501 Exam 1.txt

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  1. basic needs
    sufficient O2, nutrition, temp.,
  2. Safety Assessment asses 4 things
    • Activity and Exercise
    • Medication History
    • Fall history
    • Home Maintenance and Safety
  3. Strategies to Promote Safety- General (home setting) (7)
    • Environmental
    • Electrical
    • Fire
    • Fall risks
    • Food
    • Medication
    • Infection
    • Special concerns – home oxygen therapy
  4. Strategies to Promote Safety- Acute Care setting (5)
    • Falls
    • Medications
    • Fires
    • Electrical hazards
    • Misc.
  5. A safe health care environment is one that reduces the risk of injury, including:
    (4)
    • minimizing falls,
    • patient-inherent accidents,
    • procedure-inherent accidents, and
    • equipment-related accidents.
  6. _________are at greatest risk for home accidents that result in severe injury and death.
    Children younger than 5 years of age
  7. are at risk for injury from automobile accidents, suicide, and substance abuse.
    Adolescents
  8. Threats to _ ____'s safety are frequently associated with lifestyle habits.
    an adult’s
  9. Nursing interventions for promoting safety are individualized for patients’ (3)
    • developmental stage,
    • lifestyle,
    • and environment.
  10. The potential for microorganisms to cause disease depends on: (4)
    • the number of organisms,
    • virulence,
    • ability to enter and survive in a host,
    • and susceptibility of the host.
  11. The major sites for health care–associated infections include: (4)
    • the urinary tract and
    • respiratory tracts,
    • bloodstream, and
    • surgical or traumatic wounds.
  12. increase susceptibility to infection: (5)
    • treatments or conditions that compromise the immune response
    • Increasing age,
    • poor nutrition,
    • stress,
    • inherited conditions,
    • chronic disease,
  13. increase a hospitalized patient’s risk for acquiring a health care–associated infection. (4)
    • Invasive procedures,
    • medical therapies,
    • long hospitalization,
    • and contact with health care personnel
  14. Chain of Infection (6)
    • Infectious agent
    • Reservoir
    • Mode of transmission
    • Portal of exit
    • Portal of entry
    • Susceptible host
  15. Health Care Associated Infections (HAIs) General Cause
    delivery of health care service in a healthcare facility
  16. Health Care Associated Infections (HAIs) Types (3)
    • Iatrogenic
    • Exogenous
    • Endogenous
  17. Iatrogenic HAIs
    from a diagnostic or therapeutic procedure
  18. Exogenous HAI
    from microorganisms found outside the body ex. salmonella
  19. Endogenous HAI
    occurs when part of the pt's flora becomes altered and overgrown
  20. Health Care Associated Infections (HAIs) Sites and causes (4)
    • Urinary tract
    • Surgical or traumatic wound
    • Respiratory tract
    • Bloodstream
  21. WBC count normal values
    5,000-10,000/mm3
  22. WBC indication of infection
    • Increased - acute infection
    • decreased- certain viral or overwhelming infections
  23. erythrocyte sedimentation rate- normal value
    • Up to 15mm/hr for men
    • 20mm/hr for women
  24. erythrocyte sedimentation rate
    indication of infection
    elevated in presence of inflammatory process
  25. Iron level
    Normal level
    60-90g/100mL
  26. iron level
    indication of infection
    decreased in chronic infection
  27. culture of urine and blood
    normal values
    normally sterile, without microorganism growth
  28. culture of urine and blood
    Indication of infection
    presence of microorganism growth
  29. Asepsis
    Absence of pathogenic (diseaseproducing)microorganisms.
  30. Aseptic technique
    Practices/ procedures thatassist in reducing the risk for infection
  31. Medical asepsis, or clean technique,
    includesprocedures for reducing the number of organismspresent and preventing the transfer of organisms
  32. Surgical asepsis or sterile technique
    prevents contamination of an open wound, serves to isolate the operative area from the unsterile environment,and maintains a sterile field for surgery.
  33. Cleaning:
    the removal of all soil from object &surfaces
  34. Disinfection:
    a process that eliminates many or allmicroorganisms, with the exception of bacterialspores, from inanimate objects
  35. Sterilization:
    the complete elimination ordestruction of all microorganisms, including spores
  36. Isolation Guidelines-Tier One (5)
    • Standard Precautions
    • Used with all patients
    • Includes hand hygiene techniques
    • Includes use of personal protective equipment as needed(gloves etc.)
    • Includes cough etiquette
  37. Isolation Guidelines Tier Two (3)
    • Disease/condition specific precautions
    • Precautions for highly transmissible pathogens
    • Airborne, droplet, contact, and protective
  38. Quality & Safety Education for Nurses(QSEN) 6 competencies
    • Patient-centered Care
    • Teamwork and Collaboration
    • Evidence-based Practice (EBP)
    • Quality Improvement (QI)
    • Safety
    • Informatics
  39. Factors Influencing Hygiene (8)
    • Social practices
    • Personal preferences
    • Body image
    • Socioeconomic status
    • Health beliefs & motivation
    • Cultural variables
    • Developmental stage
    • Physical condition
  40. Hygiene Assessment Questions:
    Cultural and/or religious practices (2)
    • Do any cultural or religious practices affect your personal hygiene care?
    • How can i include these in you care?
  41. Hygiene Assessment Questions:
    Tolerance of hygiene practices (3)
    • Do hygiene activities cause any symptoms such as shortness of breath, pain or fatigue?
    • What can I do to min. these symptoms?
    • Which aspect of hygiene care worsen you discomfort or make you fatigued?
  42. Hygiene Assessment Questions:
    Assistance with hygiene (3-4)
    do you use any aids to help you with your bath such as grab bars in you tub or shower?

