Nursing 111 Final Exam

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Nursing 111 Final Exam
2014-12-07 23:15:11
NUR 111 Final

Nursing 111 Final Exam
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  1. Good Questions to ask a patient:
    • Tell me about yourself (Broad Opening)
    • What I think I hear is... (Restating)
    • Let me sit with you (Offering of Self)
  2. Questions to never ask a patient:
    • Do not use WHY or HOW (Why is never the right answer)
    • Do not ever challenge a patient
  3. Mary Breckenridge
    Mid Wife, She established the frontier Nursing Service and one of the First Midwifery Schools in the United States. Anything to deal with pregnancy, and babies health
  4. Pain is what the patient says it is
  5. Also wait at least 30 mins to 1 hour after giving pain medications before you do any kind of procedures
  6. When caring for visually impaired patients:
    Acknowledge your presence in the patient's room
    Nursing History and People:

    Linda Richards: First trained nurse in the US
    Florence Nightingale: Define nursing as both an art and science, differentiated nursing from medicine. Initiator of major reform in healthcare and nursing training in England
    Mary Elizabeth Mahoney: America's first African American Nurse to graduate from Nursing School.
    Priests were highly regarded as physicians. Good spirits brought health and evil spirits brought sickness and death. The physician was the medicine man who treated diseases by chanting. Nurse was usually the mother who cared for her family during sickness providing remedies and physical care. The nurse was viewed as a slave carrying out menial tasks on the orders of the priest-physician.
  8. Palliative Care- Taking care of the whole person: body, mind, spirit, heart, and soul- with the goal of giving patients with life-threatening illnesses the best quality of life they can have through the aggressive management of symptoms.
    Care you are receiving with any kind of illness, not just if you have 6 months left to live
  9. Bradycardia-Slow Heart Rate, pulse rate below 60 bpm
    Tachycardia-Rapid heart rate, pulse rate between 100-180 bpm
  10. Hyponatremia-Insufficient amount of sodium in the extracellular fluid

    Na+ 135-145
    • <135
    • Causes kidney disease, adrenal insufficiency, GI losses, diaphoresis (severe sweating), diuretics, polydipsia (thirst), and SIADH

    Effects are apprehension, personality change, postural hypotension, postural dizziness, abdominal cramping, N/V, coma, diarrhea, tachycardia, low urine Specific gravity
  11. Active Range of Motion- Joint movement activitated by the person
    Passive Range of Motion-Manual or mechanical means of moving the joint (Helping assist with ROM)
  12. The Safety of a patient is always Important
  13. Constipation is caused by Narcotics, and pain killers. Teach the patient to increase fluids and increase bulk.
  14. Hypoxia- Inadequate amount of oxygen available to the cells
  15. Do-not-resuscitate (DNR)- An order specifying that there be no attempt to resuscitate a patient in the event of cardiopulmonary arrest
    Living Will (Written Documentation)- Advance directive specifying the medical care a person would want or refuse should he or she lack the capacity to consent to or refuse treatment himself or herself.

    Durable Power of Attorney- Appoints an agent, trusted by the person who is ill to make decisions in the even of subsequent incapacity.
  16. Do not send a body out of the facility that is not labeled (providing postmortem care)
  17. Elizabeth Kubler-Ross (1969) a pioneer in the study of grief and death reactions, defined 5 stages of reaction. Pioneer of understanding near death experiences, she was the founder of Home of Peace which was the first place to serve AIDS patients.
    • 1.Denial and Isolation
    • 2. Anger
    • 3. Bargaining
    • 4. Depression usually consist of 2 things (Sadness/Regret and Clinical)
    • 5. Acceptance (Not everyone makes it to this stage)

    Denial: Patient denies the reality of death and may repress what is discussed

    Anger: The patient expresses rage and hostility and adopts a "why me?" attitude

    Bargaining: The patient tries to barter for more time

    Depression: The patient goes through a period of grief before death often characterized by crying and not speaking much

    Acceptance: When the stage of acceptance is reached, the patient feels tranquil. The reality of death has been accepted and the patient is prepared to die
  18. Advanced Directive- Written directive that allows people to state in advance what their choices for healthcare would be if certain circumstances should develop
    Decide who will make decisions for the patient in the case if she is unable to

    Decide what kind of medical treatment the patient wants or doesn't want

    Decide how comfortable the patient wants to be

    Decide how the patient will be treated by others

    Decide what the patient wants loved ones to know
  19. Assault- Threat or an attempt to make bodily contact with another person without that person's permission
    Battery- Assault that is carried out and includes willful, angry, and violent or negilent touching of another person's body or clothes or anything attached to or held by the other person.
  20. When interviewing people 1 on 1 is usually better unless the person is not in a good mind state, then the family should be kept close by, other wise keeping the family close by to help with information is never the answer.
  21. HIPPA- Health Insurance Portability and Accountability Act
    OSHA- Occupational Safety and Health Act of 1970 ( Government agency that establishes minimum health and safety standards for workers)
    Liability- Involves 4 elements that must be established to prove that malpractice or negligence has occured.

