Intro to Nursing - Exam 1 Questions and Answers 100% correct 2023

Intro to Nursing - Exam 1 Questions and Answers 100% correct 2023 The foundation of the nursing profession; is the systematic approach to problem-solving and providing individualized care? The Nursing Process The phases of the nursing process? Assessment, Diagnosis, Planning (includes Outcome), Implementation, Evaluation Brainpower Read More Previous Play Next Rewind 10 seconds Move forward 10 seconds Unmute 0:08 / 0:15 Full screen What is Assessment? Collection of data to help establish a goal of making a clinical nursing judgment. Difference between subjective and objective data? Subjective, from the client; Objective, from the nurse's senses. Difference between primary, secondary and tertiary sources? Primary, can only be the patient; Secondary, info from families, medical records, or other health care professionals; Tertiary, info from textbooks, nurse's and other health care team responses to patient What must be done by the nurse on admission to a health care facility? And what does it identify? In depth nursing history and physical assessment must be done and it identifies the patient's strengths and weakness/health problems. When does data collection take place? Through observations, interviews, physical assessment, and interpreting lab and diagnostic results. What is diagnosis? The clinical act of identifying problems using the assessment data collected. This step identifies an individual, family or group response to an actual or potential health problem. What is the nursing diagnosis based on? The pathophysiology of the disease process. Who established the list of nursing diagnosis for classifying nursing problems, standardizing language and facilitating communication for nurses? North American Nursing Diagnosis Association (NANDA) What is included in Outcome? Development of patient focused goals...included in the planning phase. What are the guidelines on making goals? Must be patient-focused, specific to the nursing diagnosis or patient problem, measurable, realistic and have time frame. What is involved in the Planning phase? Preparing the nursing care plan with patient input in how to identify goals and interventions to help with the identified problems. What is included in the Planning phase? Patient goals/outcomes specific to the problem, assessment, specific treatments (independent and dependent), medications, teaching, and community care. What is a Joint Commission on Accreditation of Healthcare Organizations (JACHO) requirement? The care plan is a written summary of the care that a patient is to receive. What is the action phase? Implementatio/Intervention Why are nursing actions goal oriented? To help the patient reach maximum health potential What is crucial in the implementation phase? Documentation What is determined in the Evaluation phase? The patient's reactions to nursing interventions and judging whether the goals of the plan of care were achieved. What is ongoing and continuous process performed throughout the process? Evaluation..."revised or reassessed" Vital signs are a __________ mechanism? Homeostatic What is an important component of assessment? It yields info about underlying health status What is included in vital signs? Temperature, Pulse, Respiration, Blood Pressure, Pain, Pulse Oximetry What are normal vital ranges, in adults? Pulse: 60-100; Respirations: 12-20; Temp: 97-99; Systolic: 90-120; Diastolic: 60-80 When do you assess vital signs? Upon admission, physician order, facility policy; before and after- surgery, diagnostic procedure, medication administration, nursing interventions, patient becomes symptomatic What produces heat in the body? Basal metabolism, muscle activity, hormones and cells (fever) What causes loss of heat in body? Radiation, conduction/convection, evaporation... 40% of heat is lost through head. What is included in core body temperature? Temp of deep body tissue: abdominal, chest, pelvic cavities, and cranium What is included in surface body temperature? Temp of skin, subcutaneous tissue, and fat What factors affect temperature? Age, environment, time of day, exercise, stress and hormones. (temp is lowest in am) What are the temperature sites? What is most inaccurate and most dangerous? Mouth (frenulum), axilla, rectum, ear, forehead. Most inaccurate is the axilla, most dangerous is rectum. Elevated body temperature? Hyperthermia Fever? (exceeds 99.6F) Pyrexia Decreased body temperature? Hypothermia Fever or elevated body temperature? Febrile No fever, normal range temperature Afebrile What are critical signs of hypothermia? Decreased body temp, decreased bp and urinary output What are clinical signs of pyrexia? 3 stages: Onset (tachy-cardia & pnea, feeling cold, chills), Course (no chills, glassy-eyed, warm skin, drowsy, delirium, possible convulsions), Defervescence (warm, flushed skin, sweating, decreased shivering, watch for dehydration) How do you report the temperature? In Farenheit. What are pulse characteristics? Rate: # per min; Rhythm: regularity; Quality: strength of pulsation What can affect pulse rate? Age, gender, exercise, autonomic nervous system, fever, medications, hemorrhage (hypovolemia), stress, position changes Thickening, hardening or loss of elasticity of arterial walls? Arteriosclerosis Narrowing of the interior of the artery due to build-up of: lipids, complex carbs, fibrous tissues, blood issues Atherosclerosis What are risk factors associated with pulse? High blood pressure, high cholesterol, obesity, smoking, stress, family history What does elevated pulse pressure tell you? indicative of arteriosclerosis, decreased cardiac output. What is normal pulse pressure? 30-40...<30 indicates decreased cardiac output. Low pulse pressure occurs with severe heart failure. Where are the pulse sites? From most common? Temporal, Carotid, Apical, Brachial, Radial, Femoral, Popliteal, Dorsalis pedis, Posterior tibial What is the most accurate site? Apical What are the processes of respiration? External-oxygen in, carbon dioxide out; Internal-use of oxygen, production of carbon dioxide, and cellular gas exchange What factors affect respiration? Age, gender, medications, stress, exercise, altitude Normal respiratory rate and rhythm? Eupnea Normal adult rate for respirations? 12-20 breaths/min Slower, but regular respirations? Bradypnea (can occur after certain meds or injury to the brain) Increased respiratory rate; rapid, shallow breaths? Tachypnea (not neurologic) Who should not get temperature taken via rectum? Patients with diarrhea, those that have had rectal surgery, rectal diseases, have cancer who are neutropenic Term meaning shortness of breath (SOB)? Dyspnea What is the condition where blood pressure is chronically elevated? What is the range? Hypertension; above 140/90 Blood pressure below 100/60 mm Hg? Hypotension When documenting vital signs you should: Watch for trends and report any abnormal findings to the physician. What are the phases of taking blood pressure? Phase 1 is the systolic pressure-first hear beating, Phase 2 and 3, Phase 4 is recorded as diastolic in children, Phase 5 is recorded as diastolic in adults...all part of the Korotkoff sounds Harsh inspiratory sound that may be compared to crowing; may indicate an upper airway obstruction Stridor High-pitched musical sound; partial obstruction of the bronchi or bronchioles, as in asthma Wheezing What equipment is used to monitor body temperature? Electronic thermometers, tympanic membrane thermometers, temporal artery thermometers, chemically treated paper thermometers. Glass mercury thermometers are no longer used.