NUR 3066 EXAM 1 CH 1-10 Questions & Answers

NUR 3066 EXAM 1 CH 1-10 Questions & Answers American Nurses ANA 4 broad goals 1. promote health 2. prevent illness 3. treat human responses health assessment tracks patient improvement is continuous Health Assessment includes Health history; physical assessment Additional necessary factors assessed Psychological; sociocultural; spiritual; economic; lifestyle nursing process begins with a complete and accurate health assessment ADPIE - Nursing Process Assessment Diagnosis Planning Implementation Evaluation Nontherapeutic Communication Techniques false reassurance, sympathy, distractions, etc preinteraction phase compiling existing data; preparing for patient interview from existing medical records beginning phase introduction; state purpose for interview working phase of interview -Data-gathering phase -Verbal skills include questions to patient and your responses to what is said closing phase summarizing, stating most important two to three problems or patterns inspection observing patient visually for general appearance or specific details palpation clinical touching of specific body areas to assess characteristics percussion tapping on a surface to determine the difference in the density of the underlying structure Auscultation using a stethoscope to assess movement of air or fluid within specific body systems deep palpation should not be performed on enlarged spleen inflamed appendix contact transmission of hep to pt is most common form of transmission because microorganisms from one pt is spread to another pt Quality Assurance The maintenance of a desired level of quality in a service or product, agency reviewing patient medical records can be used in civil or criminal court eMAR electronic medication administration record electronic patient medical records increases safety batch charting Waiting until the end of the shift to record events on several patients NOT GOOD general survey begins during interview phase of health assessment vital signs establishes a baseline bitch sinus arythmia when you note when heart rate increases in inspiration and decreases with expiration. Hypertention risk factors family history high cholesterol high triglycerides obesity smoking/alcohol renal disease stress gate control theory of pain body responds to pain by either: opening a neural gate to allow pain to be produced or creating a blocking effect at the synaptic junction to stop pain Steps in pain transmission 1. gate opens due to continued painful stimulus 2. pain passes from PNS to CNS 3. pain passes from spine to limbic system, cerebral cortex 4. stimulus is identified as pain, passes through efferent pathways: reaction created Nociception most common clinical interpretation of pain Four Steps of Nociception 1. Transduction 2. Transmission 3. Perception 4. Modulation transduction a stimuli which creates enough of an energy potential to cause a nerve impulse perceived by nociceptors (ex: free nerve endings) neuronal plasticity nervous system modification in pain transmission acute pain signals tissue damage visceral pain abdominal organs; "crampy, gnawing" somatic pain tissue, bones/joints; "sharp" cutaneous pain skin layers; "burning", "sharp" refered pain specific site, felt at different location (cardiac pain, phantom pain) Complex Regional Pain Syndrome (CRPS) surgery, crush-type Reassess pain every _____ for oral meds 1 hr Reassess pain every _____ for IV meds 30 min Carbohydrates Body's main source of energy protein glucose, O2, immune responses, cell structure; tissue maintenance especially for muscles; PROMOTES HEALING Lipds provide essential fatty acids; promote absorption of fat-soluble vitamins (A,D,E,K) Cholesterol essential for cellular maintenance and repair Phospolipids transport fat-soluble substances across cell membranes vitamins play a key role in metabolism of most nutrients alcohol intake can affect metabolism VITAMIN B AND K DEFICIENCY minerals iron, zinc, calcium cachexia highly catabolic state with accelerated muscle loss and a chronic inflammatory response -production of pro-inflammatory cytokines contributes to the breakdown of fat and muscle 24 hour recall most reliable when nurse charts intake on both weekdays and weekends measure nutritional status in infants and children to determine growth puberty marks the end of childhood Erickson's Model Attempts to explain psychosocial development Fixed sequence of stages that are roughly age-related Each stage poses a challenge, which must be mastered to move on Infant trust vs mistrust toddler autonomy vs shame and doubt preschooler initiative vs guilt school age industry vs inferiority adolescent identity vs role confusion early adulthood intimacy vs isolation middle adulthood generativity vs stagnation late adulthood integrity vs despair Piaget's Theory of Cognitive Development begins at birth, continues until adulthood *experience produce stage progression Infant: Piaget's Cognitive sensorimotor phase toddler piaget stage preoperational stage 2 egocentrism animism School Age Piaget Stage concrete operations 3