NR 462 Exam 1
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NR 462 Exam 1
NR 462 exam 1
What does PQRST stand for?
P- Provocative(aggravating)/ Palliative(alleviating)
What is the definition of an acute illness?
A disruption in functional ability usually
characterized by a rapid onset, intense
manifestations, and a relatively short duration
Reversible; < 3 months
Eg: Upper respiratory tract infection, Flu, etc.
What is the definition of a chronic illness?
A disruption in functional ability usually characterized by a gradual, insidious onset with
Irreversible; >3 months
Eg: H/T, DM, Cancer, etc.
What is the primary level of health promotion?
To decrease the person’s vulnerability to disease(avoid the onset of disease); the promotion of health and the prevention of illness
Parenting education, attention to personal hygiene, immunization, and avoidance of toxins
What is the secondary level of health promotion?
Early detection of disease (sign and symptom) to initiate early intervention
Cervical screening, mammography, blood pressure monitoring and blood cholesterol checking
What is the tertiary level of health promotion?
- minimize its effects and to prevent further disability (rehabilitation after condition is stabilized)
Restorative care, therapeutic interventions
What does ILIKEME stand for?
I=Identify client’s strength
L=Listen to the client’s self-description
I=Involve the client in decision making
K=Keep goals realistic
E=Encourage client to think positively
M=Maintain an environment conductive to
E=Explain to the client how to use positive
self-talk instead of negative self-talk
What are is the nursing care focus with someone who has a chronic illness?
Avoiding complications: eye complications in person with DM
Avoiding acute illness: pneumonia in a person with COPD
Promoting health: exercise
Maintaining functional status
What are the physical changes when someone ages?
Cardiovascular, Renal, Respiratory, Endocrine, GI, nervous system, sensory, reproductive, dermatologic,
What are some strategies for teaching the elderly?
Slow pace of presentation of material
Adjust time for learner condition and attention span
Avoid distractions; modify the teaching environment
Large print, non-glare paper, use of color
Difficulty seeing and difficulty with color perception
Involve family and significant
What are normal lab values for Sodium?
What are normal lab values for Potassium?
What are normal values for CO2?
What are normal lab values for Magnesium?
What are normal values for HCO3?
With a patient who has pneumonia what purpose does bed rest serve?
It reduces the cellular demand for oxygen
A client with pneumonia has a temperature ranging between 101 and 102 and periods of diaphoresis. Based on this information which of the following nursing interventions would be a priority?
Provide fluid intake of 3L/day
What signs and symptoms would a nurse expect to find when assessing a 79 year old client with pneumonia?
Confusion and lethargy
What would be an expected outcome for a problem with impaired gas exchange?
Alert and oriented to person, place, time and events
With a patient who has been diagnosed with community-acquired pneumonia which nursing intervention has the highest priority?
Obtain a sputum specimen for culture and sensitivity
What is the rational that supports multidrug treatment for clients with pneumonia?
Multiple drugs reduce development of resistant strain of the bacteria
What should a nurse assess for a patient who has pneumonia on O2 therapy to determine if they are hypoxic?
When a client with aspiration pneumonia become dyspneic, begins to cough, and is turing blue while feeding them, which is the first action the nurse should take?
Turn the client to the side
Which kind of influenza vaccination would you give to a pregnant female?
What is pursed-lip breathing taught for to patients with emphysema?
To promote carbon dioxide elimination
Which findings would you expect on a client with COPD and an upper respiratory tract infection?
Coarse crackles and rhonchi
How can the nurse best assist a patient to stop smoking?
Help the client to develop a plan to quit and suggest a formalized program available in the community
What does a 60% FEV1/FVC ratio tell you?
The client has obstructive lung disease
What should a nurse implement to a client with COPD who is SOB?
A 28 year old nonsmoker with a deficiency in the enzyme Alpa1-antitrypsin, what does this predispose the client to?
Development of lobular emphysema
What would be very concerning to a nurse caring for a patient with COPD?
Rusty colored sputum
What is the best way to determine someone's fluid balance?
To weigh them
What is the normal lab values for Ca?
What are normal lab values for Cl?
