Nursing 3 Exam 1 Study Guide Questions With Complete
Solutions
Acupressure Correct Answers is similar to acupuncture in its
application and effect. The difference is that rather than using
fine, solid needles to stimulate acupuncture points, the
practitioner uses consistent and firm pressure from fingers or
other devices.
Antiemetic armbands applied to specific acupuncture points on
the wrist have been found to be effective in decreasing nausea
both during pregnancy and chemotherapy.
Acupuncture Correct Answers involves a group of procedures
where thin, solid metallic needles are manipulated by the hand
or electrical stimulation when inserted into different anatomical
points on the body.
In traditional Chinese medicine, the needles assist in promoting
the flow of qi or chi (vital energy) along pathways known as
meridians.
Acupuncture is typically performed in weekly or biweekly
treatments. Nurses can refer appropriate patients to acupuncture
practioners.
Acute Phase of burn injury Correct Answers Time Period:
Begins 36-48 hours after injury, lasts until wound closure is
complete
Goals:
,Main nursing priorities are to assess the respiratory and
cardiovascular system and maintain function as well as identify
and prevent potential complications. Examples are pneumonia,
risk for infection, and sepsis.
Nursing Diagnosis:
Acute pain
Disturbed body image
Impaired skin integrity
Risk for ineffective airway clearance
Fear/Anxiety
Risk for imbalanced nutrition
Assessment:
A neuroendocrine assessment is very important because burn
victims have increased metabolic demands. Weight patient daily
without dressings and note weight loss/gain. A 2% weight loss
Is a mild deficit, and a 10% loss of weight is serious and the
caloric needs must be reassessed. Assess immune function
because patient is at risk for infection from impaired skin
integrity. Monitor for signs of infection. Assess neuromuscular
function because patient is at risk for complications of
immobility. Conduct active and passive ROM for all joints. Pay
special attention to the area of the burn and note the limitations
of each joint. Conduct an ongoing assessment for pain.
Interventions:
Focus on skin integrity, wound healing, and preventing further
complications. This can be achieved by wound debridement,
wound dressings that enhance the healing process, wound
,excision, wound covering through skin grafts, and infection
prevention protocols such as enforcing hand washing.
Acute phase priority problems Correct Answers During the
acute phase of the burn injury, the patient may have initial
problems that extend into the acute phase and may develop new
problems. The priority collaborative problems for patients with
burn injuries greater than 25% TBSA in the acute phase of
recovery include:
1. Wound care management due to impaired TISSUE
INTEGRITY associated with burn injury and skin grafting
procedures
2. Potential for infection of open burn wounds due to the
presence of multiple invasive catheters, reduced immune
function, and poor NUTRITION
3. Weight loss due to increased metabolic rate, reduced calorie
intake, and increased urinary nitrogen losses
4. Decreased MOBILITY due to open burn wounds, pain, scars,
and contractures
5. Decreased self-esteem due to trauma, changes in physical
appearance and lifestyle, and alterations in sensory and motor
function
Addiction: Correct Answers A physiological or psychological
dependence on a drug
-compulsive, habitual need
, Adjuvant Medications: Correct Answers Medications that are
not primarily indicated for treatment of pain, but are used to
augment pain relief medications
Adjuvant medications include antidepressants, anticonvulsants,
and corticosteroids. These drugs are particularly effective for
patients experiencing neuropathic pain in which the nerves
themselves are damaged or injured
Administration Methods: Correct Answers rectal, transdermal,
nasal, intraspinal, intravenous (IV), and subcutaneous methods
of administration
Administrative review of staff and system performance Correct
Answers -analyze hospital/agency response while still fresh
-What went right & wrong
-Involves representatives from all groups involved
Advance directives Correct Answers Written documents that
allow a person to stat, in advance specific decisions about how
he or she wants his or her own health care managed if he or she
becomes incapacitated and is unable to communicate.
Alleviation of s/e Correct Answers IVF, pain meds,
antidiarrheals, dietary changes, steroid foam to remove rectal
inflammation and irritation
Alternative medical systems Correct Answers complete
systems of theory and practice/independent of conventional
approach.
