Nur 283 Comp 2 Final Exam Review Key Concepts and Procedures Latest Update
1. Negligence-failure to provide adequate care; unintentional tort
a. Failure to communicate concerns about elder client who is confused and is being discharged home is
an example of negligence
2. Slander- Spoken remarks that cause harm Gossip
3. Assault – threat by words; intentional; intentional tort
4. Battery- act of harm... “base ball bat”; intentional tort
5. Libel- written “library” remarks of harm; intentional
6. Delegation
a. UAP- medical intake, I & O, remind
i. Intervene SHOULD NOT= assisting client who has paracentesis 2 hours ago to get out of bed
for 1st time
b. LPN- medical intake, reinforce teaching
i. Asking LPN to obtain cap blood glucose reading on client who is diaphoretic
ii. Which of the following task should Rn delegate to LPN= collection of past medical hx for
client who is admitted for cellulitis
iii. Delegate to LPN reinforce discharge teaching
7. Interdisciplinary conference/ mandatory reporting
a. Police, social services, DCF
i. Detail interview, physical exam, full hx
1. Child S/S neglect - undernourished, dirty, poorly clothed, untreated dental caries
2. Child S/S- physical abuse- spiral fracture, burns bilateral hands, redden welts on back
3. Elder neglect S/S- poor eye contact, exp meds, broken glasses and hearing aids
4. Elder physical abuse S/S= weight loss , dehydration, malnutrition, pressure ulcer, poor
hygiene
a. 72 year old who lives w/ daughter and has several pressure ulcers stage 3
b. Substance abuse mom with child
i. Report suspected abuse MUST BE REPORTED
1. Protect client from immediate harm
2. Separately interview client away from suspected abuser
3. Collect, prepare evidence
4. Safety plan, provide info on shelters, safe house
b. PT= gross motor, walking, crutches , cane
i. 2 year old impaired gross motor and fine motor who was just dx with cerebral palsy
c. OT= fine motor and ADLS, feeding, dressing
i. Occupational therapist referral for client who has Parkinson's disease and having trouble
performing activities of daily living
d. ST= language, communication , DYSPHAGIA
i. Speech therapist , the client who has COPD and has developed dysphagia
e. Hospice
i. Hospice care for Pt with terminal cancer and needs assistance with pain management at home
f. Outside public health agency
i. 27 year old who was admitted with confirmed STI
8. A fib- rapid firing in Atria= RISK FOR CLOTS can lead to MI, PE, CVA, DVT;
a. HR over 100, irregular, NO P wave , no PR interval
i. Management- anticoags, HEPRIN DRIP (warfarin), beta blockers, cardiac ablation, digoxin if
HR less 60 HOLD; toxic if 2 or more), cardioversion
ii. Treatment - o2, anti-coags, prepare for cardioversion
iii. Teaching- dig ( report signs of toxicity) , warfarin ( INR)
9. Hepatic encephalopathy (liver = removes ammonia, metabolize rx, stores glycogen, produce clotting factors,
albumin, bile)
a. Expected – acetone breath, jaundice, elevated enzymes ALT, AST, pruritus, asterixis, twitching arms
and legs, confusion, bizarre behavior
b. Report to HCP- unresponsive, coma, seizure
i. Report to HCP= client who has developed hepatic encephalopathy . It is important to notify
hCP of = pupil size from 7mm to 5mm
c. Med- lactulose- get rid of ammonia, K; NO tylenol
i. Management-client w/ end stage cirrhosis of the liver with encephopathy intervention to
reduce ammonia level= 1st
reduce intake of protein , 2nd administer lactulose
10. Meds
a. Med not working ...see patient first !!!!!!; no rush to give insulin unless DKA ( IV);
11. Chronic strep infections
Nur 283 Comp 2 Final Exam Review Key Concepts and Procedures Latest Update
, Nur 283 Comp 2 Final Exam Review Key Concepts and Procedures Latest Update
a. Swelling sign of sepsis -!!!!!
