NUR-230 EXAM 1 WITH COMPLETE EXAM QUESTIONS AND ANSWERS (VERIFIED ANSWERS) (2026) A!!

NUR-230 EXAM 1 WITH COMPLETE EXAM QUESTIONS AND ANSWERS (VERIFIED ANSWERS) (2026) A!! 1. What is gravida? - ANSWER Total number of pregnancies 2. What is para? - ANSWER Total number of viable pregnancies (at lease 20 weeks gestation) 3. Describe Naegele's Rule? - ANSWER Used to determine the expected date of delivery (EDD) 4. How is the EDD determined? - ANSWER Naegele's Rule: (First day of last period+ 7 days) - 3 months 5. What are the signs of pregnancy? - ANSWER Presumptive, Probable, Positive 6. What is a presumptive sign of pregnancy? - ANSWER N&V, breast changes, fatigue, urinary frequency 7. What is a probable sign of pregnancy? - ANSWER Goodell's sign, Chadwick's sign, Hegar's sign, positive pregnancy test 8. What is a positive sign of pregnancy? - ANSWER Hearing fetal heart tones (12 wks), Visualization of the fetus (4 wks), palpating fetal movement, and visualizing fetal movements: Ultrasound (18 wks) 9. What are the effects of pregnancy on the cardiovascular system? - ANSWER There is extra fluid on board so the CO increases 10%-50%. The heart rate increases 10-15 bpm 10. What is asked/done in first GYN appt? - ANSWER -Pap smear -STD's -Were they on birth control or antibiotics? -Currently taking any medications? -Currently using tobacco, alcohol, or illegal drugs? - Ask about resources (social, financial) -Any previous pregnancies 11. How much should caffeine be decreased to? - ANSWER 1-2 servings a day What foods are rich in iron? - ANSWER -Red meat -Dark leafy greens -Beans -Poultry 12. Nursing Process - ANSWER assessment, diagnosis, planning, implementation, evaluation assessment - ANSWER collecting subjective and objective data, validation and documentation of data. determines nursing interventions that influence health status diagnosis - ANSWER analyzing subjective and objective data to make a professional nursing judgment (nursing diagnosis) collaborative problem, or referral planning - ANSWER determining outcome criteria and developing a plan implementation - ANSWER carrying out the plan evaluation - ANSWER assessing whether outcome criteria have been met and revising the plan as necessary 13. Holistic Nursing Assessment - ANSWER collective holistic subjective and objective data to determine a clients' overall level or functioning in order to make a professional clinical judgement. Whole body and mind 14. Initial comprehensive assessment - ANSWER total health assessment when the client enters the health system 15. Ongoing/partial assessment - ANSWER data collection after the comprehensive database is established that is compared to the baseline 16. Focused/problem-oriented assessment - ANSWER thorough assessment of a particular client problem on a client with comprehensive database; does not address areas not related to the problem 17. emergency assessment - ANSWER performed in life-threatening situations 18. SBAR - ANSWER situation, background, assessment, recommendation 19. Tips for SBAR - ANSWER - communicate face to face with good eye contact - allow time for the receiver to ask question - provide documentation of the data you are sharing - validate what the receiver has heard (repeat back) - when reporting over the telephone, read back and verify (document) health promotion - ANSWER a set of actions that help people improve their health and control over it. Focused on preventing and addressing the underlying causes of illness rather than just treating and curing them Subective data - ANSWER Any information that is self reported by the patient Classify Subjective Data - ANSWER -History of present concern -Personal health history -Family history -Lifestyle and health practices -Biographical information -Physical symptoms Pain What's the general rule for prescription safety? - ANSWER start low, go slow A list of medications that are generally considered inappropriate when given to elderly people - ANSWER Beer's Criteria Many older adults will try to use _____ and ______ rather than medication. - ANSWER herbs, supplements Nurse's role regarding herbs and supplements (3)? - ANSWER -ask about OTC herbs -special assessment of herbal use before surgery -Education about the need to include supplements on med list Is pain a normal part of aging? - ANSWER NO Who covers nursing home/long term care for more than 30 days? - ANSWER medicaid Who covers acute episodes (30 days or less) of nursing home/long term care? - ANSWER medicare If one is at rehab for less than 100 days and continues to show progress, who will cover it? - ANSWER medicare In order to qualify for homecare, an individual must be ________. - ANSWER homebound What are the 2 common sensory changes in the gero population? - ANSWER -presbycusis -presbyopia make sure they don't lift heavy things, drive themselves, eye drops, might need someone to help them at home, don't take blood thinners before surgery - ANSWER nursing interventions for patient having cataract surgery treated with medicine/drops, picked up by eye doctor - ANSWER chronic/open angle glaucoma emergency, angry/red/fiery eyeballs, blood vessels breaking apart, changes in vision, pain in eye - ANSWER acute/closed angle glaucoma upper eyelid droops or sags - ANSWER ptosis test to assess central vision and to assist in the diagnosis of age-related macular degeneration (abnormal vision: distorted lines, blind spots, blurred vision) - ANSWER Amsler Grid What are 2 common diagnoses in the gero population? - ANSWER -Risk for aspiration -risk for infection little bruises due to blood vessels breaking apart towards surface, don't jump to abuse assumption!x - ANSWER actinic purpura What are the 3 main types of ulcers? - ANSWER -arterial -venous -diabetic lesions intact skin with nonblanchable redness - ANSWER stage 1 pressure ulcer partial thickness skin loss involving epidermis, dermis, or both - ANSWER stage 2 pressure ulcer full thickness tissue loss with visible fat - ANSWER stage 3 pressure ulcer Full-thickness tissue loss with exposed bone, muscle, or tendon - ANSWER stage 4 pressure ulcer Phases of the Interview - ANSWER - preintroductory - introductory - working - summary and closing phase preintroductory phase - ANSWER nurse reviews the medical record which may reveal the client's past health history and reasons for seeking health care introductory phase - ANSWER - introduction - purpose of the interview - confidential information - verify client has privacy - develop trust Working phase - ANSWER - Biographical data - Reason for seeking care - Present health concern - Past health history - Family history - Review of body system - Lifestyle and health practices Summary and Closing phase - ANSWER - summarize information - validate problems and goals - identify and discuss possible plans - ask if anything else concerns the client Types of questions to use during the the interview - ANSWER - "What is your major health concern or problem at this time?" - "How do you feel about having to seek health care?" Techniques to use during the interview - ANSWER - use open ended and close ended questions - rephrase if needed - provide information if needed Nonverbal Communication - ANSWER - Appearance - Demeanor - Facial expression - Attitude - Silence - Listening Nonverbal communication to avoid - ANSWER - Excessive or insufficient eye contact - Distraction and distance - Standing Verbal communication to avoid - ANSWER - Biased or leading questions - Rushing through the interview - Reading the questions Emotional Variations in communications - ANSWER - Interacting with an anxious client - Interacting with an angry client - Interacting with a depressed client - Interacting with a manipulative client - Interacting with a seductive client - Discussing sensitive issues Biographical Data - ANSWER - Name - Address -Phone -Gender -Provider or history (patient or other) -Birth date -Place of birth -Race or ethnic background -Primary or secondary languages spoken and read -Marital status -Religious or spiritual practices -Educational level -Occupation -Significant others or support persons What is the first breath of life characterized by? - ANSWER A gasp that generates an increase in transpulmonary pressure and results in diaphragmatic descent. What role does surfactant play in newborn lungs? - ANSWER Surfactant reduces surface tension, preventing alveolar collapse and loss of lung volume. How does the amount of surfactant relate to the risk of respiratory distress in premature infants? - ANSWER More premature infants have less surfactant, increasing the risk of respiratory distress. What happens to the fluid in the lungs during birth? - ANSWER Fluid is removed and replaced with air; passage through the birth canal helps eliminate two-thirds of the fluid. What is the normal respiratory rate for newborns? - ANSWER 30-60 breaths per minute, with short periods of apnea lasting less than 5-10 seconds. What are signs of respiratory distress in newborns? - ANSWER Central cyanosis, tachypnea, expiratory grunting, sternal retracting, and nasal flaring. What is the significance of clamping the umbilical cord after birth? - ANSWER It eliminates the placenta as a reservoir for blood, initiating cardiovascular changes. What causes the closure of the foramen ovale in newborns? - ANSWER Increased pulmonary blood flow and pressure in the left atrium after the onset of respirations. What happens to the ductus arteriosus after birth? - ANSWER It closes within 10 to 15 hours after birth due to increased pressure in the aorta. What is a neutral thermal environment (NTE) for newborns? - ANSWER An environment where body temperature is maintained without increased metabolic rate or oxygen use. What is cold stress in newborns? - ANSWER Excessive heat loss requiring compensation through non-shivering thermogenesis, which can lead to various health issues. What are some characteristics that predispose newborns to heat loss? - ANSWER Thin skin, increased skin permeability, lack of shivering ability, limited metabolic substrate stores, and large surface area-to-body mass ratio. What is bilirubin and why do newborns have high levels? - ANSWER Bilirubin is a byproduct of RBC breakdown; newborns have higher levels due to a higher turnover of RBCs. History of present illness/concern - ANSWER - Encourage the client to explain the health problem is as much detail - Ask the client to evaluate - What makes the problem worse - What makes it better, which treatments have been tried - What effect the problem has had on daily life or lifestyle - What expectations are held regarding recovery - What is the client's ability to provide self care Personal Health History - ANSWER - Focuses on questions related to the client's personal history - Childhood illnesses and immunizations to date - Previous health problems, adult hospitalizations, illnesses (physical, emotional, and mental) and then explored - Pregnancies or births - Past surgeries, injuries, or accidents - Prolonged episodes of pain or pain patterns - Allergies and use of prescription and OTC medications Written documentation that specifies medical treatment for a competent patient should the patient become unable to make decisions; also called a living will or health care directive. - ANSWER advance directive Specific type of advance directive, refrain from CPR if there is no sign of breathing or no heartbeat, does not mean withholding of other medical treatments - ANSWER Do Not Resuscitate (DNR) Type of advance directive, guide decisions about care provided or withheld under certain circumstances, must be competent to initiate and can change or revoke at any time, must be incompetent to activate, applies only to situations where person is considered terminally ill, scope and details differ from state to state - ANSWER Living Will Specific to end of life care, ensure that patient preferences are known and honored in all health care settings and situations, addresses questions about treatment at end of life - ANSWER Physician Orders for Life-Sustaining Treatment (POLST) -Who you want to make care decisions for you when you cannot make them -What kind of medical treatment you want or do not want -The level of comfort you want -How you want people to