NUR 222

Nurs 222 FINAL Exam Acute Pain - Correct Answer-Short term; symptoms appear abruptly, are intense, subside after relatively short period Chronic Pain - Correct Answer-Lasts more than 6 months, fluctuate between maximal functioning and serious relapses that are sometimes life threatening Remission - Correct Answer-Period of maximal functioning Exacerbation - Correct Answer-Symptoms are worse; may require hospitalization An exacerbation of a chronic disease - Correct Answer-Acute Illness (hospitalized) Altruism - Correct Answer-Concern for welfare and well being of others, advocate for patient, demonstrate respect for culture, beliefs, perspectives; selfless acts Autonomy - Correct Answer-Right to self determination, honors rights of patient and family, plan together, provide information; patients ultimately makes decisions Accountability - Correct Answer-Professionally and legally responsible for the type and quality of nursing care provided Human Dignity - Correct Answer-Respect for the work and uniqueness of patients and populations, culturally competent care, protect privacy and confidentiality, design care sensitive to needs Integrity - Correct Answer-Act within code of ethics and standards, honesty, accountability of own actions Social Justice - Correct Answer-Upholding moral and humanistic principles, universal access to healthcare, nondiscriminatory Cognitive - Correct Answer-The what; theory Technical - Correct Answer-The how; skills Interpersonal - Correct Answer-Communication Ethical/Legal - Correct Answer-How to stay in our practice; standards of practiced and nurse practice acts Primary Care - Correct Answer-Health promotion; focuses on keeping people healthy What does primary care do? - Correct Answer-- Assist with developing healthier lifestyles - Reduces cost of healthcare - Occurs in primary care settings - Pre-natal and well baby care Preventive Care - Correct Answer-Disease oriented What does preventive care do? - Correct Answer-- Focuses on reducing and controlling risk factors - Blood pressure and cancer screenings - Immunizations and diet counseling Diagnostic Label - Correct Answer-- The name of the nursing diagnosis as approved by NANDA International - Describes the essence of a patient's response to a health condition in as few words as possible Descriptor - Correct Answer-Linked with connecting phrase (Impaired, Compromised, Decreased, Delayed, Ineffective) Related Factor (R/T) - Correct Answer-The patient's assessment data; the reason the patient is displaying the nursing diagnosis Related Factor's 4 Categories - Correct Answer-1. Pathophysiological (biological or psychological) 2. Treatment-related 3. Situational (Environmental or personal) 4. Maturation S/T 1 - Correct Answer-Secondary to- surgical diagnosis (goes first) S/T 2 - Correct Answer-Secondary to- medical diagnoses As Evidenced By (AEB) - Correct Answer-Signs and symptoms that support the problem for problem, etiology, and symptoms ND Example - Correct Answer-(2-Ineffective) (1-Airway Clearance) (3- R/T excessive pulmonary secretions) (4- Surgery if this hospitalization) (5- S/T pneumonia) (6- AEB rhonchi, productive cough with green sputum, O2 sat 91% on 4 L/NC) Braden Scale: 6 Areas to Assess - Correct Answer-1. Sensory Perception 2. Moisture 3. Activity 4. Mobility 5. Nutrition 6. Friction and Shear Pronation - Correct Answer-Palm down Supination - Correct Answer-Palm up Rotation - Correct Answer-Head circular motion Flexion - Correct Answer-Bend Extension - Correct Answer-Straighten Medical Asepsis - Correct Answer-- Hand washing, donning clean gloves, cleaning environment and surfaces - Clean technique - Reduce and prevent the spread of microorganisms Surgical Asepsis - Correct Answer-- Surgical hand washing, and/or sterile gown, gloves, mask, sterilization of supplies - Sterile technique - Absence of all microorganisms Airborne Precautions - Correct Answer-- Used with organisms 5 microns or smaller spread through the air - Private room with negative air pressure - Keep room door closed - Use respiratory protective equipment - Transport only if necessary, patient wears surgical mask, watch closely - Organisms suspended in air for several hours - Transmitted through air currents or by individuals breathing in organisms in a room by coughing, talking, or singing - TB (tuberculosis), COVID - Respiratory protective equipment; need N95 mask which needs to be fit tested to each person Contact Precautions - Correct Answer-- Organisms transmitted by direct or indirect contact - Private room or with patients who have the same organism - Wear gloves and wash hands upon removal - Wear PPE when in contact with bodily secretions - Limit movement outside room - Most common precaution - Contact with skin, mucous membranes, clothing, bed rails, equipment, door knobs, watch pitchers, faucet handles, computers - Staph, herpes, MRSA (Methicillin Resistant Staph Aureus), VRE (Vancomycin Resistant Enterococci), C-difficile White Blood Cell Count Normal Values (WBC) - Correct Answer-- /mm (Text) - /mm (Lab) White Blood Cell Count (WBC) - Correct Answer-- Nonspecific blood tests; indicates presence of infectious agent - Elevations indicate bacterial, viral, or chronic, parasitic, allergic disorder, and severe infections WBC Differential - Correct Answer-Breaks down different types of leukocytes; more specific (basophils linked to allergic reaction, eosinophils linked to infections related to parasites, neutrophils are largest group) Sedimentation Rate (ESR) - Correct