    Do you prefer someone of the same gender to assist in you hygiene care?

    Which parts of personal hygiene can you do for yourself? Which parts do you need help with?
  43. Hygiene Assessment Questions:
    Skin care (5)
    Which type of bath do you prefer?

    How often and when do you usually bathe?

    What kind of soap and lotion do you use?

    Have you noticed any skin changes or irritation?

    Do you have any known allergies or reactions to soaps, cosmetics, or skin care products?
  44. Hygiene Assessment Questions:
    Mouth care (2)
    Do you have any mouth pain or toothaches, or have you noticed any sores in your mouth?

    Do you wear dentures or a partial plate?
  45. Hygiene Assessment Questions:
    Foot and nail care
    how do you usually care of your feet and nails?

    Do you soak your feet?

    Do you file or trim your own fingernails and toenails?
  46. Hygiene Assessment Questions:
    Hair and scalp care
    Have you recently experienced itching of the scalp or noticed flaking or dandruff?

    Have you noticed any changes in the texture or thickness of your hair?
  47. Functions of The Skin include (5)
    • Protection
    • Secretion,
    • Excretion
    • Temperature regulation
    • Sensation
  48. Skin Assessment:
    Assess: (7)
    • Color
    • Texture
    • Thickness
    • Turgor
    • Temperature
    • Hydration
    • Determine degree of cleanliness
  49. Risk Factors for Skin Impairment (7)
    • Immobilization
    • Reduced sensation
    • Nutrition and hydration
    • Secretions/excretions from skin
    • Vascular Insufficiency
    • External devices
    • Altered cognition
  50. Assessment of Feet and Nails
    Inspect all foot surfaces for: (4)
    • Dryness
    • Inflammation
    • Cracking
    • Lesions
  51. Assessment of Feet and Nails
    Inspect fingernails and toenails for: (4)
    • Lesions
    • Dryness
    • Inflammation
    • Cracking
  52. Common Foot/Nail Conditions (6)
    • Callus
    • Corn
    • Plantar wart
    • Athlete’s foot
    • Ingrown nails
    • Foot odor
  53. Normal oral mucosa: (6)
    • glistens,
    • pink,
    • soft,
    • moist,
    • smooth,
    • and without lesions
  54. Healthy teeth (4)
    • white,
    • smooth,
    • shiny,
    • & properly aligned
  55. Assessment of Oral Cavity:
    Inspect all mouth surfaces for:(4)
    • Color
    • Hydration
    • Texture
    • Lesions
  56. Common Conditions of Oral Cavity:(5)
    • Glossitis
    • Halitosis
    • Xerostomia
    • Gingivitis
    • Lesions (benign & malignant)
  57. Common Hair and Scalp Conditions (4)
    • Dandruff
    • Ticks
    • Pediculosis (Capitus, Corporis, Pubis)
    • Alopecia
  58. Partial Assessment of Eye, Ears, Nose (6)
    • Check for function and/or patency
    • Check for need for assistive devices
    • Assess for:
    •       Inflammation
    •       Swelling
    •       Drainage
    •       Lesions
  59. Common Hygiene Related Carein Acute Care
    Early Morning Care (3)
    • Wash face and hands
    • Oral care
    • Offer bedpan/urinal
  60. Common Hygiene Related Care in Acute Care
    Routine Morning Care (5)
    • Offer bedpan/urinal
    • Bath (including perineal, foot, nail & hair care & backrub)
    • Oral care
    • Clean gown and linens
    • Tidy up room
  61. Common Hygiene Related Care in Acute Care
    Afternoon Care (3)
    • Offer bedpan/urinal
    • Oral care
    • Straighten linens
  62. Common Hygiene Related Care in Acute Care
    Evening Care (6)
    • Wash face and hands
    • Oral care
    • Offer bedpan/urinal
    • Backrub
    • Change gown and linens as needed
    • Offer beverage to drink
  63. Types of Baths
    • Complete bed bath
    • Partial bed bath
    • Sponge bath at sink
    • Tub bath
    • Shower
    • Bag bath/travel bath
  64. body mechanics
    term used to describe the coordinated efforts of the musculoskeletal and nervous system
  65. body alignment
    the individuals center of gravity is stable
  66. Performance of any physical activity for the purpose of conditioning the body, improving health, maintaining fitness, or as a therapeutic measure.
    exercise
  67. exercise
    posture
  68. Activities usually performed in the course of a normal day in the client's life, such as eating, dressing, bathing, brushing the teeth, and grooming.
    activities of daily living (ADLs)
  69. Normal state of balanced muscle tension.
    muscle tone
  70. Midpoint or center of the weight of a body or object.
    center of gravity
  71. Refers to the relationship of one body part to another body part along a horizontal or vertical line.
    body alignment
  72. Occurs when a relatively low center of gravity is balanced over a wide, stable base of support and a vertical line falls from the center of gravity through the base of support.
    body balance
  73. Effect of rubbing or the resistance that a moving body meets from the surface on which it moves; a force that occurs in a direction to oppose movement
    friction
  74. Type and amount of exercise or work that a person is able to perform. Physiological, emotional
    activity tolerance
  75. Increased muscle tension resulting in muscle contraction and muscle shortening.
    isotonic contraction
  76. Increased muscle tension without muscle shortening.
    isometric contraction
  77. At the end of beds for patients can be used to push against to move up in bed.
    footboards
  78. Connection between bones; classified according to structure and degree of mobility.
    joint
  79. Tough layer of fibrous connective tissue that binds bones firmly together.
    fibrous joints
  80. Slightly moveable, highly elastic cartilage that unites bony surfaces.
    cartilaginous joints
  81. True and freely moveable joints in which contiguous bony surfaces are covered by articular cartilage and are connected by ligaments lined with a synovial membrane.
    synovial joints