treat you -What you want your loved ones to know - ANSWER Five Wishes Document intentionally causing physical harm to another person - ANSWER physical abuse the actual or threatened physical intrusion of a sexual nature, whether by force or under unequal or coercive conditions - ANSWER sexual abuse a pattern of attacking another person's emotional development and sense of worth - ANSWER emotional abuse the unauthorized, illegal, or improper use of an individual's funds, assets, or property for someone else's personal gain or advantage - ANSWER finance and material exploitation fail to care for properly - ANSWER neglect Leaving a patient after care has been initiated and before the patient has been transferred to someone with equal or greater medical training. - ANSWER abandonment a person's behaviors and way of living that threaten his or her health, safety, and well-being (unique to gerontological population) - ANSWER self-neglect What are 3 causes/risks of abuse? - ANSWER -vulnerability -social isolation and lack of social support -dementia, depression, and mental illness overwhelming exhaustion and frustration experienced by persons who must continually care for someone who is old or ill - ANSWER caregiver stress -Lack of abuse prevention policies -Insufficient staff screening -Inadequate staff education and training -Staff shortages and turnover -Characteristics of residents - ANSWER risk factors of abuse in nursing homes Who are the 4 main perpetrators of abuse? - ANSWER -caregivers -other residents -visitors -family What are 5 consequences of abuse? - ANSWER -Physical injuries -Emotional distress -Social effects -Increased risk of admission to long term care -Shorter life expectancy Nurses are _____ ________. - ANSWER mandatory reporters -Priority is safety -Early identification and treatment -Appropriate training for caregivers -family/caregiver support, counseling -Social services referrals - ANSWER Abuse Interventions A federal program of health insurance for persons 65 years of age and older - ANSWER medicare coverage for inpatient hospital care, limited SNF or home health care - ANSWER Part A of Medicare (ACUTE) medical insurance coverage - doctors' appointments, diagnostics, therapies, some equipment and supplies - ANSWER Part B of Medicare (BACKYARD) medication coverage (must have Part A and/or Part B) - ANSWER Part D of Medicare (DRUGS) usually obtained through employer - ANSWER private insurance purchase insurance on competitive market - ANSWER ACA out of pocket payment - ANSWER private pay insurance A federal and state assistance program that pays for health care services for people who cannot afford them. - ANSWER medicaid Medicaid allows a maximum of _________ in assets. - ANSWER $2,000 federal program of disability and retirement benefits that covers most working people - ANSWER social security A number of different settings exist for older adults, depending on _________ needs and level of _________ and _________. - ANSWER healthcare, independence, insurance ADLS = - ANSWER activities of daily living IADLS = - ANSWER instrumental activities of daily living 24-hour skilled care for short-term illnesses or injuries, lose the health promotion/prevention aspect - ANSWER acute care What are 5 goals of nursing care in the acute setting? - ANSWER -maximize independence -enhance functioning -promote safety -involve family -assess baseline function What's an example of an acute care setting? - ANSWER hospital What are 8 options for care after acute care? - ANSWER -Subacute care -Rehabilitation -Assisted living -Special care units (EX: dementia) -Skilled nursing facility -Home care -Home (with community resources) -Home (independent) NICHE = - ANSWER nurses improving care for healthsystem elders ACE = - ANSWER acute care for elderly the presence of one or more diseases at the same time - ANSWER comorbidity Patients are stable, don't need daily physician visits Services such as: rehab, IV therapy, TPN, respiratory care, wound management - ANSWER subacute care What are 4 examples of subacute care? - ANSWER -skilled nursing facilities -specialized hospital units -long term care hospitals -recovery units at surgery centers Goal: rehab and return to original place of residence; therapy services - ANSWER rehabilitation units In a rehab unit, if the patient is not making progress, insurance stops covering. - ANSWER true Rehabilitation units can be located in... (3 places) - ANSWER -hospital -subacute care -skilled nursing facility (SNF) a supportive living arrangement for people who need assistance with ADLs or IADLs but who are not so impaired physically or cognitively that they need 24-hour care - ANSWER Assisted Living Facilities What are 3 examples of assisted living options? - ANSWER -community based residential facility -adult family home -residential care apartment complex Place where 5 or more unrelated people live together in a community setting - ANSWER community based residential facility What are 2 common complaints about vision in older adults? - ANSWER -floaters and flashers -dry eyes Opacity of the normally clear lens which may develop as a result of aging, metabolic disorders, trauma, or heredity, only treatment is surgery - ANSWER cataracts Family Health History - ANSWER - Include maternal and paternal grandparents, aunts and uncles on both sides, parents, siblings, and the client's children Ask about significant family history such as: - ANSWER - Heart disease, high blood pressure Stroke - Diabetes - Obesity - Cancers - Arthritis - Allergies - Alcohol or drug addiction - Mental illness - Seizure disorders Review of systems - ANSWER Skin, hair, nails, head, neck, eyes, ears, mouth, nose, sinuses, thorax, lungs, breasts, regional lymphatics, heart, neck vessels, peripheral vascular, abdomen, genitalia, anus, rectum, prostate, musculoskeletal, neurologic Lifestyle and Health practices - ANSWER - Description of typical day - Nutrition and weight management - 24-hour dietary intake - Who purchases and prepares meals - Activity on a typical day and exercise habits and patterns - Rest and sleep habits and patterns - Medication