Assessment: - CORRECT ANSWER collecting vital signs, pain levels, other signs/ symptoms
Diagnosis: - CORRECT ANSWER nurse makes a nursing diagnosis based
... [Show More] on assessment of
patient; not a medical diagnosis
Planning: - CORRECT ANSWER nurse comes up with client-centered goals; need to be
measurable (client will ambulate 10 meters 3x daily for 2 wks)
Implementing: - CORRECT ANSWER following through with plan that was developed for the
patient
Evaluation: - CORRECT ANSWER goal was met, partially met, not met; how effective the plan
was for the patient and what should be changed for the patient
Normal range for temperature - CORRECT ANSWER 96.8-100.4
Normal range for pulse - CORRECT ANSWER 60-100
Normal range for respirations - CORRECT ANSWER 12-20
Normal range for BP - CORRECT ANSWER 100/60-140-90
Normal range for pulse ox. - CORRECT ANSWER >95%
SOLER - CORRECT ANSWER sit close, observe, lean forward, eye contact, relax
Types of pain - CORRECT ANSWER acute, chronic, cancer, by inferred pathology, idiopathic
Pain threshold - CORRECT ANSWER level of stimulus needed to produce the perception of
pain
Pain tolerance - CORRECT ANSWER amount of pain a patient endures without its interference
of ADLs
Factors influencing pain - CORRECT ANSWER age, fatigue, genes, neurological functions,
social factors, spiritual factors, psychological factors, cultural factors
Behavioral responses to pain - CORRECT ANSWER clenching teeth, holding painful part, bent
posture, grimaces, cries or moans, restlessness, frequent requests of the nurse; confused patient
may not show reaction
Pharmacological pain relief - CORRECT ANSWER analgesics (NSAIDS & non-opioids,
opioids, adjuvants)
NSAIDS & non-opiates - CORRECT ANSWER has analgesic/ antipyretic effects; available
OTC; used for moderate to mild pain; blocks pain impulses by inhibiting prostaglandin
synthesis; lethal when overdosed; do not take with alcohol; do not take if liver dysfunction,
possible liver failure
Opioids - CORRECT ANSWER pain relivers that contain opium or chemically related to opium;
ordered for moderate to severe pain such as post-op, chronic non-cancer, or cancer; depresses
respiratory center, causes constipation, itching, altered mental status
Naloxone (Narcan) - CORRECT ANSWER opiate antagonist, reverses opioid induced resiratory
depression
Patient Controlled Analgesia (PCA) - CORRECT ANSWER client has control with minimum
risk of overdose; system designed to deliver no more than specific number of doses
Anesthetics - CORRECT ANSWER depresses CNS from consciousness to unconsciousness; loss
of responsiveness to sensory stimuli including pain; muscle, skeletal, and visceral smooth muscle
relaxation; general or local
Basal metabolic rate (BMR) - CORRECT ANSWER energy needed to maintain life
Water - CORRECT ANSWER comprises 60-70% of body weight; cell function depends on a
fluid environment, you can only survive a few days without it, illness increases need for fluids
Free Radical Theory - CORRECT ANSWER presence of free radicals produced through normal
respiration and metabolism cause damage to existing cells, some believe this can be reversed
through consumption of vitamins and other products
Erikson's 8 stages of development - CORRECT ANSWER trust vs mistrust
autonomy vs shame and doubt
initiative vs guilt
industry vs inferiority
identity vs identity confusion
intimacy vs isolation
generativity vs stagnation
integrity vs despair
Medication absorption - CORRECT ANSWER the passage of medication molecules into the
blood from the site of administration
factors that affect med absorption - CORRECT ANSWER route of administration; ability to
dissolve; blood flow to site of administration; body surface area; lipid solubility of medication
meds are excreted through: - CORRECT ANSWER kidney, liver, bowel, lungs, exocrine glands
medication interactions - CORRECT ANSWER when one med modifies the action of another
Obese - CORRECT ANSWER increased weight for height by 10% or more
Morbid Obesity - CORRECT ANSWER 100% over weight for height
Measurements for obesity - CORRECT ANSWER waist size, BMI, ideal weight for height
causes of obesity - CORRECT ANSWER corticosteroids, estrogen, antidepression meds,
overeating, unconscious eating, physical inactivity, genetics, Pretnezone
management of obesity - CORRECT ANSWER decreased food intake, increased physical
activity
definition of nursing - CORRECT ANSWER an art and a science with limitless opportunities;
