Download NSG 241: Fundamentals Final Questions With Complete Solutions and more Exams Nursing in PDF only on Docsity!
NSG 241: Fundamentals Final Questions With Complete Solutions · Safety assessment for falls Correct Answers Johns Hopkins Hospital Fall Assessment Tool -Seven item tool Morse Fall Scale -Six item tool Hendrich II Fall Risk Model -Eight item tool 3 domains/types of learning Correct Answers - to provide effective patient teaching
- cognitive
- psychomotor
- affective effective patient teaching requires knowledge about how the patient learns a nurse cannot delegate these Correct Answers assessment planning evaluation accountability judgements adjuvant medication Correct Answers work synergistically laxative
tricyclics for neuropathic pain advocate Correct Answers interprets info and provides the necessary education, then accepts and respects the patients decisions even if they are different from the nurses own beliefs
- nurse supports the patients wishes and communicate those beliefs to other HC providers, and speak for patient aerobic exercise Correct Answers requires oxygen metabolism to produce energy. -patients may engage in rigorous walking or repeated stair climbing to achieve the positive effects of aerobic exercise. affective domain Correct Answers - recognizes the emotional component of integrating new knowledge
- takes into account the patient's feelings, values, motivations, and attitudes anaerobic exercise Correct Answers builds power and body mass. -without oxygen to produce energy for activity -ex: heavy weight lifting anuria Correct Answers failure of the kidneys to produce or excrete urine failure of the kidney to produce or excrete 50 to 100 ml or urine in 24 hrs
- role can be extended to bringing about change in the legislation on health policy issues. cognitive domain Correct Answers - learning comprises knowledge and material that is remembered
- literature written at the appropriate reading level, demonstration, and use of examples Cold therapy Correct Answers therapy using ice or cold application to reduce or prevent swelling by decreasing circulatory flow to the injured body part Promotes vasoconstriction, increases blood viscosity, decreases metabolism of tissues, has local anesthetic effect
- Decreases muscle tension - should not be applied for longer than 20 minutes or reflex vasodilation can occur collaborator Correct Answers 2 or more people work together to a common goal
- RN, UAP, LPN, PCP, Social workers, clergy, therapist work together
- responsible for ensuring all patient care orders are carried out and for communicating with the entire team
- the competency to work in teams is meant to provide safer, quality care.
colorectal screening tests should be done starting at age Correct Answers beginning at age 45 years crutches Correct Answers - increased patient mobility
- used on a short-term or long-term basis for patients with lower extremity injury or paralysis
- 2 inches under axilla and 6 inches to the side of the foot
- Forearm or Lofstrand crutches are used with long-term or permanent impairment.
- patient needs to possess adequate upper body strength and coordination when using all types of crutches defining characteristics Correct Answers are cues or clusters of related assessment data that are signs, symptoms, or indications of a problem-focused,or health promotion nursing diagnosis definition of Health literacy Correct Answers - defined in Healthy People 2020 as follows: "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions" delegator Correct Answers delegating aspects of patient care to other personnel diarrhea Correct Answers parasites and their ova (eggs) in the stool can lead to this GI symptom dorsal recumbent Correct Answers patient lying supine with legs bent
- more stability than the 2-point pattern bc only 1 of 4 points of support is lifted off
- one crutch moves forward, followed by the opposite leg, and repeats the pattern by moving the opposite crutch and then the leg forward Fowler's position Correct Answers patient in sitting position with pillow supporting thigh and legs friction reducing sheets Correct Answers - similar to transfer or slide boards
- made of specialized material that reduces shear
- when placed under a patient, the sheet minimizes the force required for repositioning or transfer Hand-off reports Correct Answers - real-time process of passing patient-specific information from one caregiver to another or among interdisciplinary team members to ensure continuity of care and patient safety
- hand-offs can be oral, as in face to face meeting or telephone communication, or they can be written or recorded. -hand-off reporting should provide accurate timely, important information about the care, treatment, and services rendered addressing the patients current condition and anticipated changes, and important information to the next caregiver to ensure patient safety health information must be Correct Answers - accurate
- accessible
- actionable when implementing in the teaching plan it can guide the information, the approach, and the evaluation of progress Hendrich II Fall Risk Model Correct Answers 8 item tool confusion/disorientation/impulsivity symptomatic depression altered elimination dizziness/vertigo gender use of antiepileptics use of benzodiazepines performance on the get up and go incentive spirometry Correct Answers inhale and exhame 5- times every 1-2 hours prevent atelactasis and pneumonia post-surgery Institutional Review Board (IRB) Correct Answers review committee established to help protect the rights and welfare of human research subjects. isometric exercise Correct Answers requires tension and relaxation of muscles without joint movement. ex: tension and relaxation of pelvic floor muscles (kegel exercise)
lithotomy Correct Answers patient lying supine with feet in stirrups Long term goals Correct Answers goals that take weeks or months to achieve low health literacy Correct Answers - associated with increased hospitalization,
- greater emergency care use,
- lower use of mammography, and
- lower receipt of influenza vaccine. lower GI tract bleeding Correct Answers produces stools with bright red blood lumbar puncture Correct Answers lumbar vertebrae manager Correct Answers - manages all activities/ treatments for patient
- promotes, restores, and maintains patients health through coordinating all the health care providers services
- also, manager of a unit in the hospital
- managing a team of patients