  82. White, shiny, flexible band of fibrous tissues binding joints together and connecting various bones and cartilage.
    ligaments
  83. White, glistening, strong, flexible, and inelastic fibrous bands of tissue that connect muscle to bone.
    tendons
  84. Nonvascular, supporting connective tissue located mainly in the joints and in the thorax, trachea, larynx, nose, and ear.
    cartilage
  85. Group of muscles that work together to bring about movement at a joint.
    antagonistic muscles
  86. Muscles that contract together to accomplish the same movement.
    synergistic muscles
  87. Muscles involved with joint stabilization. These muscles continually oppose the effect of gravity on the body and permit a person to maintain an upright or sitting posture.
    antigravity muscles
  88. Sensation achieved through stimuli from within the body regarding spatial position and muscular activity.
    proprioception
  89. Paralysis of one side of the body.
    hemiplegia
  90. Range of movement of a joint, from maximum extension to maximum flexion, as measured in degrees of a circle.
    range of motion (ROM)
  91. Muscular weakness of one half of the body.
    hemiparesis
  92. Person's ability to move about freely.
    mobility
  93. Gait assumed by a person on crutches by alternately bearing weight on one or both legs and on the crutches.
    crutch gait
  94. Manner or style of walking, including rhythm, cadence, and speed.
    gait
  95. Pathological Influences on Mobility (4)
    • Postural Abnormalities
    • Muscle Abnormalities
    • Central Nervous System Damage
    • Trauma to Musculoskeletal System
  96. Torticollis - Description
    Inclining of head to affected side, in which sternocleidomastoid muscle is contracted
  97. Torticollis - Cause
    Congenital or acquired condition
  98. Torticollis - Possible Treatments
    Surgery, heat, support, or immobilization depending on cause and severity, gentle ROM
  99. Lordosis - Description
    Exaggeration of anterior convex curve of lumber spine
  100. Lordosis - Cause
    Congenital ConditionTemporary Condition (e.g. pregnancy)
  101. Lordosis - Possible Treatments
    Spine-Stretching exercises, sleeping without pillows, using bed board, bracing, spinal fusion (based on cause and severity)
  102. Scoliosis - Description
    Lateral "S" or "C" shaped spinal column with vertebral rotation, unequal heights of hips and shoulders
  103. Scoliosis - Cause
    Sometimes a consequence of numerous congenital, connective tissue, and neuromuscular disorders
  104. Scoliosis - Possible Treatments
    Approximately half of children with scoliosis require surgeryNonsurgical treatment is with braces and exercises
  105. Congenital Hip Dysplasia - Description
    Hip instability with limited abduction of hips and occasionally adduction contractures (head of femur does not articulate with acetabulum because of abnormal shallowness of acetabulum)
  106. Congenital Hip Dysplasia - Cause
    Congenital Condition (more common with breech deliveries)
  107. Congenital Hip Dysplasia - Possible Treatments
    Maintenance of continuous abduction of thigh so head of femur presses into center of acetabulumAbduction splints, casting, surgery
  108. Knock-Knee (genu valgum)- Description
    Legs curved inward so knees come together as person walks
  109. Knock-Knee (genu valgum) - Cause
    Congenital Condition Rickets
  110. Knock-Knee (genu valgum) - Possible Treatments
    Knee braces, surgery if not corrected by growth
  111. Bowlegs (genu varum) - Description
    One or both legs bent outward at knee, which is normal until 2 to 3 years of age
  112. Bowlegs (genu varum) - Causes
    Congenital Condition Rickets
  113. Bowlegs (genu varum) - Possible Treatments
    Slowing rate of curving if not corrected by growthWith Rickets, increase of vitamin D, calcium, and Phosphorus intake to normal ranges
  114. Clubfoot - Description
    95%: medial deviation and plantar flexion of foot (equinovarus)5%: lateral deviation and dorsiflexion (calceneovalgus)
  115. Clubfoot - Cause
    Congenital Condition
  116. Clubfoot - Possible Treatments
    Casts, splints such as Denis Brown splint and surgery (based on degree and rigidity of deformity)
  117. Footdrop - Description
    Inability to dorsiflex and invert foot because of peroneal nerve damage
  118. Footdrop - Cause
    Congenital ConditionTraumaImproper position of immobilized patient
  119. Footdrop - Possible Treatments
    • None (cannot be corrected)
    • Prevention through physical therapy
    • Bracing with ankle-foot orthotic (AFO)
  120. Pigeon Toes - Description
    Internal rotation of forefoot or entire foot, common in infants
  121. Pigeon Toes - Cause
    Congenital Condition Habit
  122. Pigeon Toes - Possible Treatments
    Growth, wearing reversed shoes
  123. Factors InfluencingMobility-Immobility (7)
    • (Systemic)
    •    -Metabolic changes
    •    -Respiratory changes
    •    -Cardiovascular changes
    •    -Musculoskeletal changes
    •    -Urinary changes
    •    -Integumentary changes
    • Psychosocial effects
  124. Developmental Changes - Mobility
    Infants, Toddlers,Preschoolers (3)
    • Prolonged immobility delays:
    • gross motor skills,
    • intellectual development, or
    • musculoskeletal development
  125. Developmental Changes - Mobility
    Adolescents (2)
    • Delayed in gaining independence and in accomplishing skills
    • Social isolation can occur
  126. Developmental Changes - Mobility
    Adults (2)
    • Physiological systems are at risk
    • Changes in family and socialstructures
  127. Developmental Changes - Mobility
    Older Adults(3)
    • Decreased physical activity
    • Hormonal changes
    • Bone reabsorption
  128. General Assessment Questions- Mobility (3)
    • Changes when walking or caring for self ?
    • Stiffness, swelling, pain, difficulty moving ?
    • Shortness of breath?
