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PN 110 - Test 3 Exam Questions with Answers
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the flow of blood through the capillaries.
injury or death.
*prolonged immobility, decreased respiratory effort *Disease (pneumonia, pulmonary embolism, abscess, cancer..) *Surgery (atelectasis)
*Trauma (GSW, stabbing) *Chronic medical conditions (COPD, HF, asthma) *Medications *Aging
cachexia, distress, air hungry) *Health history (medical, surgical, medications, lifestyle behaviors, problem-based history) *Vital signs; norms: BP 120/80, HR 60-100, Resp 12-20, PO2 92-100% *Review lab results and diagnostic tests *Cardiovascular, Pulmonary, and Peripheral vascular assessment. Take note of skin color, signs of anemia and hypoxemia, clubbing of nails, barrel chest, wheezes/stri- dor, rhonchi, crackles.
*Primary prevention (early mobilization, incentive spirometry, cough and deep breath, oral hygiene, smoking cessation) *Secondary prevention (Mantoux skin test/TB test) *Tertiary prevention (medications, additional supports (trach, et, vent, bipap, cpap))
brochospasm, COPD, emphysema, abscess, cancer *Nursing Assessment: shortness of breath, dyspnea, pursed lip breathing, acces- sory muscles to breathe, lean forward. Cough/sputum, low O2 saturation, increased resp. rate, tachycardia, spinal scoliosis, thoracic expansion/barrel chest, lung sounds with crackles/rhonchi/wheezes/or absent, nail clubbing.
*3 main types: A,B,C *Typically infected 2-3 days before the onset of symptoms; very contagious!
*Nursing Assessment: blood pressure, pulses, chest pain, palpitations, lightheaded or dizzy, headache, cool extremities, pallor/cyanosis.
loss of vessel patency (open) or permeability (flow across capillaries). *Nursing Assessment: 6 P's! numbness/tingling, absence of sensation. **Pain, Pallor (color), Paralysis, Poikilothermia (dif temp than surrounding tissue), Pulselessness,
deficiency, tar and nicotine from smoking block O2 carrying capacity, Sickle cell anemia. *Nursing Assessment: fatigue, light-headed, dizzy, syncope, low O2 saturation, increased respiratory rate, tachycardia, ischemic pain.
venous disease (PVD), lower legs if peripheral arterial disease (PAD) *Primary prevention: smoking cessation, heart healthy diet, exercise, weight control *Secondary prevention: blood pressure screening *Tertiary prevention: medications
test. *Perfusion: Hgb, Hct, RBC's, WBC's Lipids (Cholesterol, HDL, LDL, Triglycerides), Cardiac enzymes, blood coagulability.
scan, pulmonary function tests, bronchoscopy. *Perfusion: Chest x-ray, CT, MRI, EKG, echocardiogram, cardiac stress tests, car- diac catheterization, arteriogram, veinogram, ultrasound of peripheral vasculature.
of RBC's is insufficient to meet physiologic needs. *Etiology: Anemia results from a lack of RBC's or dysfunctional RBC's in the body. *3 Common Causes: **Excessive loss of RBC's (trauma, hemorrhage, surgery), **Excessive destruction of RBC's (sickle cell anemia), **Deficient/defective RBC production (erythropoiesis)
during basic activities), pallor (color), lethargy (no energy).
Procrit). *Dietary Sources: Foods that enhance absorption of iron; broccoli, grapefruit, OJ, peppers, strawberries. Foods that contain high iron; beans/lentils, clams/oys- ters/shrimp, beef/turkey/liver.
*Monitor labs and report any abnormalities.
*action: replaces iron- found in hemoglobin, myoglobin, and other enzymes: allows the transportation of oxygen via hemoglobin. *reason: iron-deficiency anemia *side effects: dark stools, abd. pain, heartburn, nausea, constipation, flatulence, vomiting, diarrhea. *NUR considerations: edu. pt. on food that decreases absorption (coffee, dairy, soy, spinach, tea). edu. pt. on food that increases absorption (oj, grapefruit, strawberries). may cause GI irritation - monitor GI function! avoid using in pts. w/ GI disease!
*Everyone has a different rate of metabolism *Basal metabolic rate (BMR): energy required to maintain body functions. continu- ous!
fructose) *Complex carbs - starch & fiber, take longer to break down before used by the body (whole grains, fibrous veg, whole fruits)
*20-35g / day *Whole grains, wheat bran, cereals, fresh fruit, vegetables, legumes.
development in infants. *Lipids are fats within the body *Triglycerides are most abundant lipids in food
*supports immune system *low protein may cause generalized edema *amino acids - building blocks or protein *every day *dietary sources - meat, legumes, nuts, eggs, tofu, soy, cheese, greek yogurt, spinach, broccoli.
*facilitates metabolic process (metabolism)
*water soluble vitamins: C (immune system), B complex (forms RBC's and energy production) B-9 = folic acid, B-12 =
cyanocobalamin
*easily destroyed by air, light, heat *ingested daily *vitamin c = collagen, antibodies *vitamin b complex = forms RBC's, energy production
hormones and enzymes (milk, salmon, spinach, orange juice) *phosphorus - helps develop bone, aids in the contraction of muscles, kidney function, nerve conduction, regular heartbeat, use of major nutrients (milk, meat) *magnesium - regulates bp & hr w/ calcium, nerve and muscle function, energy, bone marrow, GABA production (halibut, seeds, nuts, tofu, swiss chard) *potassium, sodium, chloride - maintains fluid balance, nerve conduction, muscle contraction (P- milk, bananas, legumes. NA- smoked meat, salt, olives. Chloride- celery, tomatoes, sea weed, olives).