and substance use (alcohol drugs illicit drugs, etc) - Self concept and self care responsibilities - Social activities - Relationships - Values and belief systems - Past, present, and future education and work - Type of work, level or job satisfaction, work stressors - Stress levels and coping strategies - Residency, environment, neighborhood, environmental risks Objective data - ANSWER Information that is measurable and observable. Based on facts Classify Objective Data - ANSWER - vital signs - physical observations - diagnostic imaging - lab tests What are ways in which the mother can avoid heartburn? - ANSWER -Good posture -Avoid spicy foods -Eat small meals At how many weeks can you see the fetus on an ultrasound? - ANSWER 6 weeks What is the "mask of pregnancy" called? - ANSWER Cholasma What is linea nigra? - ANSWER a hyperpigmented line on the abdomen from the symphysis pubis to the top of the fundus What are stretch marks called? - ANSWER Striae gravidarum What are respiratory changes in the mother? - ANSWER -Nasal congestion/ nose bleeding due to elevated estrogen levels -RR increases What are ways to help nausea and vomiting? - ANSWER -Vitamin b6 - Ginger -Eat dry carbs first thing upon rising -Eat small frequent meals -Good posture By what week should nausea and vomiting be gone? - ANSWER Week 14 What is the effect of prolactin on the body? - ANSWER Milk production What is the effect of Estrogen on the body? - ANSWER Purpose is for growth of the fetus -Increase blood flow to the uterus -Softens the cervix -Develops the breast in prep for lactation What is the effect of Progesterone on the body? - ANSWER Smooth muscle relaxer What are things to teach the mother during pregnancy? - ANSWER -No changing of cat litter -May take a tub bath unless they have a ROM -Should not eat raw meats What is lightning? - ANSWER The dropping of the baby into the pelvis, occurs at 36 weeks What is quickening? - ANSWER the initial awareness of mother usually occurs at 16-22 weeks What is HpL? - ANSWER An insulin antagonist. It increases blood glucose in pregnancy What is HcG? - ANSWER It maintains the corpus luteum until the placenta is functional. The hormone used on a pregnancy test. proper assessment techniques - ANSWER - inspection - palpation - percussion - auscultation inspection - ANSWER - Room at comfortable temperature - Good lighting - Look and observe being touching - Completely expose part being examined while draping the rest or client as appropriate - Note characteristics - Compare appearance palpation - ANSWER - Light, moderate, deep, and bimanual palpation - use of hands to feel and assess percussion - ANSWER - Eliciting pain - Determining location, size, and shape - Determining density - Detecting abnormal masses - Eliciting reflexes auscultation - ANSWER - Eliminate distracting noise - Expose the body part being auscultated - Diaphragm, high pitched sounds; bell, low-pitched sounds palpation uses the hands to feel for - ANSWER - Texture (rough/smooth) - Temperature (warm/cold) - Moisture (dry/wet) - Mobility (fixed/movable/still/vibrating) - Consistency (hard/soft/fluid/filled) - Strength of pulses (strong/weak/thready/bounding) - Size (small/medium/large) - Shape (well defined/irregular) - Degree of tenderness Standard Precautions - ANSWER - hand hygiene - gloves - mask and protective eyewear - gown Blunt Percussion - ANSWER to strike the area with a blunt object (typically the heel of the hand) to assess the underlying organs for tenderness Direct Percussion - ANSWER a medical technique where a healthcare provider directly taps on a patient's body part with their fingers, without using an intermediary object, to assess the underlying tissue by the sound produced; essentially Indirect or Mediate Percussion - ANSWER a technique that involves striking a punch-like object with a hammer or percussor. It can also refer to a physical examination technique used to assess the resonance of the body. Percussive sounds - ANSWER - resonance - hyperresonance - tympany - dullness - flatness Validating data - ANSWER Allows the nurse to verify that subjective and objective data are reliable and accurate What are 4 respiratory changes with aging? - ANSWER -Decreased respiratory muscle strength; stiffer chest wall -Diminished ciliary and macrophage activity, drier mucus membranes -Decreased cough reflex (Increased risk of aspiration) -Decreased lung capacity What are 5 changes in the skin of the older adult? - ANSWER -Decreased thickness, elasticity -Dry skin (xerosis) - causes pruritus -Decreased vascular supply to skin and glands - decreased sweating -Decreased sensation -Decreased subcutaneous fat - affect body's cooling system As they age, hair increased in ears, nose, eyebrows. 80% lose hair by age 60 - ANSWER men As they age, hair increases on chin and face due to hormonal influences. - ANSWER women brittle, flat, pigment changes - ANSWER nails caused by blockage LOCATION: end of toes, tops of feet, lateral ankle region APPEARANCE: very little drainage, little tissue granulation - ANSWER arterial ulcers caused by blood pooling, wear stockings LOCATION: medial parts of lower legs, medial ankle region APPEARANCE: swollen with drainage, granulations present, irregular edges, shallow - ANSWER venous ulcers What 2 tests are used to assess pressure injuries? - ANSWER -Norton Risk Assessment Scale -Braden Scale Are incontinence and falls normal parts of aging? - ANSWER NO OBRA = - ANSWER Omnibus Budget Reconciliation Act of 1987 a series of federal laws that established significant changes to Medicare, Medicaid, and other healthcare programs, These regulations aim to improve the quality of life for nursing home residents by mandating comprehensive assessments, personal care plans, and specific rights for residents - ANSWER OBRA According to OBRA staffing laws, an LPN must be present ____, RN __ hrs/day __ days/week minimum - ANSWER 24/7, 8, 7 protects residents in care facilities - ANSWER Resident Bill of Rights What is the normal temperature range for newborns? - ANSWER 36.6-37.5°C (97.7-99.5°F). What indicates dehydration in a newborn's