  129. General Assessment Questions- Immobility (7)
    • Normal activity; recent changes?
    • Appetite/diet changes?
    • Normal diet?
    • Perception of length of day?
    • Quality of night sleep?
    • Red or open areas on skin?
    • Bowel or urination changes?
  130. What is meant by "concentric tension" of muscles?
    a. Increased muscle contraction results in movement.
    b. The speed and direction of movement are controlled.
    c. Tension causes no shortening or active movement.
    d. Tension does not result in isotonic contraction.
    • ANS: A
    • In concentric tension, increased muscle contraction causes muscle shortening, resulting in movement. Eccentric tension helps control the speed and direction of movement. Concentric and eccentric muscle actions are necessary for active movement and are referred to as dynamic or isotonic contraction. Isometric contraction (static contraction) causes an increase in muscle tension or muscle work but no shortening or active movement of the muscle.
  131. Muscles that attach to bones to provide the needed strength to move an object use which of the following to obtain their objective?
    a. Posture
    b. Leverage
    c. Isometric contractiond. Muscle tone
    • ANS: B
    • Leverage is an inducing or compelling force that occurs when specific bones, such as the humerus, ulna, and radius, and associated joints, such as the elbows, act together as a lever. Posture is the position of the body in relation to the surrounding space. Isometric contraction causes an increase in muscle tension but no active movement. Muscle tone is the normal state of balanced muscle tension.
  132. During voluntary movement, impulses descend from the motor strip to the spinal cord. Impulses stimulate muscles by way of
    a. Ligaments.
    b. Tendons.
    c. Neurotransmitters.
    d. Cartilage.
    • ANS: C
    • Through a complex process, neurotransmitters, or chemicals such as acetylcholine transfer electrical impulses from the nerve across the neuromuscular junction to the muscle. The neurotransmitter reaches a muscle and stimulates it. Ligaments are white, shiny, flexible bands of fibrous tissue that bind joints together and connect bones and cartilages. Tendons connect muscle to bone. Cartilage is nonvascular, supporting connective tissue located chiefly in the joints and in the thorax, trachea, larynx, nose, and ear.
  133. Although isometric contractions do not result in muscle shortening, the nurse understands that isometric contractions
    a. Result in decreased energy expenditure.
    b. Are always desirable regardless of patient condition.
    c. Are necessary for the active movement of muscles.
    d. Result in increased energy expenditure.
    • ANS: D
    • Although isometric contractions do not result in muscle shortening, energy expenditure increases. It is important to understand the energy expenditure associated with isometric exercises because they are sometimes contraindicated in certain illnesses. Isometric contractions increase muscle tension but not active movement of the muscle.
  134. Joints are the connections between bones. The joint that is freely movable is known as the _____ joint.
    a. Synostotic 
    b. Cartilaginous 
    c. Fibrous 
    d. Synovial
    • ANS: D
    • The synovial joint, or true joint, is a freely movable joint in which contiguous bony surfaces are covered by articular cartilage and are connected by ligaments lined with a synovial membrane. The synostotic joint refers to bones jointed by bones. No movement is associated with this type of joint. In the cartilaginous joint, or synchondrosis joint, cartilage unites bony components. When bone growth is complete, the joints ossify. The fibrous joint, or syndesmosis joint, is a joint in which a ligament or membrane unites two bony surfaces, permitting a limited amount of movement only.
  135. The term body alignment refers to positioning of the joints, tendons, ligaments, and muscles while standing, sitting, and lying.
    A term that is similar to body alignment isa. Weight.
    b. Posture.
    c. Friction.
    d. Body mechanics.
    • ANS: B
    • The terms body alignment and posture are similar and refer to positioning of the joints, tendons, ligaments, and muscles while standing, sitting, and lying. Weight is the force exerted on a body by gravity. Friction is a force that occurs in a direction to oppose movement. Body mechanics is a term used to describe the coordinated efforts of the musculoskeletal and nervous systems.
  136. Without balance control, the center of gravity is displaced, thus creating risk for falls and subsequent injuries. Balance is enhanced by
    a. Maintaining a narrow base of support.
    b. Creating a high center of gravity.
    c. Disregarding body posture.
    d. Keeping a low center of gravity.
    • ANS: D
    • Without balance control, the center of gravity is displaced, thus creating risk for falls and subsequent injuries. Balance is enhanced by keeping the center of gravity of the body low with a wide base of support and by maintaining correct body posture.
  137. Immobilized patients frequently have hypercalcemia, placing them at risk for
    a. Osteoporosis.
    b. Renal calculi.
    c. Pressure ulcers.
    d. Thrombus formation.
    • ANS: B
    • Renal calculi are calcium stones that lodge in the renal pelvis or pass through the ureters. Immobilized patients are at risk for calculi because they frequently have hypercalcemia. Osteoporosis is caused by accelerated bone loss. A pressure ulcer is an impairment of the skin that results from prolonged ischemia (decreased blood supply) within tissues. A thrombus is an accumulation of platelets, fibrin, clotting factors, and cellular elements of the blood attached to the interior wall of a vein or artery, which sometimes occludes the lumen of the vessel
  138. Patients on bed rest or otherwise immobile are at risk for
    a. Increased metabolic rate.