*may improve immune function and lower risk of infection and cancer *sources - beta carotene, lutein, lycopene, selenium, vitamins A,C,E
conditions, very young children! older adults!
extracellular fluid. when insufficient, there is fluid retention and severe edema. *inadequate calories/carbs cause lack of energy, lack of fuel for every cell *low protein and lower functioning cells cause a weak immune system and delayed wound healing
*Decreased cardiac output *Inadequate micronutrient and electrolytes cause impaired cardiac function (rate, rhythm, and pressure) *High cholesterol and hyperlipidemia cause atherosclerotic heart disease (ASHD). This may lead to a myocardial infarction (MI) due to blocked blood flow to heart tissue. *Higher BMI increases risk for hypertension and hyperlipidemia
breathing. This results in a build up of respiratory secretions and an inability to cough them out. Increases risk for atelectasis (blockage in alveoli) and pneumonia.
*Constipation - malabsorption causes GI upset, bleeding, firm abdomen, tender- ness. Inadequate fiber causes slow gut and constipation. *Diarrhea - decreased blood flow to the intestines causes poor absorption of water, electrolytes and nutrients. This worsened the malnutrition and may result in diarrhea.
rate thus causing decreased urinary output and kidney damage.
*depression *anxiety *low self-esteem *poor body image *self-neglect
*Nutrition Hx: food diary, screening for malnutrition in older adults (mini nutrition assessment) *Height, weight, BMI, waist-to-hip ratio, skin fold measurements *Special focus on GI and bowel elimination. Evaluate issues of oral intake, digestion, absorption.
*Cachectic - seen in people suffering from terminal illnesses who are unable to consume adequate intake of food. *Hair - thinning with dry, stiff texture; lack of shine; may lose all pigment and appear pale. *Skin - dry, rough appearance, pallor; may bruise easily, poor skin turgor; lips may be dark red and can have lesions and cracks. *Dentition - lost, cracked, painful teeth affects eating. *Dysphagia - at risk for aspiration.
*Albumin, pre-albumin *blood glucose and A1C *lipid profile *electrolytes *hemoglobin and hematocrit *blood urea, nitrogen, creatinine
*Trend weight, BMI, dietary intake *Maintain special diets *Provide for food preferences *Assist with feeding *Carefully monitor NPO patients
digestive tract. *Medications, disease processes, diets can all cause disruptions in peristalsis.
-physical activity -psychological factors -personal habits
-skin breakdown -changes in daily activities -changes in social relationships
pain, and cramping. -acute: 2-3 days, new onset -chronic: 3weeks+
gut flora.
malnutrition, muscle wasting, esteem, infection (cdiff, skin breakdown)
diagnostic testing, tube feeding, cdiff, alcohol.
movement, not enough nutrients and hydration.
hydration, advanced age, certain diseases, certain foods.
push it out. -constant watery ooze, N/V, distended stomach.
-bowel elimination pattern, patient's perception of normal -diet hx (usual diet, hydration, preferences, availability, ability to swallow/chew, food intolerance) -physical, mental, and functional abilities, home environment, transportation for groceries, social support. -family hx (GI cancer, Crohn's disease)
-inspection: look! -auscultation: listening to bowel sounds (RL, RU, LU, LL) -palpitation: soft? Tenderness? Masses? Enlarged organ?
-maintenance of regular toileting -document last BM & intervene if >3days
Sound clinical judgment requires knowledge to assess and observe situations, identify priority patient concerns, and implement evidence-based interventions to provide safe patient care.
judgments and actions that result in positive patient outcomes. Nurses make life-and-death decisions on the basis of critical thinking influenced by scientific research and best practices.
can identify if an actual problem is present. Nurses use clinical reasoning skills when considering the context and concerns of a patient or family while observing changes in a clinical situation.
-remain up-to-date on new technology/research -know sources of information -evidence-based practice
validation, and attitudes that promote learning. -baseline knowledge includes content learned in prerequisite courses. -data collection is an important concept for professional nursing practice and is integral to assessment, the first step in the
nursing process. -knowledge and data is needed for nurses to find answers when faced with new problems, questions, and situations.
-assessment data -physiology of disease, injury -lab values -diagnostic tests
responsibility, and accountability, risk taking, dis- cipline, perseverance, creativity, curiosity, integrity, and humility.
cultural beliefs, emotions, sates of mind, and other interpersonal and intrapersonal causes.
reasons for them. Erroneous assumptions can lead to safety issues in the clinical setting.
-talk through scenario with peer/expert -commit to being a lifelong learner -case studies -concept maps
Diagnose: what nursing problem can we help? Plan: write a plan on how to meet the goals Implementation: carry out the plan Evaluation: evaluate if the plan worked, revise if needed
with a nursing concept (eg. Infection). May be a problem with a physiologic system (eg. Cardiac). Review Giddens concepts or NANDA nursing diagnosis.
-goal met -goal partially met (why?) -goal not met (why?)