    Duty-Accurate Statement

    Breach of Duty-Failure to note and report

    Causation-Failure to use appropriate safety measures

    Damages- The actual harm or injury resulting to the patietn
  22. Discharge planning begins as soon as the patient is admitted.
  23. Whoch one of the following establishes criteria for the education and licensure of nurses?

    A. Nursing Process
    B. ANA Standards of nursing practice
    C. National League for Nursing
    D. Nurse Practice Acts
    D. Nurse practice Acts regulate the practice of nursing including the education and licensure

    Nurse process is a guideline for nursing practice enabling nurses to implement their roles.

    ANA Standards of nursing practice protect and allow nurses to carry out professional roles

    The National League of nursing fosters the development and improvement of nursing services
    (this multiple choice question has been scrambled)
  24. Which of the following describes concepts that occur when a nurse believes that her own beliefs, ideas, and practices, are the best or superior to those of her colleagues or patients?

    A. Cultural Diversity
    B. Culture Shock
    C. Stereotyping
    D. Ethnocentrism
    D. Ethonocentrism is the belief that one's ideas, beliefs, and practices are superior or preferred to those of others
    (this multiple choice question has been scrambled)
  25. A nurse who focuses attention on the strengths and abilities of his patients rather than their problems is helping them to achieve which of Maslow's basic human Needs?

    A. Self-actualization
    B. Self-Esteem
    C. Love and belonging
    D. Safety and Security
    E. Physiologic
    A Self-actualization
  26. Maslow's Hierarchy of Needs:

    1. Physiologic
    2. Safety and Security
    3. Love and Belonging
    4. Self-Esteem
    5. Self-Actualization
    To meet patient self-actualization needs, nurses provide a sense of direction and hope and maximize patient potential

    Self-Esteem needs are met by respecting patient values and beliefs and setting attainable goals for them

    Love and belonging needs are met by including family and friends and establishing caring relationships with patients

    Safety and Security needs are met by encouraging spiritual practices and independent decision making

    Physiologic needs are needs that must be met to maintain life
  27. 4 Phases of Wound Healing:
    1. Hemostasis-Occurs IMMEDIATELY after the initial injury, blood clotting begins, and exudate which leads to swelling and pain

    2. Inflammatory- Usually last 4-6 days, WBC move to the wound, heal and fight off infections

    3. Proliferation- Connective tissue phase, last SEVERAL WEEKS, new tissue is built and granulation is formed here

    4. Maturation- Final Stage of healing, usually begins about 3 weeks after the injury, may continue for months or years depending on size of wound and patient's health state
  28. Dehiscence is where you can see the tissue, partial or total seperation of the wound layers due to excessive stress on the wounds that are not healed. Use pillows to protect when person is coughing or moving.
    Evisceration- Is the most serious complication of dehiscence. The wound completely seperates with protrusion of the viscera organ through the incisional area. Insides come out!!

    ** Dehiscence and Evisceration of an abdominal incision is a medical emergency
  29. Pressure Ulcers: First Indication might be blanching where the area becomes pale and white also called ischemia.

    Friction-Occurs when two surfaces rub against each other

    Shearing force- Results when one layer of tissue slides over another layer (repositioning a patient by yourself)
    Stage 1- Defined area of intact skin with non blanchable redness of a localized area, usually over a bony prominence such as the elbow, heels, tailbones, or hips. Area might be painful, firm, soft, warmer or cooler compared to other tissue. Darker skinned people may not have visible blanching.

    Stage 2- Involves partial thickness loss of dermis, superficial, may present as a blister or a abrasion or open ulcer with red/pink wound bed, without slough.

    Stage 3- Full thickness tissue loss, subcutaneous fat may be visible, may include tunneling

    Stage 4- Full thickness tissue loss, exposed bone, tendon or muscle, often includes tunneling or holes as big as fist. Slough and eschar may be present on some parts of the wound bed. (thick leatherly scab or dry, crust that has necrotic and has to be removed.)