fontanelles? - ANSWER Sunken fontanelles. What is caput succedaneum? - ANSWER Localized edema from the birthing process that can cross suture lines. What does a bulging fontanelle indicate? - ANSWER Increased intracranial pressure. What is the minimum age for a circumcision to be performed? - ANSWER At least 12 hours of age. What is the proper care for the umbilical cord? - ANSWER Keep it exposed, not submerged in water, and monitor for bleeding or discharge. What is the safest sleep position for a newborn? - ANSWER On their back. What is the risk associated with pre-term infants? - ANSWER High risk for respiratory distress and infection. What is a sign of a post-term infant? - ANSWER Dry, cracked, peeling skin. What is spina bifida? - ANSWER An abnormality in the spinal cord, with varying severity. What is shoulder dystocia? - ANSWER When the baby's shoulder gets stuck in the mother's pelvis during birth. What is the first action if a newborn is turning blue? - ANSWER Always suction the mouth first, then the nose. What should be done if a newborn has a score of 7 or less on the APGAR? - ANSWER Another assessment is done in 10 minutes. What is the purpose of erythromycin ointment given to newborns? - ANSWER To prevent transmission of gonorrhea and/or chlamydia. What is the normal heart rate range for newborns? - ANSWER 120-160 bpm. What is the Babinski reflex? - ANSWER Toes fan outward when the sole of the foot is stroked, abnormal after age one. What is the tonic neck reflex? - ANSWER When the baby's head is turned to one side, the arm on that side extends forward. What is the expected number of wet diapers for a newborn per day? - ANSWER 6-10 wet diapers. What should be monitored during circumcision post-care? - ANSWER Watch for bleeding and note the first post-op void. Nursing Process = - ANSWER -assessment -diagnosis -plan -implementation -evaluation After assessment figure out what problem is and implement ___________. - ANSWER interventions what the body does to the drugs - ANSWER pharmacokinetic changes what the drug does to the body - ANSWER pharmacodynamic changes Steps of validation - ANSWER - Deciding whether data requires validation - Determining ways to validate the data - Identifying areas where data are missing Cesarean Section - ANSWER Delivery of infant through abdominal incision -Horizontal (bikini cut) - transverse (they must ALWAYS have a c-section) -Hx of uterine rupture must always have repeat c-section They are primary or elective Cultural considerations r/t labor - ANSWER Some women may be very stoic. Fathers may or may not be present May prefer alternate positioning for delivery such as squatting May prefer or request female caregiver Duration of contractions - ANSWER from the beginning of a contraction to the end of the same contraction Frequency - ANSWER from the beginning of one contraction to the beginning of the next contraction intesity - ANSWER strength of the contraction What requires Validation? - ANSWER - Discrepancies between subjective and objective data - Discrepancies between what is reported by the patient at multiple times - Abnormal or inconsistent findings Purposes for Documentation - ANSWER - Provides a chronologic source or client assessment data - establishes a baseline and trends - Provides a vehicle for communication - Acts as a source or information to help diagnose new problems - Determine the educational needs of the client, family, and significant others - Reimbursement - Constitutes a permanent legal record of the care that was or was not given to the client - "If it wasn't documented, it wasn't done!" - Forms a component of client acuity system to determine staffing mix on the unit - Provides access to significant epidemiologic data for research - Complies with legal, accreditation, reimbursement, and professional standard requirements Principles of Documenting Data - ANSWER - Confidentiality - Legibly in non erasable ink - Use correct grammar and spelling - Avoid wordiness that creates redundancy - Use phrases instead of sentences to record data - Record findings, not how they were obtained - Write entries objectively without making judgment - Record the client's understanding and perception of problems - Avoid recording the word "normal" - Record complete information - Support objective data with observations Assessment forms for documentation - ANSWER - intial assessment form - freqent or ongoing assessment form initial assessment form - ANSWER nursing admission or admission database frequent or ongoing assessment form - ANSWER flow charts that help staff to record and retrieve data for frequent reassessments Critical thinking - ANSWER how nurses process information using knowledge, past experiences, intuition, and cognitive abilities Questions to Determine your critical thinking skills - ANSWER - Do you reserve your final opinion or judgment until you have collected more or all of the information? - Do you support your opinion or comments with supporting data, sound rationale, and literature? - Do you explore and consider alternatives before making a decision? - Can you distinguish between a fact, opinion, or inference? - Do you ask your client for more information or clarification when you do not understand? - Do you validate your information and judgments with experts in the field? - Do you use your past knowledge and experiences to analyze data? - Do you try to avoid biases or preconceived ways of thinking? - Do you try to learn from past mistakes in your judgments? - Are you open to the fact that you may not always be right? Characteristics of Critical Thinking - ANSWER - Keep an open mind - Use rationale to support opinions or decisions - Reflect on thoughts before reaching a conclusion - Use past clinical experiences to build knowledge - Acquire an adequate knowledge base that continues to build - Be aware of the interactions of other - Be aware of the environment Steps of Critical Thinking - ANSWER Step one: Identify strengths (supportive cues) and abnormal data (problem cues) Step two: cluster data Step three: Draw inferences Step four: Propose possible nursing diagnoses Step