Solutions
Acupressure Correct Answers is similar to acupuncture in its
application and effect. The difference is that rather than using
fine, solid needles to stimulate acupuncture points, the
practitioner uses consistent and firm pressure from fingers or
other devices.
Antiemetic armbands applied to specific acupuncture points on
the wrist have been found to be effective in decreasing nausea
both during pregnancy and chemotherapy.
Acupuncture Correct Answers involves a group of procedures
where thin, solid metallic needles are manipulated by the hand
or electrical stimulation when inserted into different anatomical
points on the body.
In traditional Chinese medicine, the needles assist in promoting
the flow of qi or chi (vital energy) along pathways known as
meridians.
Acupuncture is typically performed in weekly or biweekly
treatments. Nurses can refer appropriate patients to acupuncture
practioners.
Acute Phase of burn injury Correct Answers Time Period:
Begins 36-48 hours after injury, lasts until wound closure is
complete
Goals:
,Main nursing priorities are to assess the respiratory and
cardiovascular system and maintain function as well as identify
and prevent potential complications. Examples are pneumonia,
risk for infection, and sepsis.
Nursing Diagnosis:
Acute pain
Disturbed body image
Impaired skin integrity
Risk for ineffective airway clearance
Fear/Anxiety
Risk for imbalanced nutrition
Assessment:
A neuroendocrine assessment is very important because burn
victims have increased metabolic demands. Weight patient daily
without dressings and note weight loss/gain. A 2% weight loss
Is a mild deficit, and a 10% loss of weight is serious and the
caloric needs must be reassessed. Assess immune function
because patient is at risk for infection from impaired skin
integrity. Monitor for signs of infection. Assess neuromuscular
function because patient is at risk for complications of
immobility. Conduct active and passive ROM for all joints. Pay
special attention to the area of the burn and note the limitations
of each joint. Conduct an ongoing assessment for pain.
Interventions:
Focus on skin integrity, wound healing, and preventing further
complications. This can be achieved by wound debridement,
wound dressings that enhance the healing process, wound
,excision, wound covering through skin grafts, and infection
prevention protocols such as enforcing hand washing.
Acute phase priority problems Correct Answers During the
acute phase of the burn injury, the patient may have initial
problems that extend into the acute phase and may develop new
problems. The priority collaborative problems for patients with
burn injuries greater than 25% TBSA in the acute phase of
recovery include:
1. Wound care management due to impaired TISSUE
INTEGRITY associated with burn injury and skin grafting
procedures
2. Potential for infection of open burn wounds due to the
presence of multiple invasive catheters, reduced immune
function, and poor NUTRITION
3. Weight loss due to increased metabolic rate, reduced calorie
intake, and increased urinary nitrogen losses
4. Decreased MOBILITY due to open burn wounds, pain, scars,
and contractures
5. Decreased self-esteem due to trauma, changes in physical
appearance and lifestyle, and alterations in sensory and motor
function
Addiction: Correct Answers A physiological or psychological
dependence on a drug
-compulsive, habitual need
, Adjuvant Medications: Correct Answers Medications that are
not primarily indicated for treatment of pain, but are used to
augment pain relief medications
Adjuvant medications include antidepressants, anticonvulsants,
and corticosteroids. These drugs are particularly effective for
patients experiencing neuropathic pain in which the nerves
themselves are damaged or injured
Administration Methods: Correct Answers rectal, transdermal,
nasal, intraspinal, intravenous (IV), and subcutaneous methods
of administration
Administrative review of staff and system performance Correct
Answers -analyze hospital/agency response while still fresh
-What went right & wrong
-Involves representatives from all groups involved
Advance directives Correct Answers Written documents that
allow a person to stat, in advance specific decisions about how
he or she wants his or her own health care managed if he or she
becomes incapacitated and is unable to communicate.
Alleviation of s/e Correct Answers IVF, pain meds,
antidiarrheals, dietary changes, steroid foam to remove rectal
inflammation and irritation
Alternative medical systems Correct Answers complete
systems of theory and practice/independent of conventional
approach.
