Medsurg 1 Rn Jersey College Final Exam

Weight, smoking, sex practices, diet - -list four modifiable risk factors. (general health promotion) Age, genetics, sex - -list three non-modifiable risk factors. (general health promotion) Cultural assessment - -what type of assessment should the nurse preform prior to initiating health teaching? Physiological integrity Safety and security Belongingness and affection Esteem and self-respect Self-actualization -- physiologic needs and life threatening issues are a priority -- confirm that these needs are met in the order listed above - -maslow's hierarchy of needs --priorities? --what order? Healthy people 2020 - -organization that identifies health promotion and disease prevention goals and lists strategies along with resources in an attempt to improve the nation's health The institute of medicine's report on the future of nursing - -organization that recommends ways to strengthen the practice of nursing in order to improve health care. The national patient safety goals - -the joint commission lists the top patient safety concerns and includes medication safety, infection prevention, surgery-related mistakes, patient identification and improving staff communication. What is this list called? Nurse practice acts - -this governs nursing practice and is a law that is put into place to protect the public - nurses must follow and comply with their state's regulations Qsen - quality and safety education for nurses institute - -institute that seeks to strengthen the knowledge, skills, and attitudes of nurses in providing continuous quality improvement in health care Medsurg Whatever the patient says it is - -what is pain? Actual or potential tissue damage - -pain is associated with __________________________________. The patient's self report - -the single most reliable indicator of pain is _______. Blood pressure, heart rate, and respirations - -pain stimulates the sympathetic nervous system and could result in an increase in ___________, ___________, and ____________. Increases glucagon production Decreases insulin secretion Depresses immune function Can lead to addictive behaviors - -physiologic effects of unrelieved pain (4) Prostaglandins - -initiate inflammation and contribute to tissue swelling and pain Nsaids - -______ primarily produce pain relief by preventing prostaglandin formation. Acetaminophen - -_____________ does not have anti-inflammatory properties. Tissue damage - -______________ stimulates the inflammatory response and puts the patient at risk for pain. Local anesthetics, non-opioids or opioids - -manage nociceptive pain with? Allodynia - -pain that is associated with a noxious stimulus Nerve route injury - -________________ could lead to allodynia. Timing: Onset - when it started Duration - where it started Frequency - how often/for how long Type - includes intensity, associated factors Influencing factors - what makes it better/worse Intensity - how bad does it hurt Quality - what does it feel like Location - where does it hurt Medsurg Medsurg Medsurg Effects on function/daily activities - -what does a comprehensive pain assessment include? Visual analog scale - -10cm line that represents no pain to worst pain on each end of the line and the patient places a mark somewhere between the two ends depending on the severity of pain Numeric rating scale - -ranges from 0 to 10 with 0 representing no pain Wong-baker faces scale (ages 3+) - -consists of cartoon faces that the patient selects to report their pain Verbal descriptor scale - -uses words to help individuals describe the intensity of their pain Wong-baker faces scale - -should never be used by the provider to match the patient's facial expression Produce a local effect - -effect produced by topical analgesics Produces drug absorption into the systemic circulaiton - -effect produced by transdermal route of analgesics Provide pca (patient controlled analgesia) - -provide ____________ to help reduce complications related to pain. Used in postoperative patients as a preventative measure for pain. Around the clock - -provide administration of analgesics __(frequency)__ for chronic and postoperative pain, never wait for chronic pain to reoccur. Aspirin or acetaminophen - -given for mild to moderate pain Nsaids - -given for moderate pain Opioid analgesics (morphine) - -given for severe pain Rectal route - -avoid which medication administration route for patients who are thrombocytopenic? Acetaminophen - -use of this analgesic could result in hepatoxicity and should not exceed 4,000mg/day. Nsaids - -analgesic that could result in gastric ulcers or contribute to cardiovascular events such as mi or stroke Medsurg Medsurg Nsaids - -analgesic that could lead to acute renal failure in patients with volume depletion or who take it for chronic pain Prostaglandin - -needed for renal blood flow Constipation, nausea, pupil constriction, and respiratory depression - -undesirable side effects of opioids Could increase absorption and result in lethal complications - -never apply heat over transdermal patches. Why? Antidepressants or anticonvulsants - -adjuvant medications used to manage neuropathic pain Metabolic alkalosis - -vomiting can lead to what acid-base imbalance Metabolic acidosis - -diarrhea can lead to what acid-base imbalance Calcium - -mineral that helps to regulate muscle contraction and relaxation High in calcium and low in phosphorus - -in the setting of hypoparathyroidism, provide a diet that is high in _______ and low in __________. Osmotic pressure - -chloride works with sodium to determine _______________. Hypochloremic metabolic alkalosis - -if chloride levels drop, bicarbonate is retained and results in _______________________________. Action potentials Weakness or excitability - -changes in electrolytes impair _________________ resulting in ________ or ____________. Fluid volume deficit (fvd) - -small shifts in intravascular volume in children increases their risk for __________________. Albumin - -proteins like _______ create an oncotic pressure. Oncotic pressure - -________________ pulls fluid from the interstitial compartment into the intravascular compartment to maintain volume. D5w - -becomes a hypotonic solution as the cells absorb the dextrose Dextrose - -________ should not be given to patients with a head injury. Medsurg Medsurg Low magnesium - -this mineral stimulates parathyroid hormone secretion when low. Magnesium - -this mineral helps with carbohydrate and protein metabolism, affects neuromuscular function, and produces vasodilation. Magnesium sulfate - -can be given to relax smooth muscle. Calcium antagonist. Calcium gluconate - -the antidote for tetany or hypermagnesmia Phosphorus - -this mineral is required for the formation of atp and helps to maintain the acid-base balance. Potassium - -this mineral/electrolyte is necessary for neuromuscular and cardiovascular function. Tall tented t waves - -ekc/ecg reading for hyperkalemia Inverted t waves - -ekg/ecg reading for hypokalemia Potassium - -the ion for repolarization. Hypokalemia Ileus - -___________ lowers the resting membrane potential and makes cells less irritable which could result in a(n)_____. Potassium sparing diuretics - -these drugs should never be used in the presence of renal injury Potassium - -check renal function prior to administering ______. Hyperkalemia - -metabolic acidosis results in ____________ Sodium - -the primary factor for osmolality and intravascular fluid volume Headaches Seizures Lethargy Tachycardia Decreased blood pressure Thready pulse Hyperactive bowel sounds Abdominal cramps - -clinical manifestations of hyponatremia. (8) Electrolyte imbalance - -assess patients for _____________________ in the setting of vomiting, diarrhea, or suctioning. Medsurg Medsurg Elevate the hob 30-45 degrees - -place patient in what position to prevent aspiration in the setting of mechanical ventilation, altered consciousness, or tube feedings? Muscle weakness Coma - -hypercalcemia results in Muscle irritability Tetany - -hypocalcemia results in Chvostek's and trousseau's signs - -classic tests/signs that are indicative of hypocalcemia. Osteoporosis - -prolonged immobility contributes to shifting of ca out of the bones leading to ____________. Laryngospasms - -can occur with low ca and is a medical emergency Calcium gluconate - -given to reverse cns depression caused by magnesium Adh (vasopressin) - -hormone that promotes fluid re-absorption by the kidneys Aldosterone - -hormone that promotes sodium retention and potassium excretion Angiotensin - -one of the most powerful vasoconstrictors in the body Brain natriuretic peptide (bnp) - -hormone that triggers na excretion and a decrease in total fluid volume Hydrostatic pressure - -moves fluid from the intravascular compartment to the intercellular compartment Edema - -an increase in hydrostatic pressure or a decrease in oncotic pressure could result in _____. Delirium - -typical sign of dehydration in the elderly Pinching the skin over the sternum or the forehead - -how to determine skin turgor Fever and burns - -_____ and _____ contribute to an insensible(non-visible) water loss and contribute to dehydration Drop in perfusion Hypovolemic shock Death - -loss of fluid volume could result in? (3) Medsurg Medsurg Changes in loc Decreased urinary output Dizziness Dry mucosal membranes Hypotension Tachycardia - -signs of fluid volume deficit Coughing and deep breathing Use of incentive spirometer - -encourage patient to do these things to help remove secretions and promote lung expansion. 2.2 pounds - -a weight gain of __pounds is equivalent to a liter of fluid retention. Supine - -what position promotes renal blood flow and the formation of urine? Impaired thirst mechanism - -why are the elderly at an increased risk for hypernatremia? Lr(lactated ringer's solution) - -should never be