ATI PN Fundamentals Study
Physical signs of pain - answersIncreased BP, HR, & RR
Describe how to assess the strength of the sternocleidomastoid muscle - answersThe
nurse should check the strength of the sternocleidomastoid muscle by placing hands
firmly against the client's upper jaw and creating resistance as the client turns her head
laterally
How should the nurse check the strength of the trapezius muscle? - answersThe nurse
should check the strength of the trapezius muscle by having the client shrug their
shoulders while the nurse applies firm pressure over the midline of the shoulders
How should the nurse check the strength of the gastrocnemius muscle? - answersThe
nurse should check the strength of the gastrocnemius muscle by grasping the client's
shin and pushing toward the client's body as the client offers resistance by attempting to
straighten her leg.
How should the nurse check the strength of the deltoid muscle? - answersThe correct
technique for checking the deltoid muscle is for the client to hold her arms out and resist
the while the nurse pushes them down.
Define complicated grief - answers- unresolved or chronic grief is a type
- involves difficult progression through the expected stages of grief
- usually work of grief is prolonged, manifestations more severe, can result in
depression or exacerbate preexisting disorder
, - client may develop suicidal ideation, intense feelings of guilt, and lowered self-esteem
- somatic complaints persist for an extended period of time
Define maturational loss - answersMaturational loss results from a developmental
process, such as growth of a child into and adult
Define disenfranchised grief - answersA loss that is unable to be shared publicly and
that society might view as controversial (ex. suicide, death of a partner who had a
spouse, abortion)
Describe the orthopneic position - answersClient sits upright either in bed or in a chair
and lean forward. This position allows maximal chest expansion and facilitates
breathing (ex. pt has dyspnea caused by respiratory infection)
Describe the dorsal recumbent position - answersClient is supine (back-lying), this
position makes breathing especially difficult for pts who have respiratory problems
Describe the Sim's position - answersPt is side-lying and partially on the abdomen with
flexion of the upper hip, knee, elbow, and shoulder. Useful for pts who are unconscious
as secretions can drain from the mouth
Describe the prone position - answersPt is lying on the abdomen, useful for pts who are
unconscious as secretions can drain from the mouth, prevents flexion contractures of
the knees and hips.
Describe nursing interventions to reduce fall risk - answers- place personal items w/in
the pt's reach
- place back of bedside commode against the wall of the room
- do NOT raise all side rails, can be considered a restraint and increase fall risk
- place pt's bed in lowest position
Which type of isolation guidelines are considered tier two precautions? -
answersTransmission-based precautions
What do airborne precautions protect against? - answers- droplet infections <5 mcg
- measles, varicella, pulmonary or laryngeal TB
What should be implemented for airborne precautions? - answers- a private room
- masks and respiratory protection devices for caregivers and visitors (N95 or HEPA
respirator if known or suspected TB)
- negative pressure airflow exchange at least 6-12 exchanges/hr
- if splashing or spraying is a possibility, full face (eyes, nose, mouth) protection
What do droplet precautions protect against? - answers- droplets >5 mcg and able to
travel 3-6 ft from pt
Physical signs of pain - answersIncreased BP, HR, & RR
Describe how to assess the strength of the sternocleidomastoid muscle - answersThe
nurse should check the strength of the sternocleidomastoid muscle by placing hands
firmly against the client's upper jaw and creating resistance as the client turns her head
laterally
How should the nurse check the strength of the trapezius muscle? - answersThe nurse
should check the strength of the trapezius muscle by having the client shrug their
shoulders while the nurse applies firm pressure over the midline of the shoulders
How should the nurse check the strength of the gastrocnemius muscle? - answersThe
nurse should check the strength of the gastrocnemius muscle by grasping the client's
shin and pushing toward the client's body as the client offers resistance by attempting to
straighten her leg.
How should the nurse check the strength of the deltoid muscle? - answersThe correct
technique for checking the deltoid muscle is for the client to hold her arms out and resist
the while the nurse pushes them down.
Define complicated grief - answers- unresolved or chronic grief is a type
- involves difficult progression through the expected stages of grief
- usually work of grief is prolonged, manifestations more severe, can result in
depression or exacerbate preexisting disorder
, - client may develop suicidal ideation, intense feelings of guilt, and lowered self-esteem
- somatic complaints persist for an extended period of time
Define maturational loss - answersMaturational loss results from a developmental
process, such as growth of a child into and adult
Define disenfranchised grief - answersA loss that is unable to be shared publicly and
that society might view as controversial (ex. suicide, death of a partner who had a
spouse, abortion)
Describe the orthopneic position - answersClient sits upright either in bed or in a chair
and lean forward. This position allows maximal chest expansion and facilitates
breathing (ex. pt has dyspnea caused by respiratory infection)
Describe the dorsal recumbent position - answersClient is supine (back-lying), this
position makes breathing especially difficult for pts who have respiratory problems
Describe the Sim's position - answersPt is side-lying and partially on the abdomen with
flexion of the upper hip, knee, elbow, and shoulder. Useful for pts who are unconscious
as secretions can drain from the mouth
Describe the prone position - answersPt is lying on the abdomen, useful for pts who are
unconscious as secretions can drain from the mouth, prevents flexion contractures of
the knees and hips.
Describe nursing interventions to reduce fall risk - answers- place personal items w/in
the pt's reach
- place back of bedside commode against the wall of the room
- do NOT raise all side rails, can be considered a restraint and increase fall risk
- place pt's bed in lowest position
Which type of isolation guidelines are considered tier two precautions? -
answersTransmission-based precautions
What do airborne precautions protect against? - answers- droplet infections <5 mcg
- measles, varicella, pulmonary or laryngeal TB
What should be implemented for airborne precautions? - answers- a private room
- masks and respiratory protection devices for caregivers and visitors (N95 or HEPA
respirator if known or suspected TB)
- negative pressure airflow exchange at least 6-12 exchanges/hr
- if splashing or spraying is a possibility, full face (eyes, nose, mouth) protection
What do droplet precautions protect against? - answers- droplets >5 mcg and able to
travel 3-6 ft from pt
