NURS 3330 Foundations Final Exam Questions
With Complete Answers
Sleep Assessment - ANSWER - sources of sleep assessment: patients are best
resource; bed partners; parents
- sleep history (any history of sleep problems) patterns, recent changes
- subjective measures of sleep: Epworth Sleepiness Scale; Pittsburgh Sleep
Quality Index; 0-10 sleep rating
- assess usual bedtime, bedtime ritual, preferred environment for sleeping,
preferred rising time
- if patient has a sleep problem, conduct a complete sleep history
- diagnosing sleep problems depends on identifying factors that impair sleep
Nursing Interventions to promote sleep - ANSWER - environmental controls
- promoting bedtime routines
- promoting safety
- promoting comfort
- establishing periods of rest and sleep
- stress reduction
- bedtime snacks, avoidance of caffeine
- pharmacological approaches
What are the effects of long term sleeping pills use? - ANSWER leads to difficulty
initiating and maintaining sleep
Pre-op Assessment - ANSWER purpose:
- establish the patient's normal pre-op function and assist the nurse in
preventing
- recognizing possible post-op complications
accomplished by:
- healthy history-- include medications
- complete physical examination
What is one key assessment piece we can do that tells us about several of the
body systems? - ANSWER Vital Signs
Why do we do Vital Signs pre-op? - ANSWER provides us a baseline for
assessment
Retrieving Health History - ANSWER - best historian to collect data is the patient
,- if patient is unable to provide this info, then the family members serve as the
resource
- patient's medical record is a great source to retrieve data on past
hospitalizations
Informed Consent - ANSWER protect the individual, acility, staff, and physicians
- description of procedure
- risk and benefits
- probability of success
- consequences of non-surgical treatment or no treatment
- any and all info that will assist the pt reach and informed decision
Physcian's responsibilities with informed consent - ANSWER responsible for
obtaining the pts consent in language the pt can understand --> get interpreter if
needed
- responsible for obtaining informed consent
Nurse's responsibilities with informed consent - ANSWER - make sure the
person signing is in fact the correct person
- witness the signature
- ensure the signature was not forced or coerced
- ensure the pt understood what was signed
Who can provide informed consent? - ANSWER - parent
- spouse
- sibling
- adult children
- guardian
- exception!!: emergency (physician must document)
Surgical Time Out - ANSWER all members of surgical team stop what they are
doing just before the surgery starts and verifies pt identification, surgical
procedure, and surgical site
Nursing Role in during Intra-operative phase - ANSWER - surgical time out
- positioning the patient
- assisting anesthesia provider
- intra-operative medication prep (not anesthetics)
Discharge Instructions - ANSWER - diet/any restrictions
- activity level (ambulating devices, driving)
- wound care/ supplies (s/s of infection)
- medications
- follow up (s/s to report, appointments)
- sign discharge instructions
, Preventing/Managing Post-Op complications - ANSWER - atelectasis
- hypovolemic shock
- thrombus/embolus formation
- paralytic ileus
- wound infection/dehiscence/evisceration
- malignant hyperthermia
*refer to worksheet*
Physical Manifestations of End of Life - ANSWER - BP lowers
- changes in HR
- fever
- breathing changes
- skin color changes
- surge of energy
- restlessness
-congestion -- "death rattle"
- eyes that no longer close or blink
- pinning of the earlobes (normally first thing you see)
- cognition changes/unresponsiveness
- dec. urinary output
- terminal fever
- slight dehydration (actually helps reduce pain)
- terminal restlessness
Palliative Care - ANSWER helps control pain and other symptoms associated
with disease process
- can be provided while seeking treatment
- patient and family care that optimizes quality of life throughout the life of a
disease or illness
- if started in early disease process can improve quality of life
Hospice Care - ANSWER holistic approach to treatment that recognizes the
impending death of an individual warrants a change form curative to palliative
care
- does not provide treatments that cure disease or prolong life
- symptom control
- comfort, dignity, and quality of life is main goal
- provided to those with progressive predictable disease outcome
- subset of palliative care
Symptom Management: Dysphagia - ANSWER difficulty swallowing
- one of the most difficult symptoms for families
interventions:
