Denial (defense mechanism) - ANSWER psychoanalytic defense mechanism by
which people refuse to believe or even to perceive painful realities.
A woman whose husband died a year ago still speaks of him in the present tense
and keeps his wardrobe in the closet.
What type of defense mechanism is she displaying? - ANSWER denial
Rationalization (defense mechanism) - ANSWER Unconsciously making excuses
or formulate logical reasons to justifying unacceptable feelings or behaviors.
A student who did not study for an examination blames his failure on he teacher's
poor lecture material and the unfairness of the examination. What type of defense
mechanism is the student displaying? - ANSWER rationalization
Displacement - ANSWER discharging intense feelings for one person onto
another object or person who is less threatening, thereby satisfying an impulse
with a substitute object.
A child who has been scolded by her other hits her doll with a hairbrush. What
type of defense mechanism is the child displaying? - ANSWER Displacement
blood culture and sensitivity - ANSWER blood specimen incubated to check for
bacterial growth
culture and sensitivity - ANSWER test performed to determine which antibiotic is
most effective against the bacteria.
When are sensitivity test results available? - ANSWER 48 to 72 hours after the
culture
What type of results would you report in a sensitivity test? - ANSWER 1. resistant
2. susceptible
3. intermediate resistance
Sepsis in the Home Environment: what do you do with contaminated dressings? -
ANSWER secure contaminated dressings and other disposable supplies in
plastic zip-closure bags before disposal.
Sepsis in the Home Environment: what do you do with contaminated linens with
blood or body secretions? - ANSWER Place contaminated linens in a sealed
plastic bag until laundered. DO NOT launder with regular family laundry.
,what are the four stages of infection? - ANSWER 1. incubation period
2. prodromal period
3. illness period
4. convalescence period
incubation period - ANSWER the period between exposure to an infection and the
appearance of the first symptoms
What stage of infection do localized and systemic signs and symptoms appear? -
ANSWER -illness period
-signs and symptoms can include: fever, headache, rash, swollen lymph nodes,
leukocytosis, diarrhea and vomiting
What is the convalescent period? - ANSWER recovery period; symptoms begin to
subside and it extends until the patient has returned to a normal state of health
Asepsis - ANSWER the practice of making the environment and objects free of
microorganisms
medical asepsis - ANSWER practices designed to reduce the number and transfer
of pathogens; synonym for clean technique
surgical asepsis - ANSWER -practices that render and keep objects and areas
free from microorganisms
-involves sterilization of all instruments and inanimate equipment that invade the
body and for wound care.
-sterile technique
example of medical asepsis - ANSWER -hand washing
-insertion of an NG tube
Example of surgical asepsis - ANSWER -administering injections
-administering IV therapy
-changing wound dressings
-performing urinary catherization
Nursing actions to promote patient safety - ANSWER -keep the bed in the low
position if not giving direct care
-lock the bed wheels to prevent the bed from rolling when the patient attempts to
get in or out
-answer call lights quickly so that the patient learns to trust you and does not feel
the need to get up without you
Major risk factors for a pressure injury - ANSWER -immobility
-inactivity
, -moisture
-malnutrition
-advanced age
-altered sensory perception
-lowered mental awareness
-friction and shear
contributing risk factors for a pressure injury - ANSWER -dehydration
-obesity
-edema
stage 1 pressure injury - ANSWER -An area of intact skin that is red, deep pink, or
mottled skin
-does not blanch with fingertip pressure
stage 2 pressure injury - ANSWER -partial thickness skin loss with exposed
dermis
-may appear as ruptured blister
stage 3 pressure injury - ANSWER -full thickness loss
-looks like deep crater extend to fascia
-subtaneous tissue damaged/necrotic fat visible
-undermining/tunneling may be present
stage 4 pressure injury - ANSWER -full-thickness skin loss with extensive tissue
necrosis or damage to muscle or bone
-the injury may appear black, necrotic tissue(eschar)
unstageable pressure injury - ANSWER -loss full thickness
-base injury covered in eschar ( tan, brown, black) in wound bed
When should you not take an oral temperature? - ANSWER When the patient has:
-smoked
-chewed gum
-consumed hot/cold beverages.
How long should you wait to take an oral temp is the patient consumed a hot or
cold beverage, smoked or recently chewed gum? - ANSWER wait 15 to 30
minutes
Rectal temperatures should not be used for - ANSWER -cardiac patients
-patients who have had rectal surgery
What should you do if the pedal pulses are weak or unequal? - ANSWER check
pulse with a Doppler stethoscope
which people refuse to believe or even to perceive painful realities.
