Nursing Exam II

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Nursing Exam II
2010-09-25 20:17:17
nursing exam II

Nursing Exam II
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  1. accreditation agencies such as ____ ____ ____ specify guidelines for documentation
    The Joint Commission
  2. requires disclosure or requests regarding health information
  3. the joint commission requires each client have an assessment (6 steps)
    • physical
    • pyschosocial
    • environment
    • self-care
    • client education
    • discharge planning needs
  4. federal and state regulations, state statutes, standards of care, and accreditation agencies......
    set nursing documentation standards
  5. confidential permanent legal document
    records or chart
  6. oral, written, audiotaped exchange of information
  7. a professional caregiver providing fomal advice to another caregiver
  8. arrangement for services by another care provider
  9. purposes of records
    • communication
    • financial billing
    • research
    • legal documentation
    • education
    • auditing/monitoring
  10. guidelines for quality documentation and reporting
    • factual
    • accurate
    • complete
    • current organized
  11. tradition method of recording
  12. what the patient says

    i.e. symptoms
  13. something observable
    i.e. signs
  14. focuses on documenting deviations....only chart whats not normal
    charting by exception
  15. incorporates a multidisciplinary approach to care....gets people out as quick as possible
    case management plan and critical pathways
  16. includes medicare and medicaid legislation for long term care documentation
    Omnibus Budget Reconciliation Act of 1987
  17. governs the frequency of written nursing records
    department of health
  18. S
    • subjective
    • objective
    • assessment
    • plan
  19. not permanent in patients file
    advance directive
  20. occurs when a microorganism invades the host but does not cause infection
  21. infectious process transmitted from one person to another
  22. chain of infection
    • infectious agent or pathogen
    • source of pathogen growth
    • portal of exit
    • mode of transmission
    • portal of entry
    • susceptible host
  23. three stages of the infection process
    • incubation period
    • prodromal stage
    • illness stage
  24. most microorganisms preer an environment within a pH range of
  25. do not usually cause disease when residing in their usual area of the body but instead participate in maintaining flora
    normal flora
  26. fluid and cells that are discharged from cells or blood vessels