- oversees, staff on a patient care unit while managing the budget and resources required for necessary functions Maslow's Hierarchy of Needs Correct Answers specifies the physiological and physiological factors that affect each persons physical and mental health
top
- self-actualization: morality, creativity, spontaneity, acceptance
- self-esteem: confidence, achievement, respect of others
- love and belonging: friendship, family, intimacy, connection
- safety and security: health, employment, property, family, social stability
- physiological needs: breathing, food, water, shelter, clothing, sleep bottom Morse Fall Scale Correct Answers 6 item history of falling existence of a secondary diagnosis use of ambulatory aid use of intravenous line or a saline lock gait mental status Needle aspirations Correct Answers procedures that are used to remove fluid and tissue for testing Nonopioid analgesics Correct Answers NSAIDs and acetaminophen for mild to moderate pain mild pain = 1 to 3
- an unpleasant sensory and emotional experience associated with actual or potential tissue damage Pain Assessment Correct Answers SOCRATES S = site (Where is it located?) O = Onset (When did the pain start? Was it gradual or sudden?) C = character (What is the quality of the pain? Is it stabbing , burning or aching in nature?) R = radiation (Does the pain radiate anywhere?) A = associations (what signs and symptoms are associated with the pain) T = time course (is there any pattern to when the pain occurs) E = exacerbating/relieving factors (Does anything make the pain worse or lessen it?) S = severity (on a scale of 0 to 10, what is the intensity of the pain?) Parecentesis Correct Answers involves removing fluid from the peritoneal cavity patient participation in Hand-off reports Correct Answers are enhanced with patient participation nurses should:
- teach patients to actively participate with staff during the bedside rounds
- ask patients to validate the information shared during the rounding process
- encourage the patients to ask questions during the rounding process
patients position in a bed Correct Answers - important to maintain proper respiratory status
- body alignment
- prevent skin breakdown
- provide comfort for a patient who is unable to reposition himself or herself physically restrained Correct Answers -decreases in cognitive performance
- requiring increased assistance with activities of daily living
- increase in actual falls
- pressure ulcers and incontinence
- use of restraints can negatively influence physical and psychological well-being and should be used as a last resort positive occult blood Correct Answers indicate disorders including:
- peptic ulcer disease
- inflammatory bowel disease
- hemorrhoids
- trauma to GI tract
- gastric or colon cancer prone Correct Answers patient lies face-down related factors Correct Answers underlying cause or etiology of a patients problem Repositioning in bed Correct Answers helps prevent the complications of immobility:
-educator -advocate -leader -change agent -manager -researcher -collaborator -delegator SBAR Communication Tool Correct Answers a communication form specifically suggested for use in nurse- physician interactions (S) active situation: what is happening at the current time? (B) related background: what are the circumstances leading up to this situation? (A) assessment of the problem: what does the nurse think the problem is? (R) recommendation for a solution: what should we do to correct the problem? semi-fowler Correct Answers patient semisitting with head elevated short term goals Correct Answers goals that are achievable in less than a week side-lying Correct Answers patient lying on side Sim's Correct Answers patient in semiprone position lying on the left side
SOAP notes Correct Answers (S) Subjective data: what do the patients and others tell you? (O) Objective data: What are the results of the physical examination, relevant vital signs, or other test? (A) Assessment: What is the patients current status? (P) Plan: What interventions are necessary? (I) interventions: What treatments did the nurse provide? (E) evaluation: What are the patient outcomes after each intervention? (R) revision: does the plan stay the same? What changes are needed to the care plan? steatorrhea Correct Answers indicates a failure to digest and absorb dietary fat steps when repositioning the bed Correct Answers - lower the head of the bed to reduce resistance to gravity during repositioning
- raise the bed to waist height of the nurse
- use bed side rails or lift equipment to assist the patient during repositioning
- align the patient's spine in the center of the bed stool analysis Correct Answers identify disorders of the:
- gastrointestinal (GI) tract
- liver
- pancreas commonly ordered to test for:
trochanter roll Correct Answers prevents outward rolling of the hip when a patient is lying on his or her back Two-point crutch walking pattern Correct Answers - patients who can bear partial weight on either or both lower extremities
- patient move one crutch forward simultaneously with the opposite leg, providing a wide base of support Types of Nursing Diagnoses Correct Answers 1. Problem- Focused 3 part
- Risk for 2 part
- Health Promotion 2 part Problem-focused nursing diagnoses are clinical judgements about undesirable human responses to health conditions or life processes that occur in an individual, family, group, or community. UAP can Correct Answers Do tasks that do not require nursing judgment (except vitals during codes). Should be routine in nature. Performed with exact standards. Stable patient care. Outcome of care should be reasonable and predictable. upper GI tract bleeding Correct Answers produces stools that are black and tarry Urobilinogen Correct Answers - produced by the breakdown of bilirubin and is responsible for the brown color of stool
-increased levels of urobilinogen result in increased RBC destruction
- decreased levels of urobilinogen result in biliary obstruction or in severe liver disease use to CONSTRUCT A GOOD RESEARCH QUESTION Correct Answers PICO and PICOT P = patient, population, problem (describe the subject of the problem) I = intervention (define which intervention is being considered for the specific patient or population C = comparison intervention (ex: comparison of traditional x- rays with magnetic resonance imaging) O = outcome (define the type of outcome to assess) ex: outcome may be change in physical sign, the result of a diagnostic test) T = time (identify the time frame in which the research will take place
