Download 2025-2026 NURS 105 FINAL EXAM|QUESTIONS WITH REAL ANSWERS|A+ RATED and more Exams Nursing in PDF only on Docsity!
2025-2026 NURS 105 FINAL EXAM|QUESTIONS WITH
REAL ANSWERS|A+ RATED
What patients are the most at risk for developing pressure ulcers? older adults who experienced trauma, spinal cord injuries, fractured hips, have diabetes; patients in long-term homes/community care or critical care settings List a few elements that cause pressure injuries pressure, friction, shearing, impaired sensory perception, impaired mobility, increased moisture Explain blanching occurs when the normal red tones of the light-skinned patient are present What are the characteristics of a stage one pressure ulcer? Pg. 1239 for pictures
intact skin with non-blanchable erythema or dyschromia (darkening); redness What are the characteristics of a stage two pressure ulcer? Pg. 1239 for pictures partial-thickness injury with visibility to the papillary layer of the dermis What are the characteristics of a stage three pressure ulcer? Pg. 1239 for pictures destruction of the papillary and reticular layers but not the subcutaneous tissue What are the characteristics of a stage four pressure ulcer? Pg. 1239 for pictures deep, full-thickness tissue loss with exposed bone, tendon, or muscle
chronic= chronic inflammation or repetitive irritation to wound; impeded healing Wound classification: Healing Process Primary intention: closed wound Secondary intention: wound edges are not approximated (closed) Tertiary intention: wound is left open for several days then edges are approximated (closed) Wound drainage: Describe serous, purulent, serosanguineous, and sanguineous fluid Serous~ clear light pink/yellow healing fluid Purulent~ thick yellow, green, tan, or brown fluid; can be odorous Serosanguineous~ pale, pink, watery fluid
Sanguineous~ bright red fluid; indicative of active bleeding How can you detect hemorrhaging? by looking for distention or swelling of the affected body part, a change in the type and amount of drainage from a surgical drain, or signs and symptoms of hypovolemic shock Explain the characteristics of different types of tissue: granulation, slough, eschar Granulation~ red, moist tissue Slough~ soft yellow or white tissue; stringy substance attached to wound bed Eschar~ black, brown, tan, or neurotic tissue **must be removed for healing to occur What needs to be documented after assessing a wound? ~type of wound/staging ~dressing type ~blanchable/nonblanchable ~color
What does an abdominal binder do? supports large incisions/weak muscles Bandaging and binding principles inspect skin, cover wounds before applying, assess dressings under bandages, assess skin frequently, assess ventilation ability Explain heat vs cold therapy effects Heat ~vasodilation ~reduced blood viscosity ~reduced muscle tension ~increased tissue metabolism ~increased capillary permeability *needs periodic removal for full effect *do not use over large areas if patient has cardiovascular problems Cold
~vasoconstriction ~local anesthesia ~reduced cell metabolism ~increased blood viscosity ~decreased muscle tension *do not use if patient has impaired circulation Factors at risk of injury from heat/cold very young/elderly, open wounds, broken skin, edema, scars, PVD, unconsciousness, spinal cord injury, abscess tooth or appendix What are three key points to take during an assessment to ensure an age-specific approach? (1) understand the interrelation between physical and psychosocial aspects of aging (2) the effects of disease and disability on functional status (3) tailoring the nursing assessment to an older person What are a few things to do during an assessment with a patient with hearing impairment?
