nursing 205 exam 2 hondros questions and answers 2023

nursing 205 exam 2 hondros questions and answers 2023 tissue integrity the ability of body tissues to regenerate and/or repair to maintain normal physiological processes interventions to maintain tissue integrity reposition turning adequate nutrition skin assessments blanching test A test of the rate of capillary refill; blanching means to cause to become pale by applying digital pressure. Non-blanchable skins stay very red even with finger pressure; indicates severe skin injury Stage 1 pressure ulcer intact skin with nonblanchable redness stage 2 pressure ulcer partial thickness skin loss involving epidermis, dermis, or both red/pink noist blister et shallow crater stage 3 pressure ulcer full thickness tissue loss with visible fat stage 4 pressure ulcer Full-thickness tissue loss with exposed bone, muscle, or tendon debridement Removal of foreign matter or dead tissue from a wound promotes healing eschar a thick layer of dead tissue and tissue fluid that develops over a deep burn area Types of drainage serous, sanguineous, serosanguineous, purulent serous drainage clear, watery fluid clear yellow serosanguineous drainage thin, watery drainage that is blood-tinged sanguineous drainage bloody drainage purulent drainage thick green, yellow, or brown drainage Braden Scale A tool for predicting pressure ulcer risk lactose intolerance The inability to completely digest the milk sugar lactose symptoms of lactose intolerance bloating, abdominal discomfort, diarrhea gas clear liquid diet a diet that consists of foods that are liquid at room temperature and leave little residue in the intestine. Ex: Water, Sprite, Ginger Ale, all beverages without any residue, broth, Jello iron rich foods red Meat, fish, poultry, legumes. spinach, liver or organ meat, tofu anorexia nervosa An eating disorder characterized by an obstinate and willful refusal to eat, a distorted body image, and an intense fear of being fat signs of anorexia nervosa A refusal to keep one's body weight at or above a normal weight for age and height; extreme weight loss, muscle wasting, eats very little insufficient nutrition excessive nutrition common obesity weight gain/ nutritional toxicity excessive calorie intake FICA spiritual assessment tool F in FICA faith I in FICA importance C in FICA community A in FICA address questions to assess spiritual needs do you attend religious regularly do you have Any spiritual needs we should discuss in need of spiritual intervention call chaplain Prayer An attempt to contact God, usually through words Faith Belief in God dietary needs food can only come from? facility no outside food communication with non speaking English use interpretive services *never use family members Jehovah's Witness no blood products if you hear a patient real about a tribal healer ask about medication and medication frequency culture competence first assess own biases attitude transcultural perspective concept attributes culture learned changed and adapted shared beliefs values et behaviors concept attributes spirituality universal impacted by illness impacted by family and culture Chinese to american may avoid eye contact nurses responsibility to make sure patient understands ask for pat to verbalize back info or ask a question of they understand Erickson stages intimacy vs isolation age group 20 to 25 years love sense of the complexity of relationship value of tenderness and loving freely fear or being alone developmental needs for elderly social gathering reminiscing 2 types of fatigue mental and psychological mental fatigue can be caused by continual mental effort and attention on a particular task, as well as high levels of stress or emotion. It typically manifests itself as a lack of mental clarity, concentration difficulties, sleepiness and, in some cases, memory loss. psychological fatigue a stress response causing mental & emotional impact of exhaustion causing a lack of motivation and inability to concentrate imbalance of exercise sleep and diet illness not eating attributes to fatigue generalized weakness easy fatigability reduce capacity to maintain performance mental fatigue impaired concentration loss of memory et emotional stability focused assessment assessment conducted to assess a specific problem; focuses on pertinent history and body regions Order of Assessment Inspection, Palpation, Percussion and Ausculation. EXCEPT with abdomen cuz you don't wanna mess with the bowels