A woman whose husband died a year ago still speaks of him in the present tense
and keeps his wardrobe in the closet.
What type of defense mechanism is she displaying? - ANSWER denial
Rationalization (defense mechanism) - ANSWER Unconsciously making excuses
or formulate logical reasons to justifying unacceptable feelings or behaviors.
A student who did not study for an examination blames his failure on he teacher's
poor lecture material and the unfairness of the examination. What type of defense
mechanism is the student displaying? - ANSWER rationalization
Displacement - ANSWER discharging intense feelings for one person onto
another object or person who is less threatening, thereby satisfying an impulse
with a substitute object.
A child who has been scolded by her other hits her doll with a hairbrush. What
type of defense mechanism is the child displaying? - ANSWER Displacement
blood culture and sensitivity - ANSWER blood specimen incubated to check for
bacterial growth
culture and sensitivity - ANSWER test performed to determine which antibiotic is
most effective against the bacteria.
When are sensitivity test results available? - ANSWER 48 to 72 hours after the
culture
What type of results would you report in a sensitivity test? - ANSWER 1. resistant
2. susceptible
3. intermediate resistance
Sepsis in the Home Environment: what do you do with contaminated dressings? -
ANSWER secure contaminated dressings and other disposable supplies in
plastic zip-closure bags before disposal.
Sepsis in the Home Environment: what do you do with contaminated linens with
blood or body secretions? - ANSWER Place contaminated linens in a sealed
plastic bag until laundered. DO NOT launder with regular family laundry.
,what are the four stages of infection? - ANSWER 1. incubation period
2. prodromal period
3. illness period
4. convalescence period
incubation period - ANSWER the period between exposure to an infection and the
appearance of the first symptoms
What stage of infection do localized and systemic signs and symptoms appear? -
ANSWER -illness period
-signs and symptoms can include: fever, headache, rash, swollen lymph nodes,
leukocytosis, diarrhea and vomiting
What is the convalescent period? - ANSWER recovery period; symptoms begin to
subside and it extends until the patient has returned to a normal state of health
Asepsis - ANSWER the practice of making the environment and objects free of
microorganisms
medical asepsis - ANSWER practices designed to reduce the number and transfer
of pathogens; synonym for clean technique
surgical asepsis - ANSWER -practices that render and keep objects and areas
free from microorganisms
-involves sterilization of all instruments and inanimate equipment that invade the
body and for wound care.
-sterile technique
example of medical asepsis - ANSWER -hand washing
-insertion of an NG tube
Example of surgical asepsis - ANSWER -administering injections
-administering IV therapy
-changing wound dressings
-performing urinary catherization
Nursing actions to promote patient safety - ANSWER -keep the bed in the low
position if not giving direct care
-lock the bed wheels to prevent the bed from rolling when the patient attempts to
get in or out
-answer call lights quickly so that the patient learns to trust you and does not feel
the need to get up without you
Major risk factors for a pressure injury - ANSWER -immobility
-inactivity
, -moisture
-malnutrition
-advanced age
-altered sensory perception
-lowered mental awareness
-friction and shear
contributing risk factors for a pressure injury - ANSWER -dehydration
-obesity
-edema
stage 1 pressure injury - ANSWER -An area of intact skin that is red, deep pink, or
mottled skin
-does not blanch with fingertip pressure
stage 2 pressure injury - ANSWER -partial thickness skin loss with exposed
dermis
-may appear as ruptured blister
stage 3 pressure injury - ANSWER -full thickness loss
-looks like deep crater extend to fascia
-subtaneous tissue damaged/necrotic fat visible
-undermining/tunneling may be present
stage 4 pressure injury - ANSWER -full-thickness skin loss with extensive tissue
necrosis or damage to muscle or bone
-the injury may appear black, necrotic tissue(eschar)
unstageable pressure injury - ANSWER -loss full thickness
-base injury covered in eschar ( tan, brown, black) in wound bed
When should you not take an oral temperature? - ANSWER When the patient has:
-smoked
-chewed gum
-consumed hot/cold beverages.
How long should you wait to take an oral temp is the patient consumed a hot or
cold beverage, smoked or recently chewed gum? - ANSWER wait 15 to 30
minutes
Rectal temperatures should not be used for - ANSWER -cardiac patients
-patients who have had rectal surgery
What should you do if the pedal pulses are weak or unequal? - ANSWER check
pulse with a Doppler stethoscope