Answer-- Rate at which RBC's settle in unclotted blood - Elevations indicate inflammation/infection Culture and Sensitivity (C & S) - Correct Answer-Indicates organism present and guides treatment (choosing correct antibiotic) Health Care Acquired Infections (HAI) - Correct Answer-When patient develops an infection that was not present or incubating at the time of admission Community Acquired Infection - Correct Answer-Present at time of admission Types of Health Care Acquired Infections (HAI) - Correct Answer-- Hospital-acquired pneumonia (HAP) - Catheter-associated urinary tract infection (CAUTI) - Central line-associated bloodstream infection (CLABSI) - Surgical site infection (SSI) - Ventilator-associated pneumonia (VAP) Exogeneous - Correct Answer-Comes from microorganisms found outside the individual (salmonella, clostridium tetani) Endogeneous - Correct Answer-Occurs when part of patient's flora becomes altered and overgrown (e. coli, yeast, strep) Physiology - Correct Answer-Provides oxygen to tissues and removes carbon dioxide and waste products from the body Primary Function of the Lungs - Correct Answer-Ventilation and diffusion Primary Function of the Heart - Correct Answer-Perfusion Ventilation - Correct Answer-Movement of air in and out of the lungs Compliance - Correct Answer-Ability of the lungs to distend or expand in response to increased intraalveolar pressure; depends on elasticity of the lungs Diffusion - Correct Answer-Movement of gases between air spaces and the bloodstream Respiration - Correct Answer-Exchange of oxygen and carbon dioxide during cellular metabolism Perfusion - Correct Answer-Movement of blood into and out of the lungs to the organs and tissues of the body Conduction System - Correct Answer-Generates impulses that initiate electrical events for normal heartbeat Sinoatrial Node - Correct Answer-Primary pacemaker located where superior vena cava enters right atrium; initiates impulses conducted throughout the heart resulting in ventricular contraction (60-100 BPM) Atrioventricular Node - Correct Answer-Specialized muscle tissue located in the floor of the right atrium near interatrial septum; mediates the impulse transmission Bundle of HIS and Purkinje Fibers - Correct Answer-Ventricular conduction fibers EKG - Correct Answer-Electrical conduction measured on Circulatory System - Correct Answer-Disease processes that affect cardiac rate, rhythm, strength of contraction, blood flow through the chambers, myocardial blood flow, and peripheral circulation will all alter cardiac functioning Controllable Factors for Heart Disease - Correct Answer-Smoking Uncontrolled HTN Physical inactivity Obesity Uncontrolled DM Cholesterol levels Uncontrollable Factors for Heart Disease - Correct Answer-Male gender Older age Family history Post menopause Ethnicity Genetic disorders (high cholesterol, HTN) Systole - Correct Answer-Contraction phase; blood moves from ventricles into systemic circulation Diastole - Correct Answer-Relaxation phase; filling time Afterload - Correct Answer-Resistance of the ejection of blood from left ventricle Preload - Correct Answer-Amount of blood in the ventricles at the end of ventricular diastole Stroke Volume - Correct Answer-Amount of blood ejected from the ventricle with each contraction; normal is 50-75 mL per contraction Cardiac Output - Correct Answer-Amount of blood ejected from LV/minute; normal range is 4-6 liters/minute Calculated Cardiac Output - Correct Answer-Stroke volume x Heart rate Heart Rate Affects Blood Flow - Correct Answer-Filling time decreased with rapid heart rate Myocardial Contractility - Correct Answer-Ability of heart to squeeze blood from the ventricles and prepare for next contraction Decreased Cardiac Output - Correct Answer-- Failure of the myocardium to eject sufficient blood volume to the systemic and pulmonary circulations - Coronary artery disease (CAD), vascular disorders, cardiomyopathic conditions, conduction disorders, and pulmonary disease Myocardial Ischemia - Correct Answer-- Coronary artery supplies insufficient blood to myocardium - Results in chest pain, especially with activity (angina) Myocardial Infarction - Correct Answer-- Blood flow is completely blocked, the tissue becomes necrotic - Severe or crushing chest pain, jaw pain, left arm pain, breathlessness, diaphoresis, and hypotension (a fall in blood pressure) Stenosis (Valvular Heart Disease) - Correct Answer-Obstructed blood flow Regurgitation (Valvular Heart Disease) - Correct Answer-Backfloor of blood; can be acquired or congential Left-Sided Heart Failure - Correct Answer-- Impaired functioning of left ventricle; caused by increased preload (fluid volume overload) or increased afterload (HTN) - Once progresses, the amount of blood ejected drops (decreased cardiac output) - Pulmonary congestion; as a result you will note crackles on auscultation and patient complaints of fatigue, dyspnea, and orthopnea (difficulty of breathing while lying down) Right-Sided Heart Failure - Correct Answer-- Impaired right ventricle; caused by pulmonary disease or pulmonary HTN - Venous congestion in the systemic circulation, distended jugular veins and peripheral edema - May from untreated or end-stage left-sided heart failure Hypovalemia - Correct Answer-- Reduced circulating blood volume (blood loss from any problem) - Shock and severe dehydration Circulatory System - Correct Answer-With significant fluid loss, body will increase the heart rate and constrict peripheral vessels to improve cardiac output