    b. Increased diarrhea (peristalsis).
    c. Altered metabolic function.
    d. Increased appetite.
    • ANS: C
    • Immobility disrupts normal metabolic functioning: decreasing the metabolic rate, altering the metabolism of carbohydrates, fats, and proteins (nutritional function); causing fluid, electrolyte, and calcium imbalances; and causing gastrointestinal disturbances such as decreased appetite and slowing of peristalsis.
  139. In caring for a patient who is immobile, it is important for the nurse to understand that
    a. The effects of immobility are the same for everyone.
    b. Immobility helps maintain sleep-wake patterns.
    c. Changes in role and self-concept may lead to depression.
    d. Immobile patients are often eager to help in their own care.
    • ANS: C
    • The immobilized patient often becomes depressed because of changes in role and self-concept. Every patient responds to immobility differently. Immobility or bed rest frequently affects coping and creates sleep-wake alterations because of changes in routine or in the environment. Because immobilization removes the patient from a daily routine, he or she has more time to worry about disability. Worrying quickly increases the patient's depression, causing withdrawal. Withdrawn patients often do not want to participate in their own care.
  140. Immobility is a major risk factor for pressure ulcers. In caring for the patient who is immobilized, the nurse needs to be aware that
    a. Breaks in skin integrity are easy to heal.
    b. Preventing a pressure ulcer is more expensive than treating one.
    c. Immobilized patients can develop skin breakdown within 3 hours.
    d. Pressure ulcers are caused by a sudden influx of oxygen to the tissue.
    • ANS: C
    • Immobility is a major risk factor for pressure ulcers. Any break in the integrity of the skin is difficult to heal. Preventing a pressure ulcer is much less expensive than treating one; therefore, preventive nursing interventions are imperative. An older adult who is immobilized can develop skin breakdown within 3 hours. Tissue metabolism depends on the supply of oxygen and nutrients to and the elimination of metabolic wastes from the blood. Pressure affects cellular metabolism by decreasing or totally eliminating tissue circulation.
  141. The nurse is caring for a patient who has been diagnosed with a stroke. As part of her ongoing care, the nurse should
    a. Encourage the patient to perform as many self-care activities as possible.
    b. Provide a complete bed bath to promote patient comfort.
    c. Place the patient on bed rest to prevent fatigue.
    d. Understand that the patient will not eat owing to a decreased energy need.
    • ANS: A
    • Nurses should encourage the patient to perform as many self-care activities as possible, thereby maintaining the highest level of mobility. Sometimes nurses inadvertently contribute to a patient's immobility by providing unnecessary help with activities such as bathing and transferring. Placing the patient on bed rest without sufficient ambulation leads to loss of mobility and functional decline, resulting in weakness, fatigue, and increased risk for falls. Anorexia and insufficient assistance with eating lead to malnutrition.
  142. When assessing the body alignment of a patient while he or she is standing, the nurse is aware that
    a. When observed posteriorly, the hips and shoulders form an "S" pattern.
    b. When observed laterally, the spinal curves align in a reversed "S" pattern.
    c. The arms should be crossed over the chest or in the lap.
    d. The feet should be close together with toes pointed out.
    • ANS: B
    • When the patient is observed laterally, the head is erect and the spinal curves are aligned in a reversed "S" pattern. When observed posteriorly, the shoulders and hips are straight and parallel. The arms hang comfortably at the sides. The feet are slightly apart to achieve a base of support, and the toes are pointed forward.
  143. The nurse is evaluating the body alignment of a patient in the sitting position. In this position
    a. The body weight is directly on the buttocks only.
    b. Both feet are supported on the floor with ankles flexed.
    c. The edge of the seat is in contact with the popliteal space.
    d. The arms hang comfortably at the sides.
    • ANS: B
    • Both feet are supported on the floor, and the ankles are comfortably flexed. With patients of short stature, a footstool is used to ensure that the ankles are comfortably flexed. Body weight is evenly distributed on the buttocks and thighs. A 1- to 2-inch space is maintained between the edge of the seat and the popliteal space on the posterior surface of the knee to ensure that no pressure is placed on the popliteal artery or nerve. The patient's forearms are supported on the armrest, in the lap, or on a table in front of the chair.
  144. The nurse is assessing body alignment for a patient who is immobilized. To do this, the nurse must
    a. Place the patient in the supine position.
    b. Remove the pillow from under the patient's head.
    c. Insert positioning supports to help the patient.
    d. Place the patient in a lateral position.
    • ANS: D
    • Assess body alignment for a patient who is immobilized or bedridden with the patient in the lateral position, not supine. Remove all positioning support from the bed, except for the pillow under the head.
  145. Physical Assessment of Mobility: Range of joint motion (2)
    • Examine movement around 3 body planes (frontal, sagittal,transverse)
    • Assess/ask about stiffness, swelling, pain, limited movement,& unequal movement
  146. Type of mvmt. for the Neck and cervical spine
    Type of Joint
    Pivotal
  147. Type of mvmt. for the Neck and cervical spine, Range (degrees) and primary muscle (5)
    1. Flexion: bring chin to rest on chest: 45o; Sternocleidomastoid

