EXAM 5 UPDATED QUESTIONS WITH
CORRECT ANSWERS
⩥ Erikson's Psychosocial Theory Older Adults. Answer: Integrity vs.
Despair
People in late adulthood reflect on their lives and feel either a sense of
satisfaction or a sense of failure. People who feel proud of their
accomplishments feel a sense of integrity, and they can look back on
their lives with few regrets.
⩥ Droplet Precautions. Answer: Droplet Precautions:
Use a private room, if available. Door may remain open.
Wear PPE upon entry into the room for all interactions that may involve
contact with the patient and potentially contaminated areas in the
patient's environment.
Transport patient out of room only when necessary and place a surgical
mask on the patient if possible.
Keep visitors 3 ft from the infected person.
⩥ Why are masks beneficial with droplet precautions?. Answer: Masks
help prevent the wearer from inhaling large-particle aerosols, which
usually travel short distances (about 3 ft), and small-particle droplet
nuclei, which can remain suspended in the air and travel longer
,distances. Masks also protect the patient from the respiratory secretions
of the health care worker. Masks discourage the wearer from touching
the eyes, nose, and mouth, thus limiting contact of organisms with
mucous membranes.
⩥ Cough Etiquette. Answer: Any patients, family members, and visitors
with undiagnosed, transmissible respiratory infections require education
to cover their mouth and nose with a tissue when coughing and promptly
dispose of the tissue. During periods of increased occurrence of
respiratory infections, offer a surgical mask to coughing patients and
other symptomatic people upon entry to the health care facility or office.
Encourage the coughing patient to maintain more than a 3-ft separation
from other people in the health care facility or office.
⩥ Factors Affecting Risk for Infection. Answer: Factors affecting the
risk for infection include: integrity of mucous membranes, pH levels of
the gastrointestinal and genitourinary tracts, immune response, age, sex,
race, heredity, level of fatigue, nutritional status, stress level, use of
invasive or indwelling medical devices and immunizations (natural or
acquired)
⩥ Abnormal Wound Drainage. Answer: Purulent drainage is made up of
white blood cells, liquefied dead tissue debris, and both dead and live
bacteria. Purulent drainage is thick, often has a musty or foul odor, and
varies in color (such as dark yellow or green), depending on the
causative organism.
,⩥ Pressure Ulcer Stage 1. Answer: A stage 1 pressure injury is a defined,
localized area of intact skin with nonblanchable erythema (redness).
Darkly pigmented skin may not have visible blanching; its color may
differ from the surrounding skin. The area may be painful, firm, soft,
warmer, or cooler as compared to adjacent tissue
⩥ Pressure Ulcer Stage 2. Answer: A stage 2 pressure injury involves
partial-thickness loss of dermis and presents as a shallow, open ulcer or a
ruptured/intact serum-filled blister
⩥ Pressure Ulcer Stage 3. Answer: A stage 3 pressure injury presents
with full-thickness tissue loss. Subcutaneous fat may be visible and
epibole (rolled wound edges) may occur, but bone, tendon, or muscle is
not exposed. Slough and/or eschar that may be present do not obscure
the depth of tissue loss. Ulcers
⩥ Pressure Ulcer Stage 4. Answer: Stage 4 injuries involve full-
thickness tissue loss with exposed or palpable bone, cartilage, ligament,
tendon, fascia, or muscle. Slough or eschar may be present on some part
of the wound bed; epibole, undermining, and/or tunneling often occur
⩥ Wound Infection. Answer: Symptoms of infection include purulent
drainage; increased drainage, pain, redness, and swelling in and around
the wound; increased body temperature; and increased white blood cell
count. Additional signs and symptoms include delayed healing and
discoloration of granulation tissue in the wound
, ⩥ Braden Scale. Answer: Braden Scale: mental status, continence,
mobility, activity, and nutrition
Using the Braden scale (VHMMN)
Lower to 9 Very high risk-V
10 to 12 High risk-H
13 to 14 Moderate risk-M
15 to 18 Mild risk-M
19 to 23 indicate No risk-N
⩥ Heat Application. Answer: The application of heat accelerates the
inflammatory response to promote healing.
The application of local heat dilates peripheral blood vessels, increases
tissue metabolism, reduces blood viscosity and increases capillary
permeability, reduces muscle tension, and helps relieve pain.
Vasodilation increases local blood flow. In turn, the supply of oxygen
and nutrients to the area is increased, and venous congestion is
decreased
Careful on large parts of the body
⩥ Dysnpea Positioning. Answer: High Fowler's Position because
accessory muscles can easily be used to promote respirations
⩥ Partial Rebreather Mask. Answer: Low Flow 8-11L/min, set flow rate
so the mask remains two thirds full during inspiration, keep reservoir
bag free of twists or kinks
CORRECT ANSWERS
⩥ Erikson's Psychosocial Theory Older Adults. Answer: Integrity vs.