changes in mental status, confusion, fall occurrence, dehydration, decreased appetite, loss of function, dizziness, incontinence What does Healthy People 2020 for older adults focus on? understanding the health services provided to older adults, chronic disease management, injury prevention, caregivers in the home Changes with aging: Integumentary List a few signs and symptoms seen with aging decreased skin resilience, moisture, elasticity spots, legions, pressure ulcers, thinning hair Changes with aging: Head and Neck List a few signs and symptoms seen with aging loss of skin elasticity, dental issues, declining visual acuity, presbyopia (age-related farsightedness), color vision changes, decreased smell and taste, hearing loss
Changes with aging: Thorax/Lungs/Heart/Vasculature List a few signs and symptoms seen with aging weaker respiratory muscles, decreased mobility of ribs, decreased lung expansion, dorsal kyphosis, decreased cardiac output, elevated BP, weaker pulses Changes with aging: GI/Abdomen List a few signs and symptoms seen with aging increased fatty tissue in trunk area, protuberant abdomen, slowing of peristalsis, alterations in secretions, delayed gastric emptying, constipation, flatulence, diarrhea Changes with aging: Breasts and Reproductive System List a few signs and symptoms seen with aging gynocomastia, breast sag and atrophy, risk for breast cancer, menopause
List a few signs and symptoms seen with aging physical, psychosocial, cognitive, and social changes are usually linked to illness or to disease and degree of chronicity performance of ADLs is a sensitive indicator of health or illness Changes with aging: Cognitive List a few signs and symptoms seen with aging pertaining to mental processes of comprehension, judgement, memory, and reasoning common in older adults~ delirium (temporary), depression (temporary), dementia (permanent) Cognitive changes: Delirium, depression, dementia Delirium Delirium~ confused state
Onset: abrupt Duration: acute Orient: impaired Memory: impaired Thinking: distorted Assess: distracted Cognitive changes: Delirium, depression, dementia Depression Depression~ disturbance/feelings of sadness and despair Onset: abrupt or gradual Duration: acute or chronic Orient: selective Memory: selective Thinking: intact, hopelessness, helplessness Assess: "I don't know" Cognitive changes: Delirium, depression, dementia
this can cause misunderstanding of health information and subsequent non-adherence assist in selecting, understanding, and using health-related information about medications What are the five senses? sight (visual), hearing (auditory), smell (olfactory), taste (gustatory), touch (tactile) Normal sensation: Define reception, perception, and reaction Reception~ stimulation of receptor (nerve cell) light, touch, or sound Perception~ integration/interpretation of stimuli in cerebral cortex Reaction~ response to the most important stimuli will elicit a reaction List three sensory alterations Sensory deficit~ deficit in normal function of sensory reception or perception; ex: hearing loss
Sensory deprivation~ an inadequate quality or quantity of stimulation; ex: reduced capacity to learn, confusion, restlessness, changes in colors/patterns Sensory overload~ a person receives multiple sensory stimuli and cannot process all of them **All of these alter balance What do proprioceptive changes cause? increased difficulty with balance, spatial orientation, and coordination List a few factors that influence sensory function age, meaningful stimuli, amount of stimuli (can cause sensory overload), social interaction, environmental factors, cultural factors Explain the difference between expressive, sensory/receptive, and global aphasia
Control stimuli~ reduce sensory overload, combine nursing activities, reduce noise, create positive environment What is "lipping"? pouring a bit of liquid out of a container to 'clean' the rim Describe the difference between medical and surgical asepsis Medical asepsis~ clean technique; hand washing, barrier technique, cleaning of environment and surfaces Surgical asepsis~ sterile technique; surgical hand washing, gown, gloves, mask When is surgical asepsis used? ~during invasive procedures that intentionally perforate the patient's skin (surgery, phlebotomy, IV infusions) ~when skin integrity is broken due to trauma, surgical incision, or burns
~during procedures that involve inserting catheters or instruments into sterile body cavities (urinary catheters, deep suctioning, trach care) List a few principles of surgical asepsis ~sterile to sterile only ~only sterile objects on the sterile field ~prolonged air exposure will make a sterile field unsterile ~one inch field edges and bottle lips are considered contaminated ~never turn back on sterile field ~keep sterile objects and gloved hands above waist What is the basal metabolic rate (BMR)? energy needed at rest to maintain life-sustaining activities for a specific amount of time What is the resting energy expenditure (REE)? amount of energy needed to consume over 24hr period for the body to maintain internal working activities while at rest