What are clinical manifestations of low Ca?
tetany, circumoral numbness, paresthesias, hyperactive DTRs, Trousseau’s sign, Chovstek's sign, seizures, respiratory symptoms of dyspnea and laryngospasm, abnormal clotting, and anxiety
What are clinical manifestations of hypomagnesia?
Acts directly on myoneural junction, affecting muscular irritability and contractions
What are clinical manifestations of hypermagnesia?
flushing, lowered BP, nausea, vomiting, hypoactive reflexes, drowsiness, muscle weakness, depressed respirations, ECG changes, and dysrhythmias
What is Chvostek's sign?
A contraction of facial muscles in response to a tap over the facial nerve in front of the ear (hypocalcemia)
What is Trousseau's sign?
Refers to carpal spasms induced by inflating a blood pressure cuff on the arm (hypocalcemia)
What does high and low potassium levels do to a T wave?
What are the signs of low Na?
What are the signs for high Na?
Increased interstitial fluid
What is typical urine output?
Which organs help to control acid base balance?
Pulmonary and Renal
What does ROME stand for?
What is the definition of compensated for ABGs?
The pH is normal and the PCO2 and HCO3 are both abnormal
What is the definition of uncompensated for ABGs?
pH is abnormal along with the PCO2 and HCO3
What is somatic pain?
aching or throbbing, localized, arises from bone, joint, muscle, skin, or connective tissue
What is visceral pain?
tumor involvement or obstruction, arises from internal organs
What are non-pharmacologic nursing interventions for managing pain?
PT, OT, stretching, strengthening
ice, heat, massage
Transcutaneous electrical nerve stimulation (TENS)
Alternative therapies (placebo response)
Therapeutic touch, massage
Cognitive-behavioral therapy (CBT)
What is the placebo effect?
A physiologic response that results from an
expectation that a treatment will work
What are the physiologic dimension of pain?
What are factors that influence the pain response?
: less tolerate pain, want pain
relief sooner ask for medication before next dose is due
: excessive crying and moaning
: women report greater than men
What is addiction?
is a chronic, neurobiologic disease characterized by:
Impaired control over drug use
Compulsive drug use
Continued use despite harm
What is the mode of transmission for influenza?
Airborne Droplet- Airborne diseases are
contagious to approx. a 5 foot perimeter
What is Hospital-acquired pneumonia?
Occurring 48 hours or longer after admission and not incubating at time of hospitalization
What is aspiration pneumonia?
Sequelae occurring from abnormal entry of
secretions into lower airway
What are the types of COPD?
Bronchitis (Blue bloater), Emphysema (pink puffer)
What is the cause of Bronchitis?
Ciliary function is reduced, bronchial walls thicken, bronchial airways narrow, and mucus may plug airways
Alveoli become damaged and fibrosed, and alveolar macrophage function diminishes
-Tough to get air in
What is the cause of Emphysema?
Decreased alveolar surface area causes an increase in “dead space” and impaired oxygen diffusion
Reduction of the pulmonary capillary bed increases pulmonary vascular resistance and pulmonary artery pressures
-causes right sided heart failure
-Pursed lip breathing (due to CO2 retention)
What are the risk factors for COPD?
Tobacco smoke causes 80-90% of COPD
Smoking damages the cleaning mechanism,
increase accumulation of mucus
Ambient air pollution
- Alpha1-antitrypsin deficiency
What are the percentages for FEV1/FVC for COPD?
What are the primary clinical manifestations of someone with COPD?
Three primary symptoms: chronic cough, sputum production, and dyspnea on exertion
What is cor pulmonale?
hypertrophy of the right side of the heart, with or without heart failure, resulting from pulmonary hypertension
What is the criteria for a nurse to administer PRN medicine?
The Nurse will use subjective and objective data – Assessment and then document reason given and results from medication
What are the six rights of medication administration?
What is the correct needle length and gauge for IM injections?
The standard length is 1.5 inches, gauge 21-25
in an obese patient you might need to use a 3 inch needle
What is the correct needle length and gauge for a subcutaneous injection?
Length- less than one inch (3/8 or 5/8), gauge is 25-27.