Despair
People in late adulthood reflect on their lives and feel either a sense of
satisfaction or a sense of failure. People who feel proud of their
accomplishments feel a sense of integrity, and they can look back on
their lives with few regrets.
⩥ Droplet Precautions. Answer: Droplet Precautions:
Use a private room, if available. Door may remain open.
Wear PPE upon entry into the room for all interactions that may involve
contact with the patient and potentially contaminated areas in the
patient's environment.
Transport patient out of room only when necessary and place a surgical
mask on the patient if possible.
Keep visitors 3 ft from the infected person.
⩥ Why are masks beneficial with droplet precautions?. Answer: Masks
help prevent the wearer from inhaling large-particle aerosols, which
usually travel short distances (about 3 ft), and small-particle droplet
nuclei, which can remain suspended in the air and travel longer
,distances. Masks also protect the patient from the respiratory secretions
of the health care worker. Masks discourage the wearer from touching
the eyes, nose, and mouth, thus limiting contact of organisms with
mucous membranes.
⩥ Cough Etiquette. Answer: Any patients, family members, and visitors
with undiagnosed, transmissible respiratory infections require education
to cover their mouth and nose with a tissue when coughing and promptly
dispose of the tissue. During periods of increased occurrence of
respiratory infections, offer a surgical mask to coughing patients and
other symptomatic people upon entry to the health care facility or office.
Encourage the coughing patient to maintain more than a 3-ft separation
from other people in the health care facility or office.
⩥ Factors Affecting Risk for Infection. Answer: Factors affecting the
risk for infection include: integrity of mucous membranes, pH levels of
the gastrointestinal and genitourinary tracts, immune response, age, sex,
race, heredity, level of fatigue, nutritional status, stress level, use of
invasive or indwelling medical devices and immunizations (natural or
acquired)
⩥ Abnormal Wound Drainage. Answer: Purulent drainage is made up of
white blood cells, liquefied dead tissue debris, and both dead and live
bacteria. Purulent drainage is thick, often has a musty or foul odor, and
varies in color (such as dark yellow or green), depending on the
causative organism.
,⩥ Pressure Ulcer Stage 1. Answer: A stage 1 pressure injury is a defined,
localized area of intact skin with nonblanchable erythema (redness).
Darkly pigmented skin may not have visible blanching; its color may
differ from the surrounding skin. The area may be painful, firm, soft,
warmer, or cooler as compared to adjacent tissue
⩥ Pressure Ulcer Stage 2. Answer: A stage 2 pressure injury involves
partial-thickness loss of dermis and presents as a shallow, open ulcer or a
ruptured/intact serum-filled blister
⩥ Pressure Ulcer Stage 3. Answer: A stage 3 pressure injury presents
with full-thickness tissue loss. Subcutaneous fat may be visible and
epibole (rolled wound edges) may occur, but bone, tendon, or muscle is
not exposed. Slough and/or eschar that may be present do not obscure
the depth of tissue loss. Ulcers
⩥ Pressure Ulcer Stage 4. Answer: Stage 4 injuries involve full-
thickness tissue loss with exposed or palpable bone, cartilage, ligament,
tendon, fascia, or muscle. Slough or eschar may be present on some part
of the wound bed; epibole, undermining, and/or tunneling often occur
⩥ Wound Infection. Answer: Symptoms of infection include purulent
drainage; increased drainage, pain, redness, and swelling in and around
the wound; increased body temperature; and increased white blood cell
count. Additional signs and symptoms include delayed healing and
discoloration of granulation tissue in the wound
, ⩥ Braden Scale. Answer: Braden Scale: mental status, continence,
mobility, activity, and nutrition
Using the Braden scale (VHMMN)
Lower to 9 Very high risk-V
10 to 12 High risk-H
13 to 14 Moderate risk-M
15 to 18 Mild risk-M
19 to 23 indicate No risk-N
⩥ Heat Application. Answer: The application of heat accelerates the
inflammatory response to promote healing.
The application of local heat dilates peripheral blood vessels, increases
tissue metabolism, reduces blood viscosity and increases capillary
permeability, reduces muscle tension, and helps relieve pain.
Vasodilation increases local blood flow. In turn, the supply of oxygen
and nutrients to the area is increased, and venous congestion is
decreased
Careful on large parts of the body
⩥ Dysnpea Positioning. Answer: High Fowler's Position because
accessory muscles can easily be used to promote respirations
⩥ Partial Rebreather Mask. Answer: Low Flow 8-11L/min, set flow rate
so the mask remains two thirds full during inspiration, keep reservoir
bag free of twists or kinks