five: Check for defining characteristics Step six: Confirm or rule out diagnosis Step seven: Document conclusions AIDET - ANSWER acknowledge, introduce, duration, explanation, thank you abnormalities to note - ANSWER Skin color, dress, hygiene, posture and gait, physical development, body build, apparent age, gender general survey - ANSWER - skin color - dress - hygiene - posture - gait - physical development - body built - apparent age - gender - LOC - behaviors - movements - facial expressions -speech - vitals Tachycardia - ANSWER Fast heart rate (HR greater than 100bpm) Bradycardia - ANSWER slow heart rate (less than 60 bpm) hyperventilation - ANSWER the condition of taking abnormally fast, deep breaths (greater than 20 breaths per minute) Dyspnea - ANSWER difficult or labored breathing blood pressure (normal) - ANSWER systolic: less than 120 diastolic: less than 80 Hypotension - ANSWER low blood pressure Hypertension - ANSWER high blood pressure Stage 1 hypertension - ANSWER Systolic: 140-159 Diastolic: 90-99 stage 2 hypertension - ANSWER Systolic: greater than 160 Diastolic: greater than 100 hypertensive crisis - ANSWER Systolic: greater than 180 Diastolic: greater than 120 Order of Vital signs - ANSWER - temperature - pulse - respiration - blood pressure - pain Oral temp - ANSWER 96.6-99.5 F Axillary temp - ANSWER 95.6-98.5 F Temporal temp - ANSWER 97.4-100.3 F Tympanic temp - ANSWER 98.0-100.9 F orthostatic hypotension - ANSWER drop of 20+ mmHg in BP from standing factors that affect vital signs - ANSWER - age - caffeine consumption - if cold or hot drink was consumed within 15 minutes prior - if smoked within 30 minutes prior - What is a risk for an ectopic pregnancy? - ANSWER Hemorrhage What should the mother do after the removal of a molar pregnancy? - ANSWER She should use protection for one year. Mother can get cancer at the time and it is detrimental to the fetus if she should get pregnant. What is considered a "term" pregnacy? - ANSWER 37-42 weeks What is considered a "preterm" pregnancy? - ANSWER 20- less than 37 weeks What is a viable pregnancy? - ANSWER Ability to live outside of the uterus: 22-24 weeks What is Vena Cava syndrome? - ANSWER Dizziness related to the fetus pressing on the inferior vena cava. Re position the patient on her left side What is gestational diabetes? - ANSWER Insulin needs decrease in the first trimester and increase in the second and third. Baby can be born macrosomic meaning larger than 9 lbs Describe pregnancy induced Hypertension - ANSWER Systolic is 30mg above baseline. Swollen hands and edema What is placenta previa? - ANSWER Abnormal implantation of the placenta in the lower uterus. No pain but bright vaginal bleeding. When does labor begin? - ANSWER With the first uterine contraction. What are the different ways that uterine contractions are assessed? - ANSWER -Frequency -Intensity -Duration -Effacement Examples of true labor - ANSWER -Regular contractions -Pain starts in back and radiates to abdomen -Cervical changes -Interval between contractions gets smaller Examples of false labor - ANSWER -Irregular contractions -Discomfort localized in the abdomen -No change in the cervix In which situations would you not give oxytocin? - ANSWER -Breech position -Placenta previa -Maternal cardiac disease What will be monitored on a patient who was just given an epidural? - ANSWER Monitor for hypotension VEAL/CHOP - ANSWER Variable = Cord compression Early = Head compression Accelerations = Ok Late = Placental insufficiency Can the rubella vaccine be given during pregnancy? - ANSWER No: it is a live vaccine What is it called when the cervix are sewed up due to an incompetent cervix? - ANSWER Cerclage What is the drug of choice for preeclampsia? - ANSWER Mag Sulfate What needs to be monitored when a patient is on Mag sulfate? - ANSWER RR, reflexes, and LOC What are the signs and symptoms of preeclampsia? - ANSWER Elevated BP and proteinuria. May cause decreased profusion to the placenta Latent phase - ANSWER 3cm of dilation. Contractions are about 3-30 minutes apart and last about 30-40 seconds. Active phase - ANSWER 4-7cm of dilation. Contractions are about 2-5min apart and last about 40-60 seconds. What is jaundice in newborns? - ANSWER A condition characterized by yellowing of the skin, sclera, and mucous membranes, typically mild and self-limiting. What is the treatment for severe jaundice in newborns? - ANSWER Phototherapy, which involves exposing the baby to UV light to break down bilirubin. What is meconium? - ANSWER The first stool of a newborn, composed of amniotic fluid, shed mucosal cells, and intestinal secretions. What does transitional stool look like in newborns? - ANSWER It has a yellow mustard seedy appearance and varies based on whether the baby is breast-fed or formula-fed. How does early feeding affect bilirubin levels in newborns? - ANSWER Babies fed sooner after birth will have lower levels of bilirubin more quickly. What is the role of the lymphatic system in newborn respiratory adaptation? - ANSWER It helps remove remaining fluid from the lungs after birth. What is the impact of elevated respiratory rate in newborns? - ANSWER It can indicate that fluid is being removed too slowly from the lungs. What is the significance of skin-to-skin contact after birth? - ANSWER It is the best way to aid in thermoregulation for the newborn. What are the four types of heat loss in newborns? - ANSWER Conduction, convection, evaporation, and radiation. What is the function of the ductus venosus in fetal life? - ANSWER It allows blood to bypass the liver; it becomes a ligament after birth. What happens to the umbilical vein after birth? - ANSWER It constricts and becomes a ligament as blood flow decreases. What is the effect of increased oxygen levels after the first breath? - ANSWER It leads to an increase in systemic vascular resistance and decreases vena cava return. What can happen if jaundice is left untreated in newborns? - ANSWER It can lead to encephalopathy and permanent brain damage. What is the color and texture of formula-fed stool? - ANSWER Tan or yellow in color and firmer. How long