    pus and serum
  27. process that involves the destruction and absorbtion of bacteria
  28. increase in number of circulating blood cells
  29. clear like plasma
  30. containing red blood cells
  31. contains WBCs and bacteria
  32. not as strong as tissue collagen and assumes the form of scar tissue
    granulation tissue
  33. type of HAI from a diagnostic or therapeutic procedure
    iatrogenic infection
  34. post operative infection that is present outside the body
  35. occur when pard of the clients flora becomes altered and an over growth occurs
  36. absence of pathogenic microorganisms
  37. writes guidlines in infection control and prevention
  38. has a thicker cell wall and holds the violet stain
    gram +
  39. thinner cell wall and does not hold violet stain
    gram -
  40. bacteria shaped like a rod
  41. bacteria shaped like a sphere
  42. bacteria shaped like a spiral
  43. anerobic bacteria infections are usually found where in the body
    bladder, GI, blood
  44. anti-infectives are broken into what two classes
    • chemical-structure
    • pharmacologic-how they work
  45. bacteriocidal medications are used to
    kill bacteria
  46. these type of infections interrupt growth
    bacteriostatic medications
  47. affects bacterial cell wall, gram +
    penicillins or cillins
  48. affects bacterial cell wall, gram -
  49. affects bacterial cell wall, both gram + and -
  50. two unclassified drugs that affect bacterial cell wall
    vancomycin and aztreonam
  51. major considerations for medications that affect the bacterial cell wall
    • anaphylatic reactions
    • photosensitivity
    • decrease effects of birth control
    • rash and diarrhea most common
    • hyperkalemia
    • nephrotoxic
  52. can cause hypotension and be ototoxic
  53. affects bacterial protein synthesis, gram + and -
  54. affects bacterial protein sythesis, gram +
  55. affects bacterial protein synthesis, gram -
  56. effective against MRSE and VRE
  57. major considerations for medications that affect bacterial protein synthesis
    • destroy normal flora
    • photosensitivity
    • rash and diarrhea most common
    • hepatoxic
    • eliminates vitamin K
  58. causes tooth discoloration
  59. are ototoxic and nephrotoxic
  60. interferes with DNA replication, gram + and -
  61. effective against c-diff
  62. effective against TB
  63. commonly used antibiotic ointment
  64. major considerations for medications that interfere with DNA replication
    • photosensitivity
    • rash and diarrhea most common
    • hepatoxic
  65. most common medications used to interfere with DNA replication
    ciprofloxacin, levofloxacin
  66. new and effective against anarobes
  67. the awareness of the postion of the body and its parts
  68. fit closely together and are fixed
    fibrous joints
  69. removal of waste products
  70. one day of full bed rest takes how many days to recover
  71. what are the three factors that contribute to venous thrombus formation
    • damage to the vessel wall
    • alterations of blood flow
    • alterations of blood constituents
  72. muscles break down into _____
  73. contractor can start as soon as ___ hours and is not reversable
  74. atelectasis means
    collapsed lung
  75. immobitiliy affects the cardio system in what way compared to the other systems
    it makes the cardio system work harder, while the other systems being to shut down
  76. changes in mobility alter what changes to the metabolic changes
    • endocrine metabolism
    • calcium resorbtion
    • functioning of the GI system
  77. when the client is immoble, the clients body often excretes more nitrogen then it ingests in proteins, resulting in _____ ______ _______
    negative nitrogen balance
  78. inflammation of the lung from stasis or pooling of secretions
    hypostatic pneumonia
  79. the most common respitory complications from immobility are ______ and ______
    • atelectasis
    • hypostatic pneumonia
  80. accumulation of platelates, fibrin, clotting factors, and the cellular elements of the blood attached to the interior wall of a vein or artery
  81. what are the changes on the musculoskeletal due to immobility
    • loss of endurance and muscle mass
    • decresed stability and balance
  82. effects on the muscles due to immobility
    • loss of muscle mass
    • muscle atrophy
  83. what are the effects on the skeletal system due to immobility
    • impaired calcium absorbtion
    • joint abnormalities
  84. what are the effects on urinary elimination due to immobility
    • urinary stasis
    • renal calculi
  85. effects on the integumentary system due to immobility
    • pressure ulcer
    • ischemia
  86. whats the acute care implementation for metabolic immobility
    • provide high protein diet
    • high caloric diet
    • vitamin B and C supplements
  87. implementation of acute care for the respiratory system due to immobilty
    • cough and deep breathe every 1-2 hours
    • chest physiotherapy
  88. fowler
  89. sims
  90. stored in bronchi trees, GI tract and skin
  91. reduces prostaglandin synthesis
    lowers body temperature
    causes centrally mediated peripheral vasodilation and sweating
  92. this class of drug can increase blood sugars
  93. assess the prothrombin time and international normalized ratio with concurrent anticoagulant use
  94. report ringing in the ears, impaired hearing, dizziness, unusual bruising or bleeding that is slow to stop with this medication
  95. analgesic
  96. this NSAID blocks cox-2 but not cox-1; causes less GI bleeding and ulcer formation;anti-inflammatory
  97. this medications serious adverse effects include MI that can be fatal and stroke
  98. used to reduce fever and relieve pain but is not a NSAID of anti-inflammatory
  99. which medicine do you take for tylenol poisoning?
    acetadote (acetylcysteine)
  100. used to treat transplant rejection
    inhibit immune response bia several different mechanisms
  101. what is the specific drug of choice for transplant rejection
    diminishes the activity of T cells and B cells and suppresses the immune response
  102. when on this immunosuppressant avoid direct sunlight, and causes renal impairment and hepatic impairment
  103. this immunosuppressant causes reduced urine flow, hypertension, tremor, hair growth in women, elevated hepatic enzymes, infections, anaphylaxis
  104. on this immunosuppressant avoid crowds
    take the same time everyday
    see dentist before to ensure good dental hygeine
  105. immunosuppressant that inhibits DNA synthesis and is metabolized in the liver
  106. immunosuppressant side effects:
    bone marrow suppression
    serious infections
    skin and lymphoid malignancies
  107. when on this immunosupp. nursing respons. include:
    obtain baseline lab tests and perform CBCs
    monitor kidney and liver function, input/output ratio, and characteristics of urine, abnormal bleeding signs, use protective isolation to reduce infections
  108. used to prevent transplant rejection, autoimmune disorders, malignancies....harvested from antibodies produced by a single B cell, very specific targeting a single type of target cell or receptor
  109. drug of choice for short term therapy of severe inflammation
  110. corticosteroids lymphocyte effect
    reduces circulating lymphocytes
  111. corticosteroids monocyte effect
    depletes body of monocytes and macrophages
  112. corticosteroids neutrophil effect
    causes neutrophil to moce from bone marrow to general circulation
  113. what are the other effects of cortiocosteroids
    blocks production of protaglandins and ILs
  114. the four types of immunosuppessants
    • calcineurin inhibitors
    • Imuran
    • Antibodies
    • Corticosteroids
  115. the skin has a ____ pH and receives approximately _____ of the blood supply
    • acid
    • 1/3
  116. what are the four functions of the skin
    • protection
    • thermoregulation
    • sensation
    • communication
  117. what are the four assessment steps for the skin
    • visual inspection of the skin
    • check bony prominences
    • skin risk assessment
    • stage any pressure ulcers
  118. helps indentify patients at risk, has been known to decrease pressure ulcer rates, pt. assessed in 6 areas of functions and scored, the lower the number the higher the risk
    Braden scale
  119. the ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue or purple hues
    stage 1 pressure ulcer
  120. partial thickness loss of skin layers involving epidermis and possibly penetrating into, but not thru the dermis...may appear to be blistering with erythema; wound base is moist and pink
    stage II pressure ulcer
  121. full thickness tissue loss extending thru the dermis to involve subQ tissue...presents as shallow crater unless covered by eschar...may include necrotic tissue, exudate or infection
    stage III pressure ulcer
  122. full thickness tissue loss with exposed bone, tendon, or muscle. slough or eschar may be present on some parts of the wound..often undermining and tunneling
    stage IV pressure ulcer
  123. skin intact, discoloration of skin, deep red to purple color, may have recesed area, may be dark blister
    deep tissue injury
  124. full thickness tissue loss in which the base of the ulcer is covered by yellow, tan, gray, green, or brown tissue and eschar in the wound bed
  125. factors that impact wound healing include (6)
    • nutrition
    • infection
    • diabetes
    • steroids
    • immunosupp.
    • age
  126. transparent dressing that is used to reduce friction, and protect small areas
  127. only insulates and protects wound...stages 1-3...agressive skin sealant..can stay on up to 7 days...NOT to be used on infection
  128. provides and maintains moisture to the wound bed, easy to apply, requires external dressing
  129. tolerates minimal damage, very comforting on wounds, insulates wounds....used for burns
  130. can be used on most wounds, moderate to heavy drainage, can be left in place for 3 or more days, requires outer dressing, made from seaweed, high absorbancy
    hydrofiber--aquacel (ag)
  131. made from seaweed
    used for heavy drainage
    turns into gel when moistened
  132. large dressings
    heavy draining wounds
    non-stick layer
  133. adaptic
    non-stick layer
    used for skin tears
    layer on wound vac
    non adherent dressing
  134. alldress
    wound covering
    gentle tape
    non-stick dressing
    island dressing