Fundamentals of Nursing EXAM 2 Questions and Correct Answers, With Complete Solution 2024.

Fundamentals of Nursing EXAM 2 Questions and Correct Answers, With Complete Solution 2024. What do nurses need to be aware of regarding patient safety A safe environment reduces the risk for accidents Vulnerable groups require help to achieve a safe environment Nurses need to understand how changes in mobility, sensory function, and cognitive function affect patient safety .... as shown by research What are the basic human (patient) needs Oxygen Nutrition Temperature Humidity What is a nurses responsibility concerning oxygen? Be alert to important functioning equipment Make sure patient understand O₂ is an explosive Colorless and odorless, don't know it is running What is a nurses responsibility concerning Nutrition? Proper refrigeration, food storage, food preparation ..... are essential What is a nurses responsibility concerning Temperature? Comfort zone 65°F to 75°F Exposure to extreme heat and cold can cause injury What is a nurses responsibility concerning Humidity? Amount of water vapor in the air Added Humidity may be needed because O2 can dry out mucous membranes. What are physical Hazards In the home- inadequate lighting and physical barriers (doors, stairs, curbs, furniture) Poison - OTC drugs, cleaning agents, plants Home fires - #1 cause = smoking, matches (CO detectors are important) Natural disasters - earthquakes, hurricanes, floods, snowstorms Threat of bioterrorist attack - anthrax Concerns for the Transmission of Pathogens Hand hygiene - most effective way to limit spread of pathogens (gel in, gel out) Human immune deficiency virus (HIV) & Hep B remain high risk for incidence exposure Insects and rodents - primarily affect the homeless Inadequate human waste disposal - cause typhoid fever & hepatitis Immunization - very important, has helped to eradicate some disease, need for education on this topic Biohazard waste - chemotherapy is an example, dealt with at hospitals all the time Common developmental safety hazards for INFANT/TODDLER/PRESCHOOLER - balance is poor - prone to accidents - putting things in mouth, nose, ears - parent education * children not restrained in car seat * don't leave your kid alone on couch Common developmental safety hazards for SCHOOL-AGE CHILD Education about safe play Use of safety equipment for sports - helmets, shinguards, etc Common developmental safety hazards for ADOLESCENT Drug/alcohol use/abuse Smoking Motor vehicle accident Common developmental safety hazards for ADULT Issues related to lifestyle habits (mountain climbing, sky-diving, driving fast) Common developmental safety hazards for OLDER ADULT Age related physiological changes - vision, hearing, sense of touch, ability to perform fine motor tasks.... All diminish Effects of medications - slow reaction time & dull the senses Illness Accidents (more prone to trips & falls... throw rugs are a death trap) Other Issues/Risk Factors that are concerns for safety Lifestyle Impaired mobility Sensory impairments Cognitive impairments Safety awareness Falls Risks in the Health Care Agency Account for most patient accidents Inherent Accident Risks in the Health Care Agency (Normal everyday things that happen) Cuts Burns Ingestion Seizures Procedure Related Risks in the Health Care Agency Medication Fluid Hospital Staff Equipment Related Risks in the Health Care Agency Malfunction Disrepair Electrical Hazards The nursing process in regards to Safety Awareness Assessment Two pronged approach to assess the environment and the patient Nursing diagnosis Fall Risk, Impaired sensory perception Planning Implementation Evaluation Interventions for Fall Concerns Place call light within reach Safety light Clear Pathway to bathroom Exit alarms/pads when patient gets out of bed Use of Restraints for Safety Measure When a patient is a danger to themselves or tp stop them from pulling out catheters and other medical devices Regulated by TJC & CMS (centers for medicare/medicaid services) - flow sheet must be completed on every patient in retraint All four side rails up is considered a restraint Consider alternatives, such as ambualarm, rather than restraints What are Restraint Regulations Requires a physician order - physician must see and assess the patient every 24 hours and write a new order - Patient must be checked every 15 minutes - Must be told what they need to do in order to have restraints removed -Must be allowed to toilet, eat. & drink Concerns for Restraints Impaired skin integrity Altered neurovascular status to extremities (cyanosis, pallor, coldness of skin, tingling, pain, numbness) Patient releases the restraint and falls and injures him/herself Safety Concerns for FIRES Smoke detectors Home or health care facility Safety Concerns for POISONING Medications Cleaning Fluids Mercury Safety Concerns for BIOTERRORISM Biological Chemical Radiological What are body mechanics? Coordinated efforts of the musculoskeletal and nervous systems Maintain balance, posture, and body alignment Mandatory for Lifting, bending, and moving Performing activities of daily living Four characteristics of Body Mechanics Body Alignment Body Balance Coordinated Body Movement Friction What is Good Nursing Body Alignment Relationship of one body part to another - don't twist Correct body alignment reduces strain on musculoskeletal structures, maintains muscle tone, and contributes to balance. What is Good Nursing Body Balance Achieved by a low center of gravity Enhanced by a wide base of support What is Good Nursing Coordinated Body Movement Must overcome an object's weight and be aware of it's center of gravity. - can be determined by having a person stand and just look to see if a person is wobbly What is Friction in Nursing Body Mechanics? The force that occurs in a direction to oppose movement. The greater the surface area of the object that is moved, the greater the friction. Effect of rubbing or resistance when a moving body meets a surface when turning Physiology & Regulation of Movement SKELETAL SYSTEM Provides attachments for muscles and ligaments and the leverage necessary for movement: Bones, joints, ligaments, tendons, cartilage Physiology & Regulation of Movement SKELETAL MUSCLE Movement of bone and joints involves active processes that are carefully integrated to achieve coordination. Due to ability to contract and relax are the working elements of movement. Movement Posture Groups Synergistic - A synergist muscle is a muscle which works in concert with another muscle to generate movement. These muscles can work with the so-called agonists or prime movers which surround a joint, or the antagonistic muscles, which move in the opposite direction Antigravity - postural movement Physiology & Regulation of Movement NERVOUS SYSTEM Regulates movement and posture, proprioception and balance with the precentral gyrus (motor strip) in the cerebral cortex. Pathological influences on body alignment, exercise, & activity Congenital Defects - Osteogenesis imperfecta - Scoliosis Disorders of Bones, Joints, & Muscles - Osteoporosis - Inflammatory & noniflamm joint disease CNS Damage - damage to any component that regulates voluntary movements Musculoskeletal Trauma - Bruises/Contusions