can IgG antibodies from the mother last in a newborn? - ANSWER Up to 6 months. What is the primary immunoglobulin passed through breast milk? - ANSWER IgA. What is the most developed sense in newborns at birth? - ANSWER Hearing. What reflex is triggered when a baby is on the mother's chest and smells breast milk? - ANSWER Rooting reflex. When is the APGAR score assessed after birth? - ANSWER At 1 minute and 5 minutes after birth. What does an APGAR score of 8-10 indicate? - ANSWER No further interventions are needed. What medication is given to newborns for clotting? - ANSWER Vitamin K. Transition phase - ANSWER 8-10cm of dilation. Contractions are about 1.5-2 minutes apart and last about 60-90 seconds. When is "POOF" done? - ANSWER Late decelerations What are the 4 stages of labor? - ANSWER 1. Labor 2. Birth 3. Expulsion of placenta 4. Family/Newborn interaction COLDSPA - ANSWER - Characteristics - Onset - Location - Duration - Severity - Pattern - Associated factors Pain in older adults - ANSWER common but NOT normal pain - ANSWER - whatever the patient says it is - unpleasant sensory and emotional experience which we primarily associate with tissue damage or describe in terms of such damage, or both neuropathic pain - ANSWER initiated or caused by a primary lesion or disease in the somatosensory nervous system prejudices, stereotypes, and assumptions based on age - ANSWER ageism Aging is mostly viewed ________. - ANSWER negatively What are 3 effects of ageism and age stereotypes? - ANSWER -poor health outcomes -psychological distress -discrimination blame age for health conditions - ANSWER age attribution the concept of older adults remaining in their current homes and communities as they age (highly encouraged) - ANSWER aging in place We want people to "age in place" for as long as possible. - ANSWER true someone who supports or promotes the needs and interests of another person - ANSWER ombudsman What are the 4 ethical guiding principles? - ANSWER -autonomy -beneficence -nonmaleficence -justice loss of autonomy = loss of _________ - ANSWER freedom -Understand and process information -Understand risks versus benefits and apply personal values -Communicate decision to others - ANSWER requirements for autonomy What are 6 ways nurses can help support patient autonomy? - ANSWER -Recognize the influence of differing religious and culturally based beliefs and personal values -Decision-making capacity should not be determined by chronologic age or a particular diagnosis -Decision-making capacity can fluctuate -Assess person's ability to understand issues -Provide evidence-based information -Support individual and caregivers What's a nurse's role for a patient with cataracts? - ANSWER pre- and post-op teaching a group of eye diseases that damage the optic nerve, which connects the eye to the brain, treated by medicines that decrease the fluid in eye and increase fluid that drains out of eye - ANSWER glaucoma Retina detaches from choroid layer of eye - leads to blindness - ANSWER retinal detachment Eye disorders are NOT a normal part of aging. - ANSWER true Changes in pigmented cells in the retina and macula d/t aging, Loss of fine vision, central visual acuity - ANSWER macular degeneration to systematically gather comprehensive patient data to identify needs, inform nursing diagnoses, developed personalized care plans, and monitor treatment effectiveness - ANSWER purpose of assessments -Commonly have one or more chronic conditions and acute issues -Manifestation of illness or adverse medication effect tends to be obscure, less predictable -Change in function caused by combination of issues -Treatment directed at symptoms not source of problem -Cognitive impairments affect accurate reporting -Myths and misunderstandings interfere with treatment - ANSWER assessment complexity -Differentiation of normal aging vs. disease -Sensory deficits -Anxiety -Reduced energy level -Pain -Tendency to reminisce - ANSWER challenges with assessment What are the 3 main components of assessment? - ANSWER -interview and health history -physical assessments -specific assessments Some assessment methods are screening tools to determine need for further ______ and _______. - ANSWER referral, assessment SPICES = - ANSWER -Sleep disorders -Problems with eating or feeding -Incontinence -Confusion -Evidence of falls -Skin breakdown Determine individual ability at baseline, need for assistance/resources, and interventions for maximizing health and functioning (environmental, physical, psychological, socio-economical) - ANSWER functional assessment evaluates essential daily functions such as personal hygiene, dressing, eating, mobility, toileting, and sometimes communication and instrumental activities like managing finances or medication. - ANSWER Cleveland Scale for Activities of Daily Living What 2 tests give you a score to help determine if an individual is a fall risk? - ANSWER Katz Index, Lawton-Brody IADL ability to use telephone, shopping, food preparation, housekeeping, laundry, mode of transportation, responsibility for own medication, ability to handle finances - ANSWER Lawton-Brody IADL bathing, dressing, toileting, transferring, continence, feeding - ANSWER Katz Index an evidence-based tool used in acute care settings to quickly identify hospitalized adults at risk of falling by assessing factors like confusion, dizziness, gender, depression, and medications - ANSWER Heinrich II Fall Risk Model What are 6 general changes with aging? - ANSWER -Decreased antibodies -slower healing -Reduced immunity -Lean body mass declines and body water is lost -Temperature regulation issues -Risk of hypo and hyperthermia d/t decreased shivering, slow metabolism, decreased sweating, decreased perception of hot and cold What are 7 changes in digestion and nutrition with aging? - ANSWER -Changes in dental health -Decreased taste buds and salivary secretions (results in eating less, adding salt) -Decreased digestive juices -Slower peristalsis - GERD -Decreased absorption of nutrients Constipation is not a normal part of aging -Incidence of gallstones increases - decrease bile