Ameritech Nursing essentials exam # 2 (Questions + Answers) Solved

ACTUAL NURSING DIAGNOSIS - Represents problem that has ;been validated but the presence of defining characteristics includes Problem r/t and aeb Antigen vs anitbody - Antigen is a foreign material that the antibody responds to components of infection cycle - infectious agent portal of exit means of transmission portal of entry susceptible host- must overcome resistance mounted by host defenses concerns and responsibilities of nursing - -recognize s/s of common health problems -predict problems in those at risk and take steps to manage risks and prevent complications -identifying human responses and promoting optimum function, independence and quality of life -initiating actions and referrals in a timely way to ensure appropriate qualified treatment. ex full diet but pt coughs when drinking. tell dr. describe Complex wound - everything (road surfing patient) describe endogenous - describe exogenous - describe full thickness wound - into the sub-q and below describe HAI -describe iatrogenic - describe nosocomial - describe objective data - Observable and measurable data that can be seen, heard, or felt by someone other that the person experiencing them, could include family member. EX: high temp, skin moisture, vomiting, ALL vital signs. Homelessness when physically manifested, ie dirty, smelly