pulse: Normal range, but often irregular
    • -Respirations: decrease Tidal Volume 
    • -BP: Systolic generally increases with age

    —
  11. What are the —Korotkoff’s sounds?
    • -I, the systolic pressure
    • -IV, muffling of sounds
    • -V, the diastolic pressure
  12. What are physiologic factors controlling blood pressure?
    • -—Cardiac output
    • -—Peripheral vascular resistance
    • -—Volume of circulating blood
    • -—Viscosity
    • -—Elasticity
  13. What does the pulse pressure equal?
    Systolic BP - Diastolic BP
  14. what does systolic pressure equal?
    Left ventricular contaction
  15. What are the routes of temperature measurement? 
    • -—Oral
    • -Electronic (via central line)
    • -—Axillary
    • -—Rectal
    • -—Tympanic membrane
    • -—Temporal
  16. What are the signs of developmental competence of an adolescent? 
    • -May examine alone without parent or sibling
    • -Give feedback that they are developing normally
    • -Do not treat like a child or adult
    • -Focus on health teaching
    • -Examine genitalia last and quickly
  17. What are the responsibilities of an RN?
    • -Clean the equipment
    • -Set Clean vs. dirty area for handling equipment
    • -Prevent Nosocomial infections
    • -Wash hands
    • -Wear gloves
    • -Follow Standard precautions
    • -ObserveTransmission-based precautions
  18. What area of the body requires a different order of skills?

    What is the order?
    The abdomen,

    • Inspect
    • Osculate 
    • Palpate 
    • Percuss
  19. What are the order of skills? 
    • •Inspection
    • •Palpation
    • •Percussion
    • •Auscultation
  20. What are the characteristics of percussion notes?
    • •Resonant= clear, hollow
    • •Hyperresonant=booming
    • •Tympany= musical & drum like
    • •Dull= muffled thud
    • •Flat= absolute dullness
  21. What is the purpose of percussion? 
    -Purpose- to assess underlying structures

    • •Map location and size of organs
    • •Signal density of a structure by a characteristic note
    • •Detecting superficial abnormal mass
    • (penetrate ~5cm deep)
    • •Elicit pain if underlying structure is inflamed
    • •Elicit deep tendon reflex using percussion hammer
  22. What is the purpose of palpation?
    • -To assess-
    • •Texture
    • •Temperature
    • •Moisture
    • •Organ location/size
    • •Swelling, vibration or pulsation 
    • •Rigidity or spasticity
    • •Crepitation
    • •Presence of lumps or masses
    • •Presence of tenderness or pain
  23. What is a part of the nursing process evaluation? 
    • -˜Refer to established outcomes
    • -Evaluate individual’s condition and compare actual outcomes with expected outcomes
    • -˜Summarize results of evaluation
    • -˜Identify reasons for failure to achieve expected outcomes
    • -˜Take corrective action to modify plan of care
    • -˜Document evaluation in plan of care
  24. What is a part of the nursing implementation phase?
    • -˜Determine patient readiness
    • -˜Review planned interventions
    • -˜Collaborate with other team members
    • -˜Supervise by delegating appropriate responsibilities
    • -˜Counsel person and significant others
    • -˜Involve person in health care
    • -˜Refer for continuing care
    • -˜Document care provided
  25. What is a part of the nursing process planning stage?
    • -˜Establish priorities
    • -˜Develop outcomes
    • -˜Set time frames for outcomes
    • -Identify interventions
    • -˜Document plan of care
  26. What are the goals of the outcome identification? 
    • -˜Identify expected outcomes
    • -˜Individualize to patient
    • -˜Ensure outcomes are realistic and measurable
    • -˜Include a time frame
  27. What are the parts of the nursing diagnosis? 
    • -˜Interpret data
    • -Identify clusters of cues
    • -Make inferences
    • -˜Validate inferences
    • ˜-Compare clusters of cues with definitions and defining characteristics
    • -˜Identify related factors
    • -˜Document the diagnosis
  28. What is involved in the assessment in the nursing process? 
    • -˜Collect data
    • -Review of clinical record
    • -Interview
    • -Health history
    • -Physical examination
    • -Functional assessment
    • -Cultural and spiritual assessment
    • -Consultation
    • -Review of the literature
  29. What is the nursing process?
    • ˜Assessment
    • ˜Diagnosis
    • ˜Outcome identification
    • ˜Planning
    • ˜Implementation
    • ˜Evaluation
  30. What is objective data? 
    • Observed when inspecting, percussing, palpating, and auscultating patient during
    • physical examination
  31. What is dementia?
    • –Gradual onset
    • –More common in elderly
    • –Causes: Alzheimer’s,Parkinson’s, CVA, HIV, head trauma
  32. What is Delirium?
    • –Acute onset
    • –Young or old
    • –Causes: infection, intoxication, withdrawal, hypoxia, F&E imbalance, post head trauma, postop
  33. What are important developmental signs for children? 
    • Differentiated crying by 4 weeks
    • Cooing at 6 weeks
    • One word sentences at 1 year
    • Multi-word sentences by 2 years
  34. What are subjective?
    Statements from the patient that are not verifiable. 
  35. Mental Status exam?
    • JOMACS
    • J-Judgement
    • O-Orentation
    • M-Memory
    • A-Appearance 
    • C-Calculation 
    • S-Speech 
  36. What are the orentation times 4?
    Person, place, time and purpose 
  37. What are the 4 main headings of mental status assessment? 
    • ABCT
    • –Appearance

