FUNDAMENTAL FOR NURSING STUDY TEST

FUNDAMENTAL FOR NURSING STUDY TEST Bone ( Ch. 18 , Pg. 268) - CORRECT ANSWER-A dense, hard type of connective tissue; 4 Basic Types of Bones- Short, Long, Flat, and Irregular; Made up of Compact and Spongy Bone Joint ( Ch. 18 , Pg. 268) - CORRECT ANSWER-A union of two or more bones in the body; Some move freely, some are slightly moveable, and some are immovable Bursa ( Ch. 18 , Pg. 268; AKA Bursae) - CORRECT ANSWER-Small Fluid-Filled Sacs that provide a cushion at the friction points in the joints Skeletal Muscles ( Ch. 18 , Pg. 268) - CORRECT ANSWER-striated muscles that are made of bundles of muscle fibers surrounded by a connective tissue sheath Tendons ( Ch. 18 , Pg. 268) - CORRECT ANSWER-Cords of Fibrous Connective Tissue that connect a muscle to a bone that connect a muscle to a joint movement Ligaments ( Ch. 18 , Pg. 268; Slide 5) - CORRECT ANSWER-Connect bones or cartilage to provide support and strength Cartilage ( Ch. 18 , Pg. 268; Slide 5) - CORRECT ANSWER-Fibrous Connective Tissue that acts as a Cushion Structures that are Involved in Positioning and Moving Patients ( Ch. 18 , Pg. 268; ) - CORRECT ANSWER-Bones, Joints, Bursae, Skeletal Muscles, Tendons Ligaments, an Cartilage Functions of Bones - CORRECT ANSWER-Provide a scaffolding to support the body; Give shape to the body and support the internal organs and skin; Provide Places for ligaments and tendons to attach and facilitate movement Functions of Muscles ( Ch. 18 , Pg. 268; Slide 7) - CORRECT ANSWER-produce movement, maintain posture, stabilize joints, generate heat, Can stretch; can be stimulated to contract electronically or to extend elastically Memorizes Photos of Figure 18.1 ad 18.2 - CORRECT ANSWERchanges occuring with in the musculoskeletal system ( Ch. 18 , Pg. 268 and 269; Slide 8) - CORRECT ANSWER-Bone mass loss may lead to osteoporosis ( more severe in women) ; Loss of bone density predisposes the elderly to fractures; Muscle Cells are lost and replaced by fat cells; Elasticity of muscle fibers is decreased, limiting flexibility; Joint motion may decrease limiting motion and mobility Principles of Body Movement for Nurses ( Ch.18 , Pg. 269, Slide 9 and 10) - CORRECT ANSWER-One of the most common injuries in health care workers is lower back strain; Get help whenever possible; ask patient to help if able ( two nurses moving a patient divides the work; it is better to wait for help than to risk injury); Use your leg muscles. Bend and Flex your knees ( Bend at the knees, not at the waist); Use the greatest number of muscles possible; use thigh, arm, or leg muscles rather than back muscles, and use a wide base of support; Keep feet approximately shoulder-width apart; Pull and pivot, using smooth, coordinated movements; avoid jerking or sudden pulling movements; Keep elbows and work closer to your body; Work at the same level or height as the object to be moved; Keep your trunk straight and do not twist when lifting or pulling; Use your arms as levers when pulling the patient towards you. Lock the elbows and rock back on your heels, using the weight of your body to move the patient. pivot ( Ch.18 , Pg. 271) - CORRECT ANSWER-turn or change direction with your feet while remaining in a fixed place Two Basic Principles of Body Movement ( Ch.18 , Pg. 271; Slide 13) - CORRECT ANSWER-1) Maintain Correct Anatomic Position ; 2) Change Position Frequently Hazards of improper alignment ( Ch.18 , Pg. 271, Slide 13) - CORRECT ANSWER- *Interference with circulation, which may lead to pressure ulcers *Muscle cramps and possible contractures *Fluid collection in lungs pressure injuries ( Ch.18 , Pg. 271) - CORRECT ANSWER-tissue injuries that form from local interference with circulation Contractures ( Ch.18 , Pg. 271) - CORRECT ANSWER-Resistance to stretch in damaged muscle that pulls a joint into a fixed or frozen position Memorize Figure 18.5 ( Slide 15) - CORRECT ANSWERPressure Ulcers ( Ch.18 , Pg. 271, Slide 16) - CORRECT ANSWER-AKA Pressure Injuries, Decubitus Ulcers, or bedsores - Occur when pressure on the skin causes an area of local tissue necrosis - Occur most often between bony prominence and an external surface - May be caused by shearin as force is applied downward and forward on tissue beneath the skin ( as when a patient slides down a chair) necrosis ( Ch.18 , Pg. 271) - CORRECT ANSWER-tissue death locally from disease or injury Shearing Force ( Ch.18 , Pg. 271) - CORRECT ANSWER-combination of friction and pressure When assessing the standing patient's body alignment.... ( Ch.18 , Pg. 271) - CORRECT ANSWER-...., begin by noting the head position in relation to the rest of the body. Symmetry ( Ch.18 , Pg. 271) - CORRECT ANSWER-Eqaulity in size, forn, and arrangement in parts of the opposite slides of a plane; a mirror image) Ambulate ( Ch.18 , Pg. 271) - CORRECT ANSWER-to walk gait ( Ch.18 , Pg. 271) - CORRECT ANSWER-style of walking Nursing Diagnoses for Problems of Body Movement - CORRECT ANSWER-Commonly used nursing diagnoses: - Risk for Injury - Impaired Physical Mobility - Risk for Impaired Skin Integrity - Impaired Walking Planning Stage for Problems of Body Movement ( Ch.18 , Pg. 272); Slide 18 - CORRECT ANSWER-- Decide how to change the patients position and whether you can delegate this task to assistive personnel - The home setting must also be considered when planning care for the patient Planning Stage for Problems of Body Movement: Goals and