NR 304 FINAL WORKSHEET

NR 304 Final Worksheet NR 304 FINAL WORKSHEET Questions: 1. Define subjective and objective data. Give three examples of each and state if the findings are documented in the history or physical examination findings. • Subjective Data what the person says about himself or herself during the physical examination; symptom is a subjective sensations that the person is feeling; o Examples: itching, pain, feelings of worry, nausea, depression, fatigue, anxiety, loneliness, etc. • Objective Data what the you as the health professional observe by inspecting, percussing, palpating, and auscultating during the physical examination; a sign is an objective abnormality that you as the examiner could detect on physical examination or in laboratory reports; observable and measurable; o Examples: blood pressure, discoloration of the skin, skin moisture, vomiting, temperature, weight, bleeding, blood cell count, etc. 2. List five actions a nurse should take when assessing a patient with a potentially critical hemodynamic state. Put your actions in priority order of 1-5. • Hemodynamic State instable blood pressure, which can lead to inadequate arterial blood flow to organs; heart failure. • Priority Actions: main goals for nurse are to evaluate the cardiac and circulatory function, as well as the response to any interventions. i. 3. What does the priority setting ABC mean? How does the nurse use this mnemonic in patient assessment? If a patient has a slow or rapid respiratory rate, is airway the primary concern? • A: airway. • B: breathing. • C: circulation. 4. What is HIPAA? Describe one situation when the nurse must adhere to HIPAA. • Health Insurance Portability and Accountability Act of 1996 (HIPAA) laws to improve efficiency in health care delivery by standardizing electronic data interchange and protection of confidentiality and security of health data by setting and enforcing standards; composed of 4 parts that have rules, which include: standards for electronic transactions, unique identifiers standards, the security rule, and the privacy rule. o Example: if patient isn’t able to give consent a spouse, relative, or a close friend can (but, the nurse must document it); 2 nurses assigned to the same patient can talk about the patient’s medical diagnosis in the patients private room; a nurse can give information about a patient over the phone if the patient gives permission to do so to that person; nurses can perform research as long as patient confidentiality is maintained at all times; 5. Describe the process of taking a pulse. What is a normal pulse? What are qualities of a normal pulse? What is the first action a nurse should take when the pulse is not as expected? • Normal Pulse 2+ bilaterally force; 60-100 beats per minute; 50-95 beats per minute in healthy individuals. o Qualities of A Normal Pulse rhythm should be regular, even tempo; symmetrical 2+ bilateral force; • Process of Taking A Pulse using the pads of your 1st 3 fingers, palpate the radial pulse @ the flexor aspect of the wrist laterally along the radius bone; if rhythm is regular, count the # of beats in 30 seconds and multiply by 2; if it’s irregular than count for a full minute; • 1ST Action if Pulse Is Not Expected 6. What is dehydration? List three subjective and three objective findings of dehydration. List the expected vital signs of a patient who is dehydrated. • Dehydration osmolar fluid loss of water, with no loss of electrolytes. o Subjective Findings:  thirst, dizziness, syncope, confusion, weakness, fatigue, nausea, o Objective Findings: dry, furrowed tongue, vomiting, weight loss, oliguria ( output of urine), distended bladder, sunken eyes, diminished capillary refill, diaphoresis, cool clammy skin, flattened neck veins,  urine specific gravity,  osmolality,  blood urea nitrogen (BUN),  electrolytes,  glucose,  serum sodium. • Expected Vital Signs of Dehydrations tachycardia, weak, thread pulse; hypotension, orthostatic hypotension,  central venous pressure; tachypnea ( respirations), hypoxia; hyperthermia 7. How is fluid volume deficit related to dehydration? How would concentrations of some solutes (solids) change with dehydration? Why? • Fluid Volume in dehydration, it is osmolar fluid loss, in which there is only a loss of water and there’s no loss of electrolytes. 8. What is an undesirable response of the body to a fever? • It can reset the thermostat of the brain @ a higher level, resulting in heat production and conservation. Why is this undesirable? What effect does it have? • It can result in an increased internal thermostat, which will mean that next time the tolerance of a fever will be higher and result in an increased heat production and increased heat conservation. 9. What is the most serious skin cancer? What is one risk factor for this cancer and one teaching item to address with your patient? Describe this most serious skin cancer below. • Most Serious Skin Cancer melanoma. o Risk Factors: fair skin, history of sunburn, excessive UV exposure, living closure to equator or @ a higher elevation, have many or unusual moles, family history of melanoma, weakened immune, etc. o Teaching Items To Address: protect your skin, limit your exposure to the sun, wear a heat or protective gear, wear sunscreen, check an unusual moles and always check on your moles to be able to note any differences, etc. 10. In dark skinned client, where is the best area to assess for jaundice (not skin or sclera)? Best place to assess for pallor? Best place to assess for cyanosis? • On Dark Skinned PT’s Where Would You Check For: o Jaundice best noted in the junction of hard and soft palate of the hands or feet, o Pallor: oral mucous membranes