    2. Extension: Return head to erect position; 45o; Trapezius

    3. Hyperextension: bend head back as far as possible 10o; Trapezius

    4. Lateral Flexion: Tilt head as far as possible toward each shoulder; 40-45o; Sternocleidomastoid

    5. Rotation: turn head as far as possible in circular mvmt.; 180o; Sternocleidomastoid & Trapezius
  148. Type of mvmt. for shoulder;Range o; Primary Muscles (8)
    1. Flexion: raise arm from side position forward to position above head; 180o; coracobrachialis, biceps brachii, deltoid, pect. major

    2. Extension: return arm to position at side of body; 180o; latissmus dorsi, teres major, triceps brachii

    3. hyperextension: move arm behind body, keeping elbow straight;45-60oLatissimus dorsi, teres major, deltoid

    4. abduction: raise arm to side to position above head with palm away from head; 180o; deltoid; supraspinatus

    5. adduction: lower arm sideways and across body as far as possible;320o; pect. major.

    6. internal rotation: with elbow flexed, rotate shoulder by moving arm until thumb is turned inward and toward back; 90o; pect. major, latissimus dorsi, teres major. subscapularis.

    7. External rotation: with elbow flexed, move arm until thumb is upward and lateral to head;90o; infraspinatus, teres major, deltoid

    8. Circumduction: Move arm in full circle; 360o; deltoid, coracobrachialis, latissimus dorsi, teres major.
  149. Type of mvmt. for shoulder- Type of Joint
    Ball and socket
  150. Elbow Type of Joint
    Hinge
  151. Type of mvmt. for Elbo; Range o; Primary Muscles (2)
    1. Flexion: bend elbow so lower arm moves toward its shoulder joint and hand is level w/ shoulder 150o; Triceps Brachii, brachialis, brachioadalis

    2. Extension: straighten elbow by lowering hand;150o; Triceps Brachii
  152. Forearm- type of joint
    Pivotal
  153. Type of mvmt. for forearm;Range; Primary Muscles (2)
    1. Supination: turn lower arm and hand so palm is up; 70-90o; supinator, biceps brachii

    2. pronation; Turn lower arm so palm is down; 70-90o; pronator teres, pronator quadratus
  154. Wrist- type of joint
    condyloid
  155. Type of mvmt. for wrist; Range; (5)
    • 1.Flexion: move palm toward inner aspect of forearm; 80-90o,
    • 2.extension: move fingers and hand posterior to mideline,80-90o 
    • 3.hyperextension: bring dorsal surface of hand back as far as possible; 80-90o
    • 4.Abduction:place hand w/ palm down and extend wrist laterally toward 5th finger; up to 30o
    • 5. Adduction:Place hand w/ palm down and extend wrist medially toward thumb; 30-50o
  156. Fingers type of joint
    Condyloid hinge
  157. type of mvmt. for fingers; range (5)
    • 1. Flexion; make fist, 90o 
    • 2. extension; straighten fingers; 90o
    • 3. hyperextension: bend fingers back as far as possible; 30-60o
    • 4.abduction: spread fingers apart; 30o
    • 5.adduction: bring fingers tog; 30o
  158. type of mvmt. for thumb; range (5)
    • flexion: (move thumb across palmar surface of hand),90o
    • extension (move thumb straight away from hand), 90o
    • abduction (extend thumb laterally)30o,
    • adduction (move thumb back toward hand)30o, opposition (touch thumb to each finger of same hand)
  159. Thumb type of joint
    Saddle
  160. Hip type of joint
    Ball and socket
  161. type of mvmt. for hip; range (6)
    • 1. Flexion (move leg forward and up)90-120,
    • extension (move back beside other leg)90-120,
    • 2. hyperextension (move leg behind body),30-50
    • abduction (move leg laterally away from body),30-50
    • 3. adduction (move leg back toward medial position and beyond if possible),30-50
    • 4. Internal rotation (turn foot and leg toward other leg),90
    • 5. external rotation (turn foot and leg away from other leg),90
    • 6. circumduction (move leg in circle),
  162. knee type of joint
    hinge
  163. type of mvmt. for knee; range (2)
    • Flexion (bring heel back toward back of thigh),120-130
    • extension (return leg to floor)120-130
  164. ankle type of joing
    hinge
  165. type of mvmt. for ankle; range (2)
    • dorsal flexion (move foot so toes are pointed upward),20-30
    • plantar flexion (move foot so toes are pointed downward)45-50
  166. foot type of joint
    gliding
  167. type of mvmt. for foot, range (2)
    inversion (turn sole of foot medially) 10 or less, eversion (turn sole of foot laterally) 10 or less
  168. toes type of joint
    Condyloid
  169. type of mvmt. for toes; range (4)
    • flexion (curl toes downward),30-60
    • extension (straighten toes),30-60
    • abduction (spread toes apart),15 or less
    • adduction (bring toes together)15 or less
  170. Physical Assessment of Mobility: Gait
    Assessment allows nurse to draw conclusions about balance,posture, safety, & ability to walk without assistance
  171. Physical Assessment of Mobility;Exercise and activity tolerance
    Monitor for symptoms such as dyspnea, fatigue, chest pain,and vital sign changes
  172. Physical Assessment of Mobility; Body alignment
    Assess Standing, sitting, lying
  173. Assessment for Physiological Hazards of Immobility:Metabolic (5)
    • slowed wound healing
    • abnormal lab data
    • muscle atrophy
    • decreased amt. of subcut. fat
    • generalized edema
  174. Assessment for Physiological Hazards of Immobility:Respiratory (5)
    • asymmetrical chest wall movement,
    • dyspnea,
    • increased resp. rate
    • crackles
    • wheezes
  175. Assessment for Physiological Hazards of Immobility:Cardiovascular (5)
    • orthostatic hypotension
    • increased heart rate
    • 3rd heart sound
    • weak peripheral pulses
    • peripheral edema
  176. Assessment for Physiological Hazards of Immobility:Musculoskeletal (6)
    • decreased ROM
    • erthema
    • increased diameter in calf or thigh
    • joint contracture
    • activity intolerance
    • muscle atrophy
  177. Assessment for Physiological Hazards of Immobility: Skin (1)
    Breaks in skin integrity
  178. Assessment for Physiological Hazards of Immobility:Elimination
    • decreased urin output
    • cloudy or concentrated urin
    • decreased frequency of bm
    • distended bladder and abdmone
    • decreased bowel sounds.
  179. Evaluation- moibility
    • Have the patient’s goals been met?
    • Have outcomes been met? If not, ask questions:
    • Are there ways we can assist you to increase your activity?
    • Which activities are you having trouble completing right now?
    • How do you feel about not being able to dress yourself and make your own meals?
    • Which exercises do you find most helpful?
    • What goals for your activity would you like to set now?
  180. Safety Guidelines- mobility (8)
    • Communicate clearly.
    • Mentally review transfer steps.
    • Assess patient mobility and strength.
    • Determine assistance needed.
    • Raise side rail on opposite side of bed.
    • Arrange equipment.
    • Evaluate body alignment.
    • Understand use of equipment.
    • Educate patient.
  181. Rest contributes to: (3)
    • Mental relaxation
    • Freedom from anxiety
    • State of mental, physical, and spiritual activity
  182. Bed rest (does or does not) guarantee that a patient will feel rested.
    does not
  183. Normal Sleep Requirements and Patterns; Neonates
    16 hours a day
  184. Normal Sleep Requirements and Patterns;Infants
    8 to 10 hours at night + naps =total of 15 hours per day
  185. Normal Sleep Requirements and Patterns: Toddlers
    Total 12 hours a day (night &naps)
  186. Normal Sleep Requirements and Patterns: Preschoolers
    12 hours a night(naps rare by 5 yrs)
  187. Normal Sleep Requirements and Patterns:School Age
    • Younger 11 – 12 hrs (6yrs)
    • Older 9 to 10 hours (11 yrs)
  188. Normal Sleep Requirements and Patterns: Adolescents
    Get ~7½ hours
  189. Normal Sleep Requirements and Patterns: Young Adults
    Get 6 to 8½ hours
  190. Normal Sleep Requirements and Patterns:Middle and Older Adults
    • Total number of hours declines
    • Progressive decline in stage 3 & 4
  191. Factors Affecting Sleep and examples (8)
    Physical illness: Hypertension, respiratory, musculoskeletal, chronic illness, GI, nausea