client, family, and community centered; diagnosis and treatment of human response to actual and
potential health problems
evidence based practice - CORRECT ANSWER interventions nurses do that are based on
evidence
roles of nurse - CORRECT ANSWER caregiver, advocate, educator, communicator, manager,
autonomy and accountability
definition of health - CORRECT ANSWER state of complete physical, mental, and social well
being not merely the absence of disease or infirmity
communication- - CORRECT ANSWER process by which people affect one another; exchange
of info, ideas, feelings; basic component of human relationships; fundamental element of nurseclient relationship
elements of communication - CORRECT ANSWER referent sender; message, receiver,
channels, feedback, interpersonal
forms of communication - CORRECT ANSWER verbal, non-verbal
factors influencing communication process - CORRECT ANSWER developmental level, gender,
values/ perception, personal space, territoriality, roles/ relationships, environment, congruence
teaching - CORRECT ANSWER interactive process that promotes learning
purpose of teaching - CORRECT ANSWER gaining new knowledge, change attitudes, adopt
new behaviors, preform new skills,
learning - CORRECT ANSWER purposeful acquisition of new knowledge, attitudes, behavior,
or skills
need for nurse to teach client - CORRECT ANSWER clarify info given by doc or other health
care providers; has to be complete, accurate, and relevant; should be based on patient's needs and
learning ability
ability to learn - CORRECT ANSWER developmental / physical ability
learning environment - CORRECT ANSWER privacy, room temperature, lighting, noise,
furniture, ventilation
infection - CORRECT ANSWER invasion of a susceptible host by pathogens or
microorganisms. resulting in disease
colonization - CORRECT ANSWER occurs when a microorganism invades the host but doesn't
cause infection
communicable disease - CORRECT ANSWER the infectious process transmitted from one
person to another
symptomatic infection - CORRECT ANSWER when the infection has signs and symptoms like
fever, cough, etc
asymptomatic infection - CORRECT ANSWER when the infection does not cause any signs or
symptoms, making the diagnosis difficult
hand hygiene - CORRECT ANSWER the most important technique used in preventing and
controlling transmission of infection
chain of infection - CORRECT ANSWER infectious agent/ pathogen > reservoir/ source for
pathogen growth > portal of exit > mode of transportation > portal of entry > susceptible host
4 stages of infection - CORRECT ANSWER incubation period, prodromal stage, illness stage,
convalescence
factors influenceing infection - CORRECT ANSWER age, stress, disease process, treatment/
condition that compromise the immune system
disinfection - CORRECT ANSWER eliminates many or all microorganisms with exception of
spores from inaminate objects
sterilization - CORRECT ANSWER complete elimination or destruction of all microorganisms
including spores
autonomy - CORRECT ANSWER commitment to include clients in decisions
beneficence - CORRECT ANSWER taking positive actions to help others
non-maleficence - CORRECT ANSWER avoidance of harm/ hurt
justice - CORRECT ANSWER being fair
fidelity - CORRECT ANSWER agreement to keep promises
professional nursing code of ethics - CORRECT ANSWER a set of guiding principles that all
members of a profession accept; helps professional groups settle questions about practice or
behavior; includes responsibility, accountability, and confidentiality
Values - CORRECT ANSWER personal belief about the worth of a given idea, attitude, custom,
or object that sets standards that influence behavior
deontology - CORRECT ANSWER defines actions as right or wrong
utilitarianism - CORRECT ANSWER proposes that the value of something is determined by its
usefulness
feminine ethics - CORRECT ANSWER focuses on the inequality between people
ethic of care - CORRECT ANSWER emphasizes the importance of understanding relationships,
especially as they are revealed in narratives
JCAHO's ethical standards - CORRECT ANSWER mandate that health care institutions provide
multidisciplinary ethics committees or similar structures to write guidelines and policies,
provides education, counselling, and support for staff on ethical issues
how to process an ethical dilemma - CORRECT ANSWER 1. ask if this is an ethical dilemma
2. gather all relevant info
3. clarify values
4. verbalize problem
5. identify possible courses of action
6. negotiate a plan