and the conjunctiva of the eye. o Cyanosis: oral mucous membranes and the conjunctiva of the eye. 11. To document pitting edema, the nurse measures the following depths of pitting. What is the corresponding scale (1+, 2+, 3+, 4+ ) for: • 2mm deep = 1+ • 4mm deep = 2+ • 6mm deep = 3+ • 8mm deep = 4+ 12. What is a body system complication for the client who is a chronic heavy drinker? Name 3 possible associated findings associated with this complication. • Body System Complication(s) for Heavy Drinkers liver disease, alcoholic liver disease, fatty liver, hepatitis, cirrhosis, pancreatitis, cancer, ulcer and gastrointestinal problems, immune system dysfunction, neurological damages, vitamin deficiencies, etc. • Possible Findings Associated With This Complication stomach ulcers, acid reflex, heartburn, gastritis, weakens your immune system and causes a decreased in WBCs, difficulty processing information BC it interferes with the brain receptors and neurotransmitters, as well as their cognitive function, malnourishment, anemia, tiredness, weakness, memory loss, etc. 13. It is important to encourage the elderly client to continue to be as active as possible. List five complications associated with the inability to move independently. • Complications Associated With Elderly Being Unable To Move Independently: a. Urinary System retention, stasis, renal calculi, incontinence, as well as UTI’s. b. Gastrointestinal Systemconstipation, impaction, and difficulty evacuating. c. Musculoskeletal System disuse osteoporosis, hypercalcemia, and fractures; joints can become stiff, painful, along w/impaired range of motion and contractures that include foot drop, which is a plantar flexion contracture; muscles can be weak and atrophy can result. d. Respiratory System thickening of respiratory secretions, the pooling of respiratory secretions, and an  inability of the client to mobilize and expectorate these secretions, all of which can lead to atelectasis, hypostatic pneumonia, and respiratory tract infections; can also lead to shallow, ineffective respirations,  movement, and a  in terms of the client’s vital capacity. e. Circulatory System venous stasis, venous dilation,  BP, edema, embolus formation, thrombophlebitis, and orthostatic hypotension, which is a risk factor also often associated w/client falls. f. Metabolic System  rate of metabolism, which can lead to unintended weight gain, a negative calcium balance secondary to the loss of calcium from the bones during immobilization, a negative nitrogen balance secondary to an  in terms of catabolic protein breakdown, and anorexia. g. Integumentary System skin breakdown, pressure ulcers, and poor skin turgor. h. Psychological Alterations apathy, isolation, frustration ,a lowered mood, as well as depression. 14. Describe fluid volume overload. List a possible cause of FVO. List three signs/symptoms of FVO. • Fluid Volume Overload (FVO) also known as hypervolemia, is a medical condition where there is too much fluid in the blood; the excess fluid is primarily salt and water, which builds up throughout the body resulting in weight gain; it’s expansion of the extracellular fluid volume, including the intravascular or interstitial space; • Possible Cause of FVO may be the product of compromised mechanisms for regulating water and sodium, as seen in congestive heart failure, hepatic failure, and renal failure; liver malfunction; inaccurate sodium and water retention include low protein sources, use of corticosteroids, glomerulonephritis, nephritic syndrome, nephropathy, hyperaldosteronism, and liver cirrhosis; too much intake of sodium and fluids; fluid shift into the intravascular space that may occur in response to fluid remobilization during burn therapy, as a result of giving albumin, and from mannitol or any hypertonic fluid administration. o S/S: SOB,  respiratory rate, both due to  in RBC’s,  pulses w/ bounding character stemmed from circulatory overload and concomitant elevation of cardiac contractility, labored breathing and difficulty of breathing caused by an  15. Describe fluid volume deficit. List a possible cause of FVD. List three signs/symptoms of FVD. • Fluid Volume Deficit (FVD) this refers to dehydration, water loss alone WITHOUT a change in the amount of sodium;  intravascular, interstitial, and/or intracellular fluid. • Possible Cause of FVD severe diarrhea, vomiting, fever, heat exposure, too much exercise, or work-related activity,  urination due to infection, diseases such as diabetes o S/S: not peeing or having very dark yellow pee, very dry skin, feeling dizzy, rapid heartbeat, rapid breathing, sunken eyes, sleepiness, lack of energy, confusion or irritability, fainting, etc. 16. Differentiate between oral candidiasis and leukoplakia. List one possible cause of each. • Oral Candidiasis a white, cheesy, curd-like patch on the buccal mucosa and tongue; it scrapes off, leaving a raw, red surface that bleeds easily; termed ‘Thrush’ in newborn; o Possible Causes: it is an opportunistic infection that occurs after the use of antibiotics and corticosteroids, as well as in immunosuppressed people. • Leukoplakia chalky white, thick, raised patch with well-defined borders; the lesion is firmly attached an does not scrape off; it may occur on the lateral edges of the tongue. o Possible Causes: due to chronic irritation and occurs w/heavy smoking and alcohol use; lesions are precancerous; must refer to specialist. 17. What is a common manifestation that an elderly client has an acute problem such as infection or stroke? • Elderly client’s tend to present with severe confusion when faced with certain problems, and it is important to be prepared to know the symptoms that may present.