salt synthesis -Increased potential for malnutrition Constipation is a normal part of aging. - ANSWER false What are 5 cardiovascular changes with aging? - ANSWER -Arterial wall thickening and stiffening -Left ventricular and atrial hypertrophy -Sclerosis of atrial and mitral valves -Strong arterial pulses, diminished peripheral pulses, cool extremities -Decreased cardiac reserve and efficiency nociceptive pain - ANSWER normal response to noxious injury to tissues such as skin, muscles, visceral organs, joints, tendons, or bones inflammatory pain - ANSWER result of activation and sensitization of the nociceptive pain pathway by a variety of mediators released at a site of tissue damage acute pain - ANSWER - short term - usually associated with a specific injury - predictable beginning and ending - stops when injury heals - self protective: warns of impending injury chronic pain - ANSWER - long term - usually associated with a specific cause or injury - described as constant - does not step when injury heals examples of acute pain - ANSWER surgery, injury, birth examples of chronic pain - ANSWER arthritis, fibriomyalgia pain descriptors - ANSWER - Cutaneous - Visceral - Deep somatic - Radiating - Referred - Phantom - Neuropathic - Nociceptive - Inflammatory Dimensions of pain - ANSWER - Physical - Sensory - Behavioral - Sociocultural - Cognitive - Affective - Spiritual QUESTT - ANSWER -Question the child -Use pain rating scales -Evaluate behavior and physiological changes -Secure the parents' involvement -Take cause of pain into account -Take action and evaluate results Pain scales - ANSWER charts used to measure a patients pain intensity level Face scale - ANSWER the most common pain scale used with children. Numerical scale - ANSWER rates pain from 0-10 Subjective Data related to pain - ANSWER - pain level - pain description - location of pain - (essentially just COLDSPA) Objective data related tp pain - ANSWER - physical assessment - posture - facial expression - skin integrity - vital signs - grimacing - agitation - diaphoresis - bracing - sighing - change in sleep or appetite Subjective Data related to pain – ANSWER What are some services provided at a community based residential facility? (4) - ANSWER -room and board -supervision -support services -up to 3 hours of nursing care per week Place where 3 or 4 adults live who are not related to the operator reside and receive care - ANSWER adult family home What are some services provided at an adult family home? (2) - ANSWER -above level of room and board -up to 7 hours per week of nursing care per resident Independent apartment units - ANSWER residential care apartment complex What are some services provided at an a residential care apartment complex? (3) - ANSWER -room and board -up to 28 hours/week of supportive care -nursing services a type of nursing home that provides the most intensive nursing care available outside of a hospital - ANSWER skilled nursing facility Decision to move into SNF depends on individual's physical/cognitive ____, ____ system, and community _______. - ANSWER needs, support, resources ongoing, comprehensive assessment of resident, focusing on functional abilities - ANSWER resident assessment instrument -Can be multiple services or just a few -Number of visits covered by Medicare or other private insurance plans -Person must be homebound -Must have physician's statement supporting the need - ANSWER home care Does medicare pay for... -24 hour a day care at your home -Meals delivered to your home -Homemaker services (like shopping and cleaning) that are not related to care plan -Custodial or personal care that helps you with daily living activities (like bathing, dressing, or using bathroom), when this is the only care you need - ANSWER NO What are the 2 main functions of ears? - ANSWER -hearing -equilibrium Hearing declines ____ % ages 65-74, ____ % ages 75-84, and ____% for those over 85. - ANSWER 25, 33, 50 Loss of hearing is often correlated with worsening ________ ability. - ANSWER intellectual Problems in the ear are often due to disorders of _________. - ANSWER equilibrium problem with sound transmission from external through middle ear, cerumen impaction, otitis media - ANSWER conductive hearing loss inner ear, auditory nerve, brainstem - ANSWER sensorineural hearing loss affects both sensorineural and conductive - ANSWER mixed hearing loss gradual age-related decline in hearing - ANSWER presbycusis fluid in middle ear - ANSWER otitis media swimmer's ear, affects external ear canal - ANSWER otitis externa earwax builds up and blocks ear canal - ANSWER cerumen impaction ringing in hear - ANSWER tinnitus Ringing in the ear is NOT a normal part of aging. - ANSWER true implement effective communication strategies by establishing the patient's preferred communication method, minimizing background noise, speaking clearly and slowly, and using visual aids like communication boards - ANSWER nursing intervention for hearing loss Older adults (and all people) should be careful with the use of _______. - ANSWER Q-tips There are lots of _____ _____ in the eyes. - ANSWER blood vessels transparent, refracts incoming light rays - ANSWER cornea white of eye, maintains shape - ANSWER sclera layer of blood vessels - ANSWER choroid light sensitive membrane - ANSWER retina colored area - ANSWER iris dark spot in middle - ANSWER pupil controlled by muscles to bring things into focus for retina - ANSWER lens ____ and ____ work together to open and close to adjust to incoming light. - ANSWER pupil, lens What are 9 vision changes typical in older adults? - ANSWER -Eyelids - loss of tone (ptosis) -Conjunctiva thins, yellows, dryness -Sclera - brown spots -Cornea yellows, ring of fat deposits (arcus senilis) -Decreased pupil size -Decreased focus on close objects (presbyopia) -Clouding, yellowed lenses -Decreased ability to see changes with colors (lens yellows, so red, orange and yellow are easiest to see) -Decreased peripheral vision farsighted (hard to see up close) - ANSWER hyperopia nearsighted (hard to see far away) - ANSWER myopia weak muscles in eye - ANSWER strabismus