    UNSTAGEABLE- Full thickness tissue loss, base of the ulcer is covered by slough and or eschar in the wound bed
  30. Heat DILATES peripheral blood vessels, reduces muscle tension, and helps prevent pain
    Cold therapy CONSTRICTS and reduces muscle spasms and promotes comfort. Decreases swelling and inflamation.
  31. Clearliquid diet- gelatin, broth, popsicles, clear juices, carbonated drinks, ginger ale, and apple juice.

    Full liquid diet- Milk, milk drinks, puddings, vegetables juices
    Soft diet- Usually regular diets that have been modified to elimate foods that are hard to digest and chew. May also be known as bland diet

    Pureed diet- Liquids and foods blenderized to liquid form
  32. Nonmaleficience-Avoid Causing harm
  33. Which of the following values involves acting in accordance with an appropriate code of ethics and accepted standards of practice?

    A. Integrity
    B. Altruism
    C. Autonomy
    D. Human Dignity
    E. Social Justice
    A. Integrity involves acting in accordance with a code of ethics and accepted standards of practice

    Altruism is a concern for the welfare of others

    Autonomy is the right to self-determination

    Human dignity is respect for the worth and uniqueness of individuals and populations

    Social justice is upholding moral, legal, humanistic principles
    (this multiple choice question has been scrambled)
  34. Nurses deliver care in nonjudgemental manner and are sensitive to diversity
  35. A nurse attempts to obtain an order for a feeding tube for an anorexic teenager who refuses to eat. What is the term for the ethical problem this nurse is experiencing?

    A. Advocacy in market driven environment
    B. Allocation of scarce nursing resources
    C. Paternalism
    D. Deception
    E. Confidentiality
    C. Paternalism occurs when a nurse acts for a patient without consent to secure good or prevent harm

    Deception occurs when a nurse deceives a person for a perceived benefit

    Patient Confidentiality is questioned when a patient confidence may lead to harm

    Allocation of scarce nursing resources and advocacy in market-driven environment involves patient harm due to inadequate staffing/finances
    (this multiple choice question has been scrambled)
  36. Which of the following is designed to provide pallaiative and supportive care services for dying persons?

    A.Voluntary Agencies
    B. Respite Care
    C. Parish Nursing
    D. Hospice Services
    D. Hospice provides physical, psychological, social, and spiritual care for dying persons. Up to 1 year of death of family member the family can get things from the Hospice facility

    Respite care is provided for caregivers for homebound ill, disabled, or elderly patients

    Parish nursing emphasizes holistic care, health promotion, and disease prevention activities

    Voluntary agencies are community agencies that are often non profit and provide a setting for support groups
    (this multiple choice question has been scrambled)
  37. The home health care nurse cannot regulate the setting where care is provided but must adapt to the patient's environment
  38. ADPIE: 5 Step Nursing Process

    Assessing-Collecting, validating, and communication of patient data (Providing a background)

    Diagnosing- Analyzing patient data to identify patient strengths and problems

    Planning- Specifying patient outcomes and related nursing interventions

    Implementing-Carrying out the plan of care (Doing something)

    Evaluating- Measuring extent to which patient achieved outcomes
  39. Which step of the nursing process is a nurse using when she analyzes patient data to determine her patient's strengths following a CVA?

  40. WOTF assessments would be performed on a patient to gather data about his previously diagnosed liver cancer?

    Focused Assessment
    In a focused assessment the nurse gathers data about a condition that has already been diagnosed

    An intital comprehensive assessment is performed shortly after the patient is admitted to the healthcare agency or service

    When a physiologic or psychological crisis presents, the nurse performs an emergency assessment

    A time-lapsed assessment compares a patients current status to baseline data obtained ealier
  41. Subjective Data- Information percieved by the patient but can't be verified

    Ex. Stomach ache
    Objective Data- Information that is observable and measureable

    Ex. Temperature and Throw up
  42. Erikson- Theory of psychosocial development
    based on Freud
    Trust Vs. Mistrust-Infancy

    Autonomy Vs. Shame and doubt-Toddler

    Initiative Vs. Guilt -Preschool

    Industry Vs. Inferiority-School-age

    Identity Vs. Role Confusion-Adolescance

    Intimacy Vs. Isolation-Young Adulthood

    Generativity Vs. Stagnation-Middle Adulthood

    Ego Integrity Vs. Despair- Later Adulthood
  43. Normal temperature

    36.0-37.5 Celsius (97.0-99.5 Farenheit)