Nur 283 Comp 2 Final Exam Review Key Concepts and Procedures Latest Update
1. Negligence-failure to provide adequate care; unintentional tort
a. Failure to communicate concerns about elder client who is confused and is being discharged home is
an example of negligence
2. Slander- Spoken remarks that cause harm Gossip
3. Assault – threat by words; intentional; intentional tort
4. Battery- act of harm... “base ball bat”; intentional tort
5. Libel- written “library” remarks of harm; intentional
6. Delegation
a. UAP- medical intake, I & O, remind
i. Intervene SHOULD NOT= assisting client who has paracentesis 2 hours ago to get out of bed
for 1st time
b. LPN- medical intake, reinforce teaching
i. Asking LPN to obtain cap blood glucose reading on client who is diaphoretic
ii. Which of the following task should Rn delegate to LPN= collection of past medical hx for
client who is admitted for cellulitis
iii. Delegate to LPN reinforce discharge teaching
7. Interdisciplinary conference/ mandatory reporting
a. Police, social services, DCF
i. Detail interview, physical exam, full hx
1. Child S/S neglect - undernourished, dirty, poorly clothed, untreated dental caries
2. Child S/S- physical abuse- spiral fracture, burns bilateral hands, redden welts on back
3. Elder neglect S/S- poor eye contact, exp meds, broken glasses and hearing aids
4. Elder physical abuse S/S= weight loss , dehydration, malnutrition, pressure ulcer, poor
hygiene
a. 72 year old who lives w/ daughter and has several pressure ulcers stage 3
b. Substance abuse mom with child
i. Report suspected abuse MUST BE REPORTED
1. Protect client from immediate harm
2. Separately interview client away from suspected abuser
3. Collect, prepare evidence
4. Safety plan, provide info on shelters, safe house
b. PT= gross motor, walking, crutches , cane
i. 2 year old impaired gross motor and fine motor who was just dx with cerebral palsy
c. OT= fine motor and ADLS, feeding, dressing
i. Occupational therapist referral for client who has Parkinson's disease and having trouble
performing activities of daily living
d. ST= language, communication , DYSPHAGIA
i. Speech therapist , the client who has COPD and has developed dysphagia
e. Hospice
i. Hospice care for Pt with terminal cancer and needs assistance with pain management at home
f. Outside public health agency
i. 27 year old who was admitted with confirmed STI
8. A fib- rapid firing in Atria= RISK FOR CLOTS can lead to MI, PE, CVA, DVT;
a. HR over 100, irregular, NO P wave , no PR interval
i. Management- anticoags, HEPRIN DRIP (warfarin), beta blockers, cardiac ablation, digoxin if
HR less 60 HOLD; toxic if 2 or more), cardioversion
ii. Treatment - o2, anti-coags, prepare for cardioversion
iii. Teaching- dig ( report signs of toxicity) , warfarin ( INR)
9. Hepatic encephalopathy (liver = removes ammonia, metabolize rx, stores glycogen, produce clotting factors,
albumin, bile)
a. Expected – acetone breath, jaundice, elevated enzymes ALT, AST, pruritus, asterixis, twitching arms
and legs, confusion, bizarre behavior
b. Report to HCP- unresponsive, coma, seizure
i. Report to HCP= client who has developed hepatic encephalopathy . It is important to notify
hCP of = pupil size from 7mm to 5mm
c. Med- lactulose- get rid of ammonia, K; NO tylenol
i. Management-client w/ end stage cirrhosis of the liver with encephopathy intervention to
reduce ammonia level= 1st
reduce intake of protein , 2nd administer lactulose
10. Meds
a. Med not working ...see patient first !!!!!!; no rush to give insulin unless DKA ( IV);
11. Chronic strep infections
Nur 283 Comp 2 Final Exam Review Key Concepts and Procedures Latest Update
, Nur 283 Comp 2 Final Exam Review Key Concepts and Procedures Latest Update
a. Swelling sign of sepsis -!!!!!
Nur 283 Comp 2 Final Exam Review Key Concepts and Procedures Latest Update