- can change diet
With Complete Answers
Sleep Assessment - ANSWER - sources of sleep assessment: patients are best
resource; bed partners; parents
- sleep history (any history of sleep problems) patterns, recent changes
- subjective measures of sleep: Epworth Sleepiness Scale; Pittsburgh Sleep
Quality Index; 0-10 sleep rating
- assess usual bedtime, bedtime ritual, preferred environment for sleeping,
preferred rising time
- if patient has a sleep problem, conduct a complete sleep history
- diagnosing sleep problems depends on identifying factors that impair sleep
Nursing Interventions to promote sleep - ANSWER - environmental controls
- promoting bedtime routines
- promoting safety
- promoting comfort
- establishing periods of rest and sleep
- stress reduction
- bedtime snacks, avoidance of caffeine
- pharmacological approaches
What are the effects of long term sleeping pills use? - ANSWER leads to difficulty
initiating and maintaining sleep
Pre-op Assessment - ANSWER purpose:
- establish the patient's normal pre-op function and assist the nurse in
preventing
- recognizing possible post-op complications
accomplished by:
- healthy history-- include medications
- complete physical examination
What is one key assessment piece we can do that tells us about several of the
body systems? - ANSWER Vital Signs
Why do we do Vital Signs pre-op? - ANSWER provides us a baseline for
assessment
Retrieving Health History - ANSWER - best historian to collect data is the patient
,- if patient is unable to provide this info, then the family members serve as the
resource
- patient's medical record is a great source to retrieve data on past
hospitalizations
Informed Consent - ANSWER protect the individual, acility, staff, and physicians
- description of procedure
- risk and benefits
- probability of success
- consequences of non-surgical treatment or no treatment
- any and all info that will assist the pt reach and informed decision
Physcian's responsibilities with informed consent - ANSWER responsible for
obtaining the pts consent in language the pt can understand --> get interpreter if
needed
- responsible for obtaining informed consent
Nurse's responsibilities with informed consent - ANSWER - make sure the
person signing is in fact the correct person
- witness the signature
- ensure the signature was not forced or coerced
- ensure the pt understood what was signed
Who can provide informed consent? - ANSWER - parent
- spouse
- sibling
- adult children
- guardian
- exception!!: emergency (physician must document)
Surgical Time Out - ANSWER all members of surgical team stop what they are
doing just before the surgery starts and verifies pt identification, surgical
procedure, and surgical site
Nursing Role in during Intra-operative phase - ANSWER - surgical time out
- positioning the patient
- assisting anesthesia provider
- intra-operative medication prep (not anesthetics)
Discharge Instructions - ANSWER - diet/any restrictions
- activity level (ambulating devices, driving)
- wound care/ supplies (s/s of infection)
- medications
- follow up (s/s to report, appointments)
- sign discharge instructions
, Preventing/Managing Post-Op complications - ANSWER - atelectasis
- hypovolemic shock
- thrombus/embolus formation
- paralytic ileus
- wound infection/dehiscence/evisceration
- malignant hyperthermia
*refer to worksheet*
Physical Manifestations of End of Life - ANSWER - BP lowers
- changes in HR
- fever
- breathing changes
- skin color changes
- surge of energy
- restlessness
-congestion -- "death rattle"
- eyes that no longer close or blink
- pinning of the earlobes (normally first thing you see)
- cognition changes/unresponsiveness
- dec. urinary output
- terminal fever
- slight dehydration (actually helps reduce pain)
- terminal restlessness
Palliative Care - ANSWER helps control pain and other symptoms associated
with disease process
- can be provided while seeking treatment
- patient and family care that optimizes quality of life throughout the life of a
disease or illness
- if started in early disease process can improve quality of life
Hospice Care - ANSWER holistic approach to treatment that recognizes the
impending death of an individual warrants a change form curative to palliative
care
- does not provide treatments that cure disease or prolong life
- symptom control
- comfort, dignity, and quality of life is main goal
- provided to those with progressive predictable disease outcome
- subset of palliative care
Symptom Management: Dysphagia - ANSWER difficulty swallowing
- one of the most difficult symptoms for families
interventions:
- can change diet