    Calculating F to C:
    Subtract 32
    Multiply by 5
    Divide by 9

    Oral Thermometer Blue
    Rectal Thermometer RED
    • Afebrile-Without Fever
    • Febrile-With Fever
  44. Parasympathetic Stimulation of the SA Node via the vagus nerve decreases the heart rate
    Elvis died on the toilet. Bearing down to poop!
  45. Posterior Tibial is behind the ankle
    Apical Pulse- Assessed by auscultating over the apex of the heart (close to/ between 4 and 5th rib)
  46. Tachypnea-Increased respiratory rate
    Badypnea-Decreased respiratory rate

    Apnea-Periods with no breathing
    Dyspnea-Difficult or labored breathing
    Orthopnea-Ability to breathe easier in an upright position (chair/recliner, sitting up)

    Eupnea-Normal respirations
    Pulse Oximeter- Can be placed on ear lobe or finger, or toes

    Not with fake nails or nail polish

    Concern if under 90
  47. Blood pressure:

    Systolic- refers to the top number, basically means the force of the blood through the arteries with the contraction of the heart. Heart beat, highest pressure

    Normal Range is less than 120

    Dystolic- refers to the bottom number, means the force of the blood through the arteries with the relaxation of the heart muscles, lowest.

    Normal range is less than 80
    The difference between two numbers is known as the pulse pressure
  48. Hypertension-Blood pressure above normal for a sustained period

    Hypotension-Below normal blood pressure

    Orthostatic HyPOtension-Low blood pressure associated with weakness or fainting when an individual rises to sitting or standing position.
  49. Providing Culturally competent patient education: Develop an understandning of the patient's culture
  50. Reservoir- The natural habitat of the organism

    Means of transmission- How the organism is transmitted from it's resevoir (directly, indirectly, vectors, airborne droplets)
    Stages of Infection:

    1. Incubation period- Time between the pathogen's invasion of the body and the appearance of symptoms of infection. Organisms are growing and multiplying

    2. Prodromal Stage- Is the most infectious stage and early signs and symptoms may be present but are often vague. Patient doesn't realize they are contagious

    3. Full stage of illness- Presence of specific signs and symptoms indicates this stage. Symptoms may be localized or systemic

    4. Covalescent period- Recovery period from the infection. Signs and symptoms disappear and the individual returns to a healthy state
  51. Asepsis- All activities to prevent infection or break the chain of infection
    Medical Asepsis-Clean technique, Things that keep down or prevent infections from being passed around.

    Ex. Hand washing, wearing gloves

    Surgical Asepsis- Sterile technique, Inserting a foley catheter. Trying to keep things out!
  52. WOTF statements accurately describes part of the process involved when a patient leaves AMA?

    The Patient's signature must be witnessed, and the form becomes apart of the patient's record
  53. A patient is legally free to leave the hospital against medical advice (AMA). The patient must sign the form releasing the physician and healthcare institution and should be informed of any risks prior to signing the form
  54. A nurse who fails to log off a computer after documenting patient care has breached patient confidentiality
  55. Space and territory- 18 inches to 4 feet optimal distance for a nurse to sit from a patient (body proximity)
  56. Among adults older than 65, FALLS are the leading cause of injury fatality.

    R-Rescue anyone in immediate danger

    A-Activate the fire code and notify appropriate person

    C-Confine the fire by closing doors and windows

    E-Evacuate patients and other people to safe are
  57. The LIVER is the primary site for drug metabolism

    Most drugs excreted by the KIDNEYS (primarily), other routes of excretion include lungs, bile, GI tract, sweat, salivary and mamary glands
    TERATOGENIC- Means that a drug is know to have a potential to cause developmental defects in embryo/fetus and are definitely contraindicated. Examples include alcohol, dilantin, and accutane
  58. Parts of a Medication Order:

    Patient's Name
    Date and Time order is written
    Name of drug to be administered
    Dosage of drug ordered
    Route by which drug is to be given
    Frequency of administration of the drug
    Signature of person ordering the drug/writting the order
    5 Rights to Medication Administration:

    • Right Medication
    • Right Patient
    • Right Dosage
    • Right Route
    • Right Time

    • ** Right to Refuse
    •     Right Documentation
  59. Medication administration requires 3 checks:

    1. When the nurse reaches for the container or package

    2. Immediately before opening/pouring medication

    3. When placing container and/or before giving medication to patient