NSG 430 Exam 1 – Questions With Fully Solved
Solutions
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Terms in this set (51)
Patient stability -mild signs of deterioration: mild confusion, tachypnea
-6-8 hours before cardiac or respiratory arrest
PCU vs ICU -ICU nursing is delivering ICU care to patients
wherever they may be
-PCU is progressive care units (intermediate or step
down) that provide transition between ICU and
general care unit
>at risk for serious complications
,Complexity of unstable clients #1: physiologically unstable
-critical analysis and decision making
#2: risk of complications
-frequent assess and treatments, high risk of delirium
#3: IV polypharmacy-titration
-vasoactive, thrombolytics, sedation, insulin, nutrition
#4: advanced tachnology/devices
-vents, ICP, svO2, CCRT
#5 psychosocial, ethical and safety concerns
Needs of caregivers -information
-reassurance
-access
They need these bc without them they feel powerless
and will show signs of this
Unstable client S/S -↓ Level of consciousness, Anxiety, Confusion,
Weakness, Restlessness
Feeling of impending doom
-Cool, clammy skin, Pallor, Cyanosis
-Dysrhythmias, Tachycardia
-Hypotension, Narrowed pulse pressure
-Rapid, weak, thready pulses
-Tachypnea, dyspnea, or shallow, irregular respirations
-↓ O2 saturation
-Temperature dysregulation• Chills
-Obvious hemorrhage or injury, Nausea and vomiting
,Rapid response FUNCTIONS
-identification and activation on client deterioration
-initiate response for assessment, intervention, triage
-bedside nurse gives SBAR!
FAILURE TO RECOGNIZE
-failure to recognize changes, diagnostics, clinical
deviations from normal, lack of nurse intuition
TEAM
-respiratory ventilates
-nursing supervisor is general support
-provider is hospitalist
-ICU nurse and assigned client nruse
PROTOCOLS
-begin tx before provider arrives
-O2 airway management
-12 EKG
-labs, meds
-critical thinking in action, contact the provider fast
Palliative care vs hospice PALLIATIVE
-*begins during RESTORATIVE or curative health care
-indication: diagnosis of a life-limiting illness
HOSPICE
-life expectancy is 6 months or less
-requires physician certification
END OF LIFE CARE GOALS
-when death is imminent
-provide comfort, improve quality of remaining life,
ensure dignified death
, End of life MANIFESTATIONS
-decreased metabolism, body function
-respiration ceases first, heart stops beating after a
few mins
-slow, irregular breathing, cheyne-stokes respirations
-inability to cough or clear secretions (death rattle=
grunting, gurgling, congested breathing)
-*hearing is the last sense to disappear
-decreased sensation, perception of pain and touch
-blurred vision, absent blink reflex, patient appears to
stare, eyelids half open
-decreased taste and smell
-mottling on hands, feet, arms, legs
-cold and clammy skin
-cyanosis of nose, nail beds, knees
-*waxlike skin when very near death
-gradual urinary output decrease, incontinent of urine,
unable to urinate
-slowing of GI, accumulation of gas, distention and
nausea
-loss of sphincter control
-bowel movement may occur at death
-trouble holding bosy posture and alignment
-loss of facial muscle time: sagging jaw, difficulty
speaking, loss of gag reflex, swallowing is difficult
-increased heart rate, then later slowing and weakend
pulse
-irregular rhythm of heart, decreased BP, delayed
absorption of IM or SQ drugs
PSYCHOSOCIAL MANIFESTATIONS
-altered decision making
-anxiety, fear- spirituality associated with decreased
dispair
-life review
-peacefulness, saying goodbyes, withdrawal
Solutions
Add to calendar
Play your way to mastery with fun games
Match Blocks Charms NEW
Terms in this set (51)
Patient stability -mild signs of deterioration: mild confusion, tachypnea
-6-8 hours before cardiac or respiratory arrest
PCU vs ICU -ICU nursing is delivering ICU care to patients
wherever they may be
-PCU is progressive care units (intermediate or step
down) that provide transition between ICU and
general care unit
>at risk for serious complications
,Complexity of unstable clients #1: physiologically unstable
-critical analysis and decision making
#2: risk of complications
-frequent assess and treatments, high risk of delirium
#3: IV polypharmacy-titration
-vasoactive, thrombolytics, sedation, insulin, nutrition
#4: advanced tachnology/devices
-vents, ICP, svO2, CCRT
#5 psychosocial, ethical and safety concerns
Needs of caregivers -information
-reassurance
-access
They need these bc without them they feel powerless
and will show signs of this
Unstable client S/S -↓ Level of consciousness, Anxiety, Confusion,
Weakness, Restlessness
Feeling of impending doom
-Cool, clammy skin, Pallor, Cyanosis
-Dysrhythmias, Tachycardia
-Hypotension, Narrowed pulse pressure
-Rapid, weak, thready pulses
-Tachypnea, dyspnea, or shallow, irregular respirations
-↓ O2 saturation
-Temperature dysregulation• Chills
-Obvious hemorrhage or injury, Nausea and vomiting
,Rapid response FUNCTIONS
-identification and activation on client deterioration
-initiate response for assessment, intervention, triage
-bedside nurse gives SBAR!
FAILURE TO RECOGNIZE
-failure to recognize changes, diagnostics, clinical
deviations from normal, lack of nurse intuition
TEAM
-respiratory ventilates
-nursing supervisor is general support
-provider is hospitalist
-ICU nurse and assigned client nruse
PROTOCOLS
-begin tx before provider arrives
-O2 airway management
-12 EKG
-labs, meds
-critical thinking in action, contact the provider fast
Palliative care vs hospice PALLIATIVE
-*begins during RESTORATIVE or curative health care
-indication: diagnosis of a life-limiting illness
HOSPICE
-life expectancy is 6 months or less
-requires physician certification
END OF LIFE CARE GOALS
-when death is imminent
-provide comfort, improve quality of remaining life,
ensure dignified death
, End of life MANIFESTATIONS
-decreased metabolism, body function
-respiration ceases first, heart stops beating after a
few mins
-slow, irregular breathing, cheyne-stokes respirations
-inability to cough or clear secretions (death rattle=
grunting, gurgling, congested breathing)
-*hearing is the last sense to disappear
-decreased sensation, perception of pain and touch
-blurred vision, absent blink reflex, patient appears to
stare, eyelids half open
-decreased taste and smell
-mottling on hands, feet, arms, legs
-cold and clammy skin
-cyanosis of nose, nail beds, knees
-*waxlike skin when very near death
-gradual urinary output decrease, incontinent of urine,
unable to urinate
-slowing of GI, accumulation of gas, distention and
nausea
-loss of sphincter control
-bowel movement may occur at death
-trouble holding bosy posture and alignment
-loss of facial muscle time: sagging jaw, difficulty
speaking, loss of gag reflex, swallowing is difficult
-increased heart rate, then later slowing and weakend
pulse
-irregular rhythm of heart, decreased BP, delayed
absorption of IM or SQ drugs
PSYCHOSOCIAL MANIFESTATIONS
-altered decision making
-anxiety, fear- spirituality associated with decreased
dispair
-life review
-peacefulness, saying goodbyes, withdrawal