Expected Outcomes ( Ch.18 , Pg. 272); Slide 19 - CORRECT ANSWER-- Patient will experience no musculoskeletal injury - Former level of mobility will be reattained within 6 months - Skin integrity will remain intact while patient is on bed rest -Patient will not experience injury while ambulating - Patien should have full ROM exercise actively or passively performed several times a day. Implementation Stage for Problems of Body Movement: Positioning Planning Stage for Problems of Body Movement ( Ch.18 , Pg. 272); Slide 25 - CORRECT ANSWERAccomplishes 4 Objectives: 1) Positioning Provides Comfort 2) Positioning relieves pressure and other parts, decreasing the patients risk of developing bedsores 3) Positioning prevents contractures, deformities, and respiratory problems 4) Positioning improves circulation Common Positions and their Variations for Body Positioning Planning Stage for Problems of Body Movement: Supine ( Ch.18 , Pg. 272-3); Slide 26 - CORRECT ANSWER-- Patient lying on her back - Fowler's Position: Supine with the HOB elevated 60-90 degrees - Semi-Fowler's Position: Supine with the HOB elevated 30-60 degrees - Low Fowler's Position: Supine with the HOB elevated 15-30 degrees. - Dorsal Recumbent Position- Supine with Knees flexed and feet flat on the bed; used for many procedures and examinations - Dorsal Lithotomy Position- Feet in Stirrups and Legs spread farther apart; used in pelvic exams Common Positions and Variations: Side-Lying Lateral ( Ch.18, Pg. 273; Slide 31-33) - CORRECT ANSWER-- Patient Lying on her side: Alleviates pressure on bony prominences of the back - Oblique Side-Lying Position: Removes Pressure from the shoulder and hip; easier for patients - Sims Position: A variation used for rectal examination or insertions of tubes or suppositories Common Positions and Variations: Prone ( Ch.18; Pg.273; Slides 34 and 35) - CORRECT ANSWER-- Patient Lying Face-Down - Often used for patients with spinal cord injury - Not generally well tolerated; except oddly for patients with severe acute respiratory distress syndrome; can potentially be deadly for people with epilepsy - Knee-Chest Position - Face Down, with chest, knees, and elbows resting on the bed - Used for rectal examinations Common Positioning Devices ( Pg. 277; Ch.18 Slide 37 and 38 - CORRECT ANSWER- -Pillows- Used to support the body or extremities - Boots or Splints- Maintain dorsiflexion - Footboards, high-top sneakers: Maintain dorsiflexion - Trochanter Rolls- Prevent external rotation of leg -Trapeze, Side Rails, Bed Boards- Allows patient to adjust position by raising the trunk and buttocks off the bed. - Sandbags: Used to immobilize an extremity, provide support, and maintain body alignment - Hand Rolls: Help prevent contractures and prevent dorsiflexion of the wrist Moving Patient up the Bed ( Ch.18; Slide 39, Pg.277) - CORRECT ANSWER-- Using a lift sheet: Requires at least two people standing on opposite sides of the bed; Both face the bed and use the sheet to move the patient up the bed; Moving the patient is performed as a coordinated effort; Patient is lifted and moved, not dragged Logrolling ( Pg. 280, Ch.18, Pg. 280) - CORRECT ANSWER--Turning the patient as a single unit - Body alignment maintained at all times - Used to change bed linen, can be performed with or without a lift sheet - Requires two people if patient cannot turn herself Lifting and Transferring ( Ch.18) - CORRECT ANSWER-- Patients may transfer independently or require different levels of assistance - Always dangle a patient at bedside before transferring to a wheelchair, and observe for dizziness or nausea - Remember to lock the wheels on wheelchairs or gurneys before attempting to transfer a patient - Stretchers used for transporting a patient who is unable to sit on a wheelchair - Either lift equipment or two nurses should transfer a patient to a wheelchair if patient unsteady, weak, or heavy - Determine how much help you will need to move or transfer the patient - Get help whenever possible - Make sure wheels on beds, wheelchairs, and gurneys are locked - Use a transfer device when possible - Dangle the patient before ambulating - Use a gait belt when ambulating a patient Principles Guiding Range-of-Motion Exercise ( Ch.18, Pg. 281) - CORRECT ANSWER-- Move the body part and stretch the muscles and keep the joint flexible, but avoid movement to the point of discomfort - Perform ROM exercises of the joints of helpless or immovable patients at least twice a day, or more often if tolerated - Support the limb above and below the joint when performing passive exercises of arms and legs - Perform each movement a minimum of 3-5 times - Involve patients in planning their exercise program, and encourage active performance of the exercise if allowed and capability returns Transfer Devices - CORRECT ANSWER-- Pull or lift sheets - Mechanical lifts - Roller boards - Slide boards - Transfer or gait belts Structure of skin - CORRECT ANSWER-epidermis, dermis, hypodermis - Integumentary System- Skin, hair, nails - Sweat, and Sebaceous Glands: Skin- Largest organ of the body ( Two main layersEpidermis [AKA Stratum Corneum] and the Stratified Epithelial Tissue ( Melonocytes, which determine skin color; does not contain blood vessels) - Dermis integumentary system - CORRECT ANSWER-Consists of the skin, mucous membranes, hair, and nail Epidermis - CORRECT ANSWER--AKA Stratum Corneum Outer layer of skin; Part of the Structure of the Skin