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Foundations of nursing Flashcards | StudBud
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Foundations of nursing
Foundations of nursing
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1
You have a patient who has a unstageable pressure injury, when looking in the wound what will you see?
Persistent nonblanchable deep, red, maroon, revealing a dark wound bed
Full thickness skin and tissue loss in which the extent cannot be confirmed
Full-thickness skin and tissue loss with exposed fascia, muscle and bone
Intact skin with a localized area of nonblanchable erythema
2
What is transduction?
Neurotransmitters
Cellular damage from injury results in the release of excitably neurotransm
CNS extracts information from pain impulse
Converts energy produced by stimuli into electrical energy
3
What are the different types of nursing care delivery models?
Primary nursing
Team nursing
Total patient care
Patient and family centered care
4
Pain is
Do not use nonverbals as cues
Subjective
Exists when the patient says it exists
Objective
5
Explain the impact of illness on a patient and family
Impact on self-concept
Behavioral and emotional changes
Impact on body image
Impact on family roles and family dynamics
6
What is intrapersonal communication?
Communication within family
Interaction of one individual with large groups of people
Interaction that occurs between two people or within a small group
Communication that occurs within an individual
7
What is the normal blood pressure for an adult
120/65
94/56
110/65
<120/80
8
What is primary nursing?
One RN assumes the responsibility for a caseload of patients
Promotes mutual partnerships among the patient, family, and HC team
Provides care through a group of people led by a nurse
You care primarily for one patient at a time
9
What is SBAR format?
Situation, background, acknowledge, recommendation
Symptoms, background, acknowledge, recommendation
Symptoms, background, assessment, recommendation
Situation, background, assessment, recommendation
10
Factors that influence blood pressure
Sympathetic stimulation
Medications
Gender
Age
11
What are the five categories of loss and grief?
Necessary, amount, perceived, maturational, situational
Necessary, actual, perceived, maturational, suspected
Necessary, actual, perceived, maturational, situational
Necessary, actual, personal, maturational, situational
12
A postoperative patient is using PCA. You will evaluate the effectiveness of the medication when
Body language is incongruent with reports of pain relief
Vital signs have returned to baseline
You compare assessed pain with baseline pain
Family members report that pain has subsided
13
Poor communicator rely on their organizational skills, this is an example of what ego-defense mechanism?
Conversion
Displacement
Dissociation
Compensation
14
What are principles of thermoregulation?
Heat loss
Heat production
Behavioral patterns
Neural and vascular control
15
Which is an example of an external variable?
Emotional factors
Intellectual background
Family practices
Spiritual factors
16
Physical therapy after a cerebrospinal accident is
Secondary prevention
Initial prevention
Tertiary prevention
Primary prevention
17
What puts the older adult at risk for impaired oral mucus membranes
Foods high in sodium
Hard and dry foods
Radiation therapy to head and neck
Dehydration, inability to take fluids or fluids by mouth (NPO)
18
What is the definition of inference?
Gather information about the patients condition
Information you obtain through use of your senses
Your judgement or interpretation of these cues
Identify the patients problem
19
What are the different ways to examine an adult experiencing pain?
The face scale
Pain level 0-10
OLD CART
Asking close ended questions about pain
20
Pain is
Objective
Felt by all
What the patient says it is
Subjective
21
Which type of white blood cell accounts for the largest percentage of differential
Neutrophils
Lymphocytes
Eosinophils
Monocytes
22
What is perception?
CNS extracts information from the pain impulse-location, duration, quality
Converts energy produced by stimuli into electrical energy
Cellular damage from injury results in the release of excitatory transmitte
Neurotransmitters
23
What is the percentage of neutrophils within the blood?
0.5%-1%
20%-40%
55%-70%
2%-8%
24
When a fire starts what is the nurses first response?
Close the door to contain the fire
Attempt to extinguish the fire
Assist the patient to a safe area
Report the fire
25
Which law requires nurses to protect public health, safety, and welfare?