    Drugs and substances: Hypnotics, diuretics, narcotics,antidepressants, alcohol,caffeine, beta-blockers,anticonvulsants

    Lifestyle:Work schedule, social activities, routines

    Usual sleep patterns: May be disrupted by social activity or work schedule

    Emotional stress Worries, physical health, death,losses

    Environment Noise, routines

    Exercise and fatigue: Moderate exercise and fatigue cause a restful sleep

    Food and calorie intakeTime of day, caffeine, nicotine,
  192. Hypnotics effects of sleep: (4)
    • interfere w/ reaching deeper sleep
    • provide only temp. (1 week) increase in quantity of sleep
    • eventually cause "hangover" during day. (excess drowsiness, confusion, decreased energy)
    • sometimes worsen sleep apnea in older adults.
  193. Antidepressants and stimulants effects on sleep (2)
    • suppress REM sleep
    • decrease total sleep time
  194. Alcohol effects on sleep (3)
    • speeds onset of sleep
    • reduces REM sleep
    • awakens person during night and causes difficulty returning to sleep
  195. Caffeine effects on Sleep (3)
    • prevents person from falling asleep
    • causes person to awaken during night
    • interferes with REM sleep
  196. Diuretics effects on sleep (1)
    nighttime awakenings caused by nocturia
  197. beta-adrenergic blockers effects on sleep (3)
    • cause: nightmares
    • insomnia
    • awakening from sleep
  198. benzodiazepines effects on sleep (3)
    • alter REM sleep
    • increase sleep time
    • increase daytime sleepiness
  199. Nicotine effects on sleep (4)
    • decreased total sleep time
    • decreased REM sleep time
    • causes awakenings from sleep
    • causes difficulty staying asleep
  200. Narcotics effects on sleep (2)
    • suppress REM sleep
    • cause increase daytime drowsiness
  201. Anticonvulsants effects on sleep (2)
    • decreased REM sleep time
    • cause daytime dorwsiness
  202. Circadian rhythms
    Affected by light, temperature, social activities, and work routines.
  203. Purpose of sleep (3)
    • Remains unclear
    • Physiological and psychological restoration
    • Maintenance of biological functions
  204. Physical illness can cause pain, physical discomfort, anxiety,depression, and sleep disturbances: (6)
    • Respiratory disorders
    • Nocturia
    • Pain
    • Restless leg syndrome (RLS)
    • Thyroid conditions
    • PUD
  205. Sleep disorders linked to numerous other illnesses: Cardiovascular
    • Hypertension
    • Nocturnal angina
    • Tachycardia
    • ECG changes
    • Stroke
  206. Hypersomnolence =
    Excessive sleepiness.
  207. A polysomnogram:
    involves the use of electroencephalography (EEG), electromyography (EMG), and electro-oculography (EOG) to monitor stages of sleep and wakefulness during nighttime sleep.
  208. Sleep hygiene =
    Practices that a patient associates with sleep.
  209. Cataplexy
    is sudden muscle weakness during intense emotions such as anger, sadness, or laughter; it can occur at any time during the day.
  210. Sleep paralysis
    is the feeling of being unable to move or talk just before waking or falling asleep.
  211. Insomnia description and cause
    • Characterized by difficulty falling asleep, frequent wakening, and/or short sleep (non-restorative)
    • Causes – situational stresses, poor sleep hygiene or underlying physical/psychological disorder
  212. Sleep apnea
    • Characterized by lack of airflow through nose/mouth for 10 seconds or longer during sleep
    • Types – central, obstructive, & mixed
    • Most common is obstructive sleep apnea (OSA)
  213. Obstructive Sleep Apnea:  Risk factors
    • MAJOR: obesity, hypertension
    • OTHER –smoking, heart failure, Type 2 DM, alcohol, family history
  214. Obstructive Sleep Apnea: Patho –
    muscles/structures of oral cavity or throat  relax during sleep. Upper airway becomes blocked diminishing or stopping nasal airflow….decline inarterial oxygen levels
  215. Obstructive Sleep Apnea S/S
    excessive daytime sleepiness
  216. Obstructive Sleep Apnea- Complications
    • – cardiac dysrhythmias,
    • R heart failure,
    • pulmonary hypertension,
    • stroke, & angina
  217. Narcolepsy: Patho
    dysfunction of mechanisms regulatingsleep/wake states
  218. Narcolepsy S/S –
    excessive daytime sleepiness, cataplexy, sleepparalysis
  219. Narcolepsy: RX
    – stimulants , antidepressants, brief daytime naps(20 min), good sleep hygiene, dietary measures, &avoid factors increasing drowsiness
  220. Sleep Deprivation  Causes –