7. evaluate plan
quality of life - CORRECT ANSWER central to discussions about futile care, cancer therapy,
physician assisted suicide, DNR
futile care - CORRECT ANSWER interventions unlikely to produce benefit for the client
standards of care - CORRECT ANSWER legal guidelines for defining nursing practice and
identifying the minimum acceptable nursing care
consent - CORRECT ANSWER a signed form required for all routine treatment, hazardous
procedures, and some other treatments; provisions made for deaf, illiterate, and foreign language
clients
what does mobility mean? - CORRECT ANSWER allows ability to move freely about;
musculoskeletal and nervous systems working together to make movement; decreases risk for
injury
oliguria - CORRECT ANSWER patient has some form of renal failure; not producing as much
urine as regular patient; strict I&Os
anuria - CORRECT ANSWER irreversible renal disease; need kidney transplant or dialysis; not
producing urine; increased phosphorus in system
polyuria - CORRECT ANSWER excessive urine; sign of diabetes or hormone issue
hematuria - CORRECT ANSWER blood in urine; not a good sign
nocturia - CORRECT ANSWER voiding at night; early sign of hypertension; pressure on
bladder during pregnancy
functional incontinence - CORRECT ANSWER can't make it to the bathroom in time; every 1/2
hr or 1 hr bring patient to bathroom/ put on schedule
stress incontinence - CORRECT ANSWER usually in women who didn't do kegels during labor
reflex incontinence - CORRECT ANSWER on urge to go; it just comes out
urinary incontinence - CORRECT ANSWER can be temporary; affects everyone especially
elderly
causes of urinary incontinence - CORRECT ANSWER urethral obstruction, surgical trauma,
alterations in sensory/ motor innervation, medication side effects, anxiety
dysuris - CORRECT ANSWER pain or burning on urination
urinalysis - CORRECT ANSWER pH; protein; glucose; ketones; blood; specific gravity; WBCs;
bacteria
factors affecting bowel elimination - CORRECT ANSWER age, diet/fluid intake, physical
activity, psychological factors, personal habits, position during defecation, pregnancy, surgery/
anesthesia, meds/laxatives/ cathartics
constipation - CORRECT ANSWER stool gets lodged in the intestines; a symptom not a disease
impaction - CORRECT ANSWER result of unrelieved constipation; leaky drainage
diarrhea - CORRECT ANSWER liquid stool; associated with disorders affecting digestion,
absorption, and secretion in GI tract
incontinence - CORRECT ANSWER inability to control passage of feces or gas through rectum
loose stool - CORRECT ANSWER chunks of stool
pressure ulcers - CORRECT ANSWER tissue damage caused when the skin and underlying soft
tissue are compressed between a bony prominence and an external surface for an extended
period; tissue ischemia that leads to necrosis
stage 1 ulcer - CORRECT ANSWER intact skin; red/irritation; unblanchable
stage 2 ulcer - CORRECT ANSWER broken skin; partial thickness; blister epidermis and
dermis; can ooze
stage 3 ulcer - CORRECT ANSWER epidermis, dermis, and subQ tissue; oozing, signs of
infection; full thickness loss
stage 4 ulcer - CORRECT ANSWER full thickness loss; can see organs/ bones; very painful
granulation tissue - CORRECT ANSWER healing tissue; looks beefy
slough - CORRECT ANSWER dead tissue; yellowish, brownish; makes wound unstageable; has
to be debritied
eschar - CORRECT ANSWER necrotic/black; surgically removed
xerosis - CORRECT ANSWER dry skin; becomes reddish; low humidity; frequent washing
pruritis - CORRECT ANSWER chemical, allergic, physical agent; drugs, food, sweat-act on
nerve fibers, releases histamine and affects itch receptors; insect bites, scabies, medication
(opioid) , systemic effect
health care delivery system - CORRECT ANSWER complex, dynamic, constantly changing;
past 10-15 yrs managed care, primary care provider; services provided by a wide variety of
licensed/ non-licensed staff
new philosophy of health care - CORRECT ANSWER manage health; wellness and prevention
old philosophy of health care - CORRECT ANSWER manage illness; disease management
myocardial infarction - CORRECT ANSWER pain (sudden onset, substernal, crushing/
tightness/severe; affects back, neck, jaw, arm, shoulder), dyspnea, syncope with low BP,
shortness of breath, nausea, vomiting, sweating, increased heart rate, DENIAL
hyperventillation (kussmaul) - CORRECT ANSWER >40 RR; over-breathing, decreased CO2
leads to alkaline; panic attack, stress/anxiety, fever/infection, intense exercise