Standards of practice
Nurse practice act
Code of ethics
Quality and safety education for nurses (QSEN)
26
Disinfection is
Eliminating almost all pathogenic organisms
Removing organic material
Destroying all forms of microbial life
Removing inorganic material
27
What does SOAP stand for?
Subjective data, objective data, assessment, plan
Identifies a nursing diagnosis, nursing interventions, nursing evaluation
Data, action of nursing intervention, response of the patient
Within defined limits
28
What is the definition of shear?
force exerted against the skin while the skin remains stationary, bone move
Surface damaged caused by skin rubbing against another surface
Subjective information
Usually occurs over a bony prominence
29
What is the definition of growth?
Biological plan for the predictable milestones for growth and development
The fourth stage of psychosexual development
Mental growth
Measurable aspect of a persons increase in physical dimensions
30
What is body image?
The subjective concept of physical appearance
Evokes behavioral changes in the functioning of patient or family
Mental self-image
How a family views ones body
31
When the skin edges cannot come together because of extensive tissue loss, gradual wound healing
Occurs by tertiary intention
Occurs by secondary intention
Cannot occur
Occurs by primary intention
32
Factors that cause a variation in blood pressure
Hypotension
Hypertension
Orthodontic hypotension
None of these
33
What conditions place a patient at risk for impaired oral mucus membranes?
Dehydration
Medication
Trauma (give examples)
Radiation to head or neck
34
Who is the theorist that developed the theory of psychosexual?
Freud
Kohlberg
Erikson
Piaget
35
Which individual is responsible for the theory of cognitive development
Kohlberg
Erikson
Freud
Piaget
36
What is displacement?
Transferring emotions, ideas or wishes from a stressful situation to less
Unconsciously repressing anxiety producing emotional and transferring it
Coping with a stressor though actions and behaviors
Avoiding emotional conflicts
37
What are elements of a sleep history?
Sleep deprivation
Sleep pattern and quality
Medications
Nutrition
38
What is a one of the five rights of delegation
Right nurse
Right drug
Right verification
Right circumstance
39
Your pt is hard of hearing, how are you going to talk to him?
Speak slower and pronunciate words
Increase tone of voice and get closer
Get an interpreter
Come back later and try again
40
What are factors that variations in pulse rate?
Hemorrhage
Temperature
Exercise
Dysrhythmia
41
What does RACE stand for?
Rescue, activate, confine, extinguish
Rescue, alleviate, confine, extinguish
Rescue, assist, confine, extinguish
Rescue, assist, concur, extinguish
42
The best definition of health is
Vital signs within normal range
A state of complete well-being
Absence of disease
Maintenance of a normal weight
43
What is an appropriate nursing intervention for a pt with fluid imbalances
Restriction of fluids
Monitor/measure I&O
Dehydration
Physical assessment
44
Describe things that cause variations in respirations
Sighing, Bradypnea, tachypnea
Binders
Amount of fluid intake
Ventilation, diffusion, eupnea
45
Culture is
A nonspecific phenomenon and is adaptive but uneccessary
Learned through language acquisition and socialization
Biologically determined on physical characteristics
Genetically determined on the basis of racial background
46
The nurse will assist a female patient to what position for a genitalia exam?
Lithotomy
Knee-chest
Supine
Dorsal recumbent
47
To individualize teaching needs, you must write directions at a
8th grade level
6th grade level
4th grade level
5th grade level
48
A _____ loss happens when the person can no longer touch, hear, see, or have near them valued people or objects
Maturational
Situational
Actual
Perceived
49
Team nursing
Provides care through a group of people led by a nurse
The original care delivery model developed by Florence Nightingales time
Promotes mutual partnership among the pt, family, and health care team
One RN assumes the responsibility for a caseload of patients
50
Hearing loss is associated with the aging process is known as?