    • s/s of various illnesses, stress, medications
    • environmental andshift work
    • S/S – may be physiological or psychological
  221. Parasomnias
    Occur more often in children; if in adulthood often indicate more serious disorder
  222. ParasomniasTypes
    – SIDS, somnambulism, night terrors,nightmares, enuresis, body rocking, bruxism
  223. Parasomnias RX –
    varies with disorder; maintaining safety a big issue
  224. Sleep Assessment: Sleep history (7)
    • Description of sleep problems
    • Usual sleep pattern
    • Presence of illness
    • Current life events
    • Emotional/mental status
    • Bedtime routine and environment
    • Behaviors of sleep deprivation
  225. Sleep Assessment: Specific Assessment Questions
    • Nature of problem
    • Signs and symptoms
    • Onset and duration of signs/symptoms 
    • Severity 
    • Predisposing factors
    • Effect on Patient
  226. Sleep Interventions (8)
    • Environmental controls
    • Promote bedtime routines
    • Promote safety
    • Promote comfort
    • Establish rest/sleep periods
    • Reduced stress 
    • Bedtime snacks 
    • Pharmacologic measures
  227. Self-Concept
    • A subjective sense of self and a complex mixture of unconscious and conscious thoughts,attitudes, and perceptions
    • A positive self-concept gives a sense of meaning, wholeness, and consistency to a person.
    • A healthy self-concept has a high degree of stability and generates positive feelings toward the self.
    • Self-esteem is closely related.
  228. Components of Self Concept (4)
    • Identity
    • Body image
    • Role performance
    • Self esteem
  229. Self concept stressor
    – any real or perceived change that threatens identity, body image, and role performance.
  230. The ____ ____  of the stressor most importantfactor influencing reaction
    individual’s perception
  231. Ability to adapt to stressor r/t (3)
    • Number of stressors
    • Duration of stressor
    • Health status
  232. Able to adapt to stressors – lead to
    positive self concept
  233. Inability to adapt to stressors – lead to
    negative self concept
  234. Role conflict
    – individual must assume 2 or more rolesthat are inconsistent, contradictory or mutuallyexclusive
  235. Sick role
    – expectations or others & society of how onebehaves when ill
  236. Role ambiguity
    – unclear role expectations
  237. Role strain
    – combines role conflict & ambiguity
  238. Self Esteem Stressors Childhood –
    • inability to meet parental expectations,
    • harsh criticism,
    • inconsistent discipline,
    • sibling rivalry
  239. Self Esteem Stressors: Pregnancy –
    unique self-concept stressors
  240. Self Esteem Stressors Adults-
    • failure in work,
    • unsuccessful relationships
  241. Self Esteem Stressors: Older adults –
    • health issues,
    • declining socioeconomicstatus,
    • spousal loss/bereavement,
    • loss social support
  242. The Nurse’s Effect on the Patient’sSelf-Concept:
    • Nurses need to remain aware of their own feelings, ideas, values, expectations, and judgments:
    •    Use a positive and matter of fact approach.
    •    Build a trusting relationship.
    •    Be aware of facial and body expressions.
  243. Assessment of Self Concept: Nature of Problem (5)
    •  How would you describe yourself?
    •  What aspects of your appearance do you like?
    •  Tell me about the things you do that make you feel good about yourself.
    •  Tell me about your primary roles.
    • How effective are you in carrying them out?
  244. Assessment of Self Concept:Onset and Duration (3)
    •  When did you start feeling differently about your self?
    •  How long have you struggled with ____________?
    •  Can you remember a time when you felt good about yourself?
  245. Assessment of Self Concept: Effect on Patient (3)
    •  Tell me how your self-concept affects your ability to take care ofyourself
    •  What impact does your self-esteem have on relationships?
    •  How does your self esteem affect other areas of your life?
  246. Behaviors Suggestive of Altered Self-Concept
    • Avoidance of eye contact
    • Slumped posture
    • Unkempt appearance
    • Overly apologetic
    • Hesitant speech
    • Overly critical or angry
    • Frequent or inappropriatecrying
    • Negative self-evaluation
    • Excessively dependent
    • Hesitant to express viewsor opinions
    • Lack of interest in what is happening
    • Passive attitude
    • Difficulty in making decisions

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