treatment for hyperventillation - CORRECT ANSWER have patient hold one nostril; try to
reduce patient;s stress/panic; purse-lipped breathing
hypoventillation - CORRECT ANSWER decreased ability to remove CO2 from body; pH below
7.35; RR below 12; emphysema/ CVA; hypoxic
treatment for hypoventillation - CORRECT ANSWER if narcotic based, reduce/ discontinue;
stroke- high fowlers/ oxygen; other meds to increase breathing
hypoxia - CORRECT ANSWER decreased tissue oxygenation; restlessness, anxiety, confusion,
increased heart rate and RR
chenye-strokes - CORRECT ANSWER irregular breathing; altering rapid/apnea episodes; near
death breathing pattern
tamaflu - CORRECT ANSWER stops flu virus multiplication; increases risk for self injury; take
within 48 hr of onset
avian flu - CORRECT ANSWER H5N1; bird to human trough droppings, saliva, blood; stayed
in Asia
swine flu - CORRECT ANSWER H1N1; person to person transmission; touching infected
surfaces; nose/throat culture; vaccine
laryngitits - CORRECT ANSWER inflammation/ swelling of larynx; occurs as single problem or
with resp infection; risk/irritant-smoking; dry coughing; voice changes; throat cultures to check
for strep; comfort care
arteriosclerosis - CORRECT ANSWER hardening of arteries
atherosclerosis - CORRECT ANSWER affects intima of arteries; plaque froms and narrows
lumen of arteries; pain when tissues don't get oxygen
causes of atherosclerosis - CORRECT ANSWER lifestyle; HTN; smoking; diabetes; genetic
treatment for atherosclerosis - CORRECT ANSWER decreased cholesterol intake; smoking
cessation; blood work; exercise
peripheral artery disease - CORRECT ANSWER caused by atherosclerosis; usually lower
extremities; deprives lower extremities of oxygen; cramps and muscle pain with activity
stage 1 PAD - CORRECT ANSWER asymptomatic; Bruit may be present; toes cool to touch;
slow capillary bed refill
stage 2 PAD - CORRECT ANSWER claudication; muscle pain/ cramping
stage 3 PAD - CORRECT ANSWER rest pain
stage 4 PAD - CORRECT ANSWER necrosis/ gangrene; loss of oxygen to toes > toes fall off/
need to be removed
treatment for PAD - CORRECT ANSWER Statins- help metabolize cholesterol; Crestor, Lipitormuscle pain, leg pain, cramping, diarrhea
deep vein thrombosis - CORRECT ANSWER clots in the veins; usually in the extremities
Virchow's triad - CORRECT ANSWER stasis-immobility, bed ridden, car/plane/ train travel
vessel wall injury, fracture, trauma
hypercoagulability- altered coagulation (birth control, hormone therapy, smokers, dehydration)
treatment for pulmonary emboli - CORRECT ANSWER prevention- anticoagulant therapy;
thrombolytic therapy; surgery to remove thrombus
hematocrit - CORRECT ANSWER blood blood viscosity
When is a problem an ethical dilemma? - CORRECT ANSWER When:
- A review of scientific data is not enough to solve it.
- It involves a conflict between two moral imperatives.
- The answer will have a profound effect on the situation and the client.
Ethical decision making - CORRECT ANSWER Process that requires striking a balance between
science and morality
A nurse is caring for a client who decides not to have surgery despite significant blockages in his
coronary arteries. The nurse understands that this client's choice is an example of which of the
following
ethical principles?
A. Fidelity
B. Autonomy
C. Justice
D. Nonmaleficence - CORRECT ANSWER B. Autonomy
In this situation, the client is exercising his right to make his own personal decision about
surgery, regardless of others' opinions of what is "best" for him. This is an example of autonomy.
A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse
understands that this aspect of care delivery is an example of which of the following ethical
principles?
A. Fidelity
B. Autonomy
C. Justice
D. Beneficence - CORRECT ANSWER D. Beneficence
Beneficence is taking positive actions to help others. By administering pain medication
before the client attempts a potentially painful exercise like ambulation, the nurse is taking a
specific and positive action to help the client.
A nurse is instructing a group of nursing students about the responsibilities involved with organ
donation and procurement. When the nurse explains that all clients waiting for a kidney
transplant have
to meet the same qualifications, the students should understand that this aspect of care delivery is
an
example of which of the following ethical principles?
A. Fidelity
B. Autonomy
C. Justice
D. Nonmaleficence - CORRECT ANSWER C. Justice [Show Less]