Presbyopia
Menieres disease
Presbycusis
Tinnitus
51
The thorax of an older adult who has chronic lung disease is expected to be
Normal with minimal barrel shaping
Normal
Barrel shaped
Round
52
Palliative care is
Is for the elderly
Requires an interdisciplinary team
Only done in intensive care units
Utilizes advanced medical treatments to provide care
53
Your pt is visually impaired, how would you accommodate?
Offer audio tapes for instructional information
Provide written material in the original sized font
Touch the patient before verbally communicating with them
Make lighting dim so it does not hurt their eyes
54
What is a internal factor effecting communication?
Working relationships
Family
Physical health
Balance of power and control
55
A patient had just undergone an appendectomy.When talking with the patient several pain relief interventions, what is ri
Nonopioids
PCA pain management
Adjunctive therapy
NSAIDs
56
For patients who don’t speak English, what would you do?
Provide written materials in English and in pts primary language
Establish a method for patient to signal desire to communicate
Have an interpreter
Communicate through their family, friends, and significant others to pt
57
What are the factors influencing pain?
Degree of pain, response to pain, subjective, personalized
Age, gender, nutritional status, mobility
Age, gender, physiological factors, anxiety
Physiological factors, social factors, spiritual factors, cultural factors
58
What is the definition of sterilization?
Removing inorganic material
Removing organic material
Destroying close to all microbial life
Destroying all forms of microbial life
59
Poor skin turbot can predispose a patient to what?
Direct trauma
Skin breakdown
Dehydration
Edema
60
What is the difference between systolic and diastolic pressure?
Pulse pressure
Hypertension
Diastolic pressure
Systolic pressure
61
Which organization sets forth the code of ethics for nursing?
The board of nursing
The American Medical Association
The National League for Nursing
The American Nurses Association
62
A patients heart rate that is 48 is considered
Bradycardic
A normal heart rate for an adult
Tachycardic
A normal heart rate for an infant
63
Diarrhea is caused by
Abnormally slow peristalsis
Low fiber diets
Aging
Abnormally fast peristalsis
64
What is the temperature of moderate hypothermia?
Less than 30C or less than 86F
34-36C or 93.2-96.8F
30-34C or 86-93.2F
36-38C or 98.6-100.4F
65
Patient and family centered care has four concepts, they are
All of the above
Dignity and respect, information sharing, participation, collaboration
Dignity and respect, patient autonomy, hiding information, participation
None of the above
66
The nurse knows that religion can be best defined as
Source of energy needed to cope with difficult situations
A system of organized beliefs and worship
Multidimensional concept that gives comfort
Relationship with a higher power, authority, or spirit
67
What is the most common form of dementia?
Alzheimer’s disease
Ischemic vascular dementia
Delirium
Depression
68
What is a guideline for legally sound documentation?
End each entry with date and time, and begin with signature and credentials
If comment is wrong, scratch out the comment
Record most facts
Avoid using generalized empty phrases
69
How is hygiene for older adults different than a younger person?
They refuse to shower due to lack of motivation
Older adults get cold easier and faster
Older adults skin is more fragile and thinner
They are typically dirtier
70
What is the acceptable respiratory rate for an adult
16-20
35-40
25-32
12-20
71
What are the Braden scale sub scales?
Sensory perception, moisture, activity, mobility, nutrition, shear/friction
Sensory perception, moisture, age, mobility, nutrition, shear/friction
Skin, perception, moisture, age, mobility, nutrition, friction
Skin, perception, moisture, age, mobility, nutrition, shear/friction
72
What is the termination phase?
When the nurse and the patient meet and get to know each other
Occurs at the end of a relationship
Occurs before meeting the pt
When the nurse and pt work together to solve problems and accomplish goals
73
What is friction?
Force exerted against skin while skin remains stationary, bone moves
When your legs rub together
The force of two objects against each other
Surface damage caused by skin rubbing against another surface
74
What are the advantages of computerized documentation?
