NURS 1871 <Ans> Fundamentals of Nursing FINAL EXAM REVIEW
1. What is the nursing process <Ans> ADPIE
Assess <Ans>
gather information about the patient's condition
Diagnose
identify the patient's problems
Plan
Plan care and desired outcomes and identify appropriate nursing actions
Implement
perform the nursing actions identified in Planning
Evaluate
determine if goals and expected outcomes are achieved
2. Subjective data <Ans> patients' verbal descriptions of their health problems
patient feelings, perceptions, and self-reported symptoms
3. Objective data <Ans> Findings resulting from
direct observation
When you collect objective data, apply
critical thinking intellectual standards so that you can correctly interpret your find- in
4. PQRST <Ans> Palliative
Quality
,Region
Severity
Time
5. SBAR <Ans>
Situation
Background
Assessment
,Recommendation
6. Wheal <Ans> an irregularly shaped, superficial localized edema that varies
and is caused by a hive or mosquito bite
7. Papule <Ans> a palpable, solid elevation in the skin like an elevated nevus
8. Macule <Ans> a flat, nonpalpable change in skin color like freckles or petechiae
9. Petechiae <Ans> pinpoint, round spots that appear on the skin as a result of
bleeding
10. Pustule <Ans> a circumscribed elevation on the skin that is filled with pus and
may be caused by a staphylococcal infection or acne
11. Papilla <Ans> small rounded protuberance on a
part or organ of the body
12. Factors that contribute to pressure injuries <Ans> - Impaired sensory
perception
- Alteration in LOC
- Shear
- Friction
- Moisture
- Nutrition
- Impaired mobility
- Tissue perfusion
- Infection
- Age
- Psychosocial impact of wounds
- Poor circulation
, - Other disease processes
13. Stage 1 <Ans> non-blanchable erythema of intact skin <Ans> keep area dry,
turn pt more frequently, transparent dressing
14. Stage 2 <Ans> Partial-thickness skin loss with exposed dermis <Ans> no
epidermis, mo drainage, blister, barrier cream, zinc oxide, moisture risk, hydrocolloid
15. Stage 3 <Ans> Full-thickness skin loss <Ans> full-thickness but no slough or
eschar, can see subcutaneous tissue
16. Stage 4 <Ans> Pressure-injury that has full-thickness skin and tissue loss
<Ans> clean wound, then get a culture, negative pressure to drain and increase
perfusion
17. Unstageable <Ans> Eschar and/or slough present <Ans> in this stage you
can't see the depth of the pressure ulcer
18. Deep tissue pressure injury <Ans> appears as a bruise, has potential to
open, non-blanchable <Ans> non blanchable, purple in color, starts at the
subcutaneous level, cause of this is chronic pressure
19. Intentional wound <Ans> created for therapy, i.e. surgical
20. Unintentional wound <Ans> resulting from trauma, i.e. fall
1. What is the nursing process <Ans> ADPIE
Assess <Ans>
gather information about the patient's condition
Diagnose
identify the patient's problems
Plan
Plan care and desired outcomes and identify appropriate nursing actions
Implement
perform the nursing actions identified in Planning
Evaluate
determine if goals and expected outcomes are achieved
2. Subjective data <Ans> patients' verbal descriptions of their health problems
patient feelings, perceptions, and self-reported symptoms
3. Objective data <Ans> Findings resulting from
direct observation
When you collect objective data, apply
critical thinking intellectual standards so that you can correctly interpret your find- in
4. PQRST <Ans> Palliative
Quality
,Region
Severity
Time
5. SBAR <Ans>
Situation
Background
Assessment
,Recommendation
6. Wheal <Ans> an irregularly shaped, superficial localized edema that varies
and is caused by a hive or mosquito bite
7. Papule <Ans> a palpable, solid elevation in the skin like an elevated nevus
8. Macule <Ans> a flat, nonpalpable change in skin color like freckles or petechiae
9. Petechiae <Ans> pinpoint, round spots that appear on the skin as a result of
bleeding
10. Pustule <Ans> a circumscribed elevation on the skin that is filled with pus and
may be caused by a staphylococcal infection or acne
11. Papilla <Ans> small rounded protuberance on a
part or organ of the body
12. Factors that contribute to pressure injuries <Ans> - Impaired sensory
perception
- Alteration in LOC
- Shear
- Friction
- Moisture
- Nutrition
- Impaired mobility
- Tissue perfusion
- Infection
- Age
- Psychosocial impact of wounds
- Poor circulation
, - Other disease processes
13. Stage 1 <Ans> non-blanchable erythema of intact skin <Ans> keep area dry,
turn pt more frequently, transparent dressing
14. Stage 2 <Ans> Partial-thickness skin loss with exposed dermis <Ans> no
epidermis, mo drainage, blister, barrier cream, zinc oxide, moisture risk, hydrocolloid
15. Stage 3 <Ans> Full-thickness skin loss <Ans> full-thickness but no slough or
eschar, can see subcutaneous tissue
16. Stage 4 <Ans> Pressure-injury that has full-thickness skin and tissue loss
<Ans> clean wound, then get a culture, negative pressure to drain and increase
perfusion
17. Unstageable <Ans> Eschar and/or slough present <Ans> in this stage you
can't see the depth of the pressure ulcer
18. Deep tissue pressure injury <Ans> appears as a bruise, has potential to
open, non-blanchable <Ans> non blanchable, purple in color, starts at the
subcutaneous level, cause of this is chronic pressure
19. Intentional wound <Ans> created for therapy, i.e. surgical
20. Unintentional wound <Ans> resulting from trauma, i.e. fall