    –Behavior

    –Cognition

    –Thought processes
  38. What is a mental disorder?
    • •a significant behavioral or psychological pattern associated with: distress or
    • disability and has a significant risk of pain, disability, or death, or a loss
    • of freedom.

    –Organic disorder: brain disease of known specific organic cause

    –Psychiatric mental illness: no organic etiology established
  39. What is mental status?
    •a person’s emotional and cognitive functioning.

    • –Optimal functioning aims toward
    • simultaneous life satisfaction in work, caring relationships, and within the self
    • –Usually, mental status strikes a balance between good and bad days, allowing person to function socially and occupationally
  40. What does R.E.S.P.E.C.T stand for?
    • R= Realize that you must know the heritage of yourself and your patient.
    • E= Examine the patient within the cultural context.
    • S= Select questions that are simple and speak them slowly.
    • P = Pace questioning throughout the exam.
    • E = Encourage patient to discuss meaning of health and illness with you.
    • C = Check patient’s understanding and acceptance of recommendations.
    • T = Touch the patient within the
    • boundaries of his or her heritage.
  41. What are some Health-Related Behaviors Affected by Religion?
    • Meditating
    • Exercising/physical fitness
    • Sleep habits
    • Vaccinations
    • Willingness to undergo physical examination
    • Pilgrimage
    • Truthfulness about how patient feels
    • Maintenance of family viability
    • Hoping for recovery
    • Coping with stress
    • Genetic screening and counseling
    • Living with a disability 
    • Caring for children
  42. What is culturally competent?
    • •Understanding and attending to
    • total context of patient’s
    • situation including:

    • -Immigration status, Stress factors, Social factors, & Cultural similarities and
    • differences
  43. What is culturally appropriate?
    • •Applying underlying background
    • knowledge necessary to provide the best possible health care
  44. What is culturally sensitive?
    • •Possessing basic knowledge of and
    • constructive attitudes toward diverse cultural populations
  45. What is Illness?
    • The loss of the person’s balance, within one’s
    • being—physical, mental and/or spiritual—and
    • in the outside world—natural, communal, and/or metaphysical
  46. What is Health?
    • The balance of the person, both within one’s
    • being—physical, mental and/or spiritual—and
    • in the outside world—natural,communal, and/or metaphysical, is a complex, interrelated phenomenon
  47. What are factors that effect wound healing? 
    • Nutrition
    • Oxygenation
    • Infection
    • Age
    • Chronic health condition
    • Medications
    • Smoking
  48. When doing pain assessment what do you want to know? 
    • Pain Scale
    • When
    • Alleviating factors
    • Stop, look, and listen
    • Before, during, and after
    • Medication and results
  49. When cleaning and irrigating a wound how should you move?
    • -Least to most contaminated 
    • -Clean to dirty
    • -Top to bottom 
  50. What is the goal of cleaning a wound? 
    Remove dead tissue and debris, which impedes healing
  51. Nursing Diagnosis for wounds
    • Impaired Tissue Integrity
    • Risk for Infection
    • Pain
    • Disturbed Body Image
    • Deficient Knowledge (wound care)
  52. What types of drainage come from a wound?
    • -Serous
    • -Sanguineous
    • -Serosanguineous
    • -Purulent
  53. What is important with a Jewish patient who has died?
    Typically need to be buried before sundown 
  54. What do you do to asses a wound bed?
    • Wound dimensions (size and depth)
    • Tunneling and undermining
    • Bed texture
    • Bed moisture
    • Wound odor
    • Margins and surrounding skin
    • Pain?
  55. What is required with escar tissue? 
    Debridement
  56. Risk Factors for Alteration in Skin Integrity
    • -Immobility
    • -Limited activity levels
    • -Incontinence
    • -Impaired nutritional status
    • -Infection
    • -Anemia
    • -Diminished sensations
    • -Altered level of consciousness
    • -Cachexia(emaciation)
    • -Friction and shear injury
    • -Obesity
    • -Hydration
    • -Aging skin
    • -Medications that delay healing
    • -Decreased blood flow to lower extremities
  57. Braden Scale
    Numeric value for 6 risk factors related to impaired skin integrity

    Total score <18 = risk

    • 6 risk factors:
    • Sensory Perception, Moisture, Activity, Mobility, Nutrition and Friction & Sheer
  58. Skin self-examination, using the ABCDE rule?
    –A—asymmetry

    –B—border

    –C—color

    –D—diameter

    • –E—elevation
    • and enlargement

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