Is not flexible or expandable
Slows down documentation and results of diagnostic tests
Eliminates safety issues related to illegible handwriting
Built in reminders and alerts to help HCPs select most appropriate option
75
Which of the following is true?
Amount of pain is reflective of actual tissue damage
Chronic pain is psychological in nature
Patients are the best judges of their pain
Regular use of narcotic analgesics leads to drug addiction
76
What is faith?
Multidimensional and gives comfort while a person endured hardships
Has a positive effect on health and leads to spiritual health
Has firm beliefs about something despite the lack of physical evidence
An awareness of ones inner self and sense of connection to a supreme being
77
Which vegetarian diet consumes milk and milk products but avoids eggs and other animal-based foods?
Ocolactovegetarian
Ovovegetarian
Vegan
Lactovegetarian
78
What are strategies to work effectively as a member of interpersonal health care team?
Roles/responsibilities
Interprofessional communication
Values/ethics for interprofessional practice
Teams and teamwork
79
What are the strategies to work effectively as a team member of a health care team?
Teams are decided by a higher up within the medical field
Decision making, staff involvement, leadership skills
Clinical care coordination, team communication
Teams are highly individualized so it depends on the team
80
Brandons IBS is
Defense mechanism
A gas
A liquid
A solid
81
What are factors that disrupt sleep?
No light
Scheduling meals around sleep
Stress
High fat, high caloric meals
82
Converting energy produced by stimuli into electrical impulses
Modulation
Transmission
Transduction
Perception
83
What are the steps to effective delegation?
Assess the knowledge and skills of the person whom you are delegating
Listen attentively and provide feedback
Communicate clearly
Match task to assistants skills
84
What is a sustained fever?
Fever spikes mixed with usual temperature levels
Periods of febrile episodes mixed with acceptable temperature values
Fever spikes and falls without return to acceptable temperature levels
Constant body temperature continuously about 38C that show little fluctuati
85
____ is an interaction of biological, sociological, and psychological factors
Growth
Development
Maturation
The latency stage of development
86
What is a factor that promotes sleep?
Adequate fluid intake
No bedtime snacks
Loud environment
Scheduling meals during time of sleep
87
Where are pressure injuries commonly found?
Over a bony prominence
On the stomach
Where clothing it too tight
Caused by rubbing
88
The body can produce heat through
Radiation
Shivering
Evaporation
Convection
89
An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates
A dysrhythmia
Bradycardia
A pulse defect
Tachycardia
90
What theorist developed the logical, cognitive, and motor theory?
Freud
Piaget
Kohlberg
Erikson
91
Instructing a healthy individual to get a flu shot on a yearly basis is an example of
Primary prevention
Preventing illness
Secondary prevention
Tertiary prevention
92
What are strategies to work effectively as a member of an inter-professional health care team?
Decision making
Staff involvement
Clinical care coordination
Leadership skills
93
Which term best describes the movement of air in and out of the patients lungs?
Respiration
Ventilation
Diffusion
Perfusion
94
What are the three essential components of professional nursing?
Care
Cure
Coordination
Composure
95
What is self-concept?
It depends in part on body image and roles
Is objective
Is determined by family
Your mental image of all aspects of your personality
96
List the correct order of the nursing process
Assessment, disengage, planning, implementation, evaluation
Assessment, diagnosis, planning, implementation, empathy
Absorb, diagnosis, planning, implementation, evaluation
Assessment, diagnosis, planning, implementation, evaluation
97
What is meta communication?
Internal factors that influence communication
Broad term that refers to all factors that influence communication
Interaction with a large group of people
Uses of spoken or written words
98
Factors influencing respirations
Drinking
Water
Acute pain
Neurological injury
99
A short-term illness is considered to be
For a couple of days
Chronic
Less than 3 days in a hospital
Acute
100
If your patient is mute, unable to speak, or cannot speak clearly, what will you do?
Answer call lights in person
Offer audio tapes for instructional information
Give them hearing aids
Speak louder and slower
