NURS 225 Exam 1 Study Guide.
maturational crisis - Answer Developmental stages crisis
situational crisis - Answer crisis based on distressing events
adventitious crisis - Answer crisis based on traumatic external events (hurricane,
terrorism, etc.)
Phase 1 of crisis - Answer person is exposed to the serious stressor they try usual coping
methods to deal with the stressor
Phase 2 of crisis - Answer usual coping mechanisms fail, they attempt to try new coping
mechanisms by using trial and error attempts at problem solving
Phase 3 of crisis - Answer anxiety reaches severe and panic levels. Resolution may occur
at this stage by compromising needs or redefining the situation
Phase 4 of crisis - Answer anxiety overwhelms the person and leads to serious personality
disorganization, depression, confusion, violence against others, or suicidal behavior
primary crisis intervention - Answer promotes mental health and reduces mental illness to
decrease the incidence of crisis
secondary crisis intervention - Answer interventions that promote safety, reduce anxiety
(facility-based)
tertiary crisis intervention - Answer Provides support for those who have experienced
severe crisis, and now recovering from a disabling mental status
Plan of care for a client in acute crisis - Answer - assess for SI or HI thoughts or plans
- take initial steps to make patient feel safe and less anxious
- listen carefully
- assist patient with tasks as they will be unable to do them
- identify social supports
- identify needed coping mechanisms
- involve patient in identifying realistic, acceptable interventions
- plan regular follow-ups to assess progress
foundations for crisis intervention - Answer - goal of any patient in crisis is to return them to
the pre-crisis level of functioning or higher
- crisis intervention is here and now oriented
- early intervention increases the chance for positive outcomes
- crisis has a limited duration and usually resolves within 4-6 weeks
,assessing patients perception of the crisis event - Answer - what leads you to seek help
now?
- has anything upsetting happened recently?
- describe how you are feeling right now.
- how does this situation affect your life?
assess patients coping skills - Answer - what have you been doing to relieve anxiety
- what has helped you in the past to relieve anxiety?
- what have you tried this time?
Robert's Seven-Stage Crisis Intervention Model - Answer - plan and conduct crisis
assessment
- establish rapport
- identify major problems
- deal with feelings and emotions
- generate and explore alternatives
- develop and form an action plan (crisis resolution)
- follow-up plan and agreement
Normal infant temperature - Answer 37.5C (99.5F)
Normal infant heart rate - Answer 120-150 bpm (1 week- 3 mo)
(up to 180 bpm-- neonate)
normal infant respiratory rate - Answer 25-30 breaths per minute
Normal infant systolic BP - Answer 65-78 (1 yr: 80-114)
normal toddler temperature - Answer 37.2-37.7C (99.0-99.9F)
normal toddler heart rate - Answer 70-130
normal toddler respiratory rate - Answer 21-30 breaths per minute
normal toddler systolic bp - Answer 86-120
normal preschooler temperature - Answer 37-37.2C (98.6-99.0F)
normal preschooler heart rate - Answer 60-110
normal preschooler respiratory rate - Answer 21-25 breaths/minute
normal preschooler systolic bp - Answer 91-125
normal school age temperature - Answer 36.7C (98.1F)
,normal school age heart rate - Answer 60-110 bpm
normal school-age respiratory rate - Answer 12-21 breaths/min
normal school age systolic bp - Answer 97-130
adolescent normal temperature - Answer 36.6C (97.9F)
normal adolescent heart rate - Answer 50-90 bpm
normal adolescent respiratory rate - Answer 16-19
normal adolescent systolic bp - Answer 111-145
P wave - Answer atrial depolarization
QRS complex - Answer ventricular depolarization
steps for ECG interpretation - Answer 1. Determine rate
2. assess for regularity
3. assess P wave
4. measure PR interval
5. Measure QRS
6. examine ST segment
7. assess T waves
8. measure QT interval
determining rate - Answer Counting the rate from the top of the QRS and counting the P
waves to make sure that they are equal
assessing regularity - Answer - Atrial regularity→ P wave to P wave
- Ventricular regularity→ R wave to R wave
assess P wave - Answer - Present?
- Consistent shape?
- Upright?
- One before every QRS?
measure PR interval - Answer - Measure from beginning of the P wave to end of the PR
segment
- Should be 0.12-0.20s
- Is the PR interval the same throughout the strip?
- Want the PR to be same throughout the strip
- Could indicate heart block
, measure QRS interval - Answer - Measure from the beginning of the Q wave to the end of
the S wave
- Should be 0.04-0.10
- Do they all look the same throughout the strip?
assess ST segment - Answer Has to be more than 1 small box (higher or lower) in different
leads
ST segment should be in a straight line
assess T wave - Answer Is it peaked or inverted?
measure QT interval - Answer - Measure from the beginning of the QRS to end of the T
wave
- Ventricular depolarization & repolarization
- Should be equal to or less than half the distance of the RR interval (0.36-0.44 seconds)
arrhythmia - Answer Abnormal rhythms of the heart's electrical activity system that can
affect its ability to effectively pump oxygenated blood to throughout the body
Depolarization - Answer leads to contraction of the heart
repolarization - Answer relaxation of the heart
PR interval - Answer 0.12-0.20 sec
QRS interval - Answer 0.04-0.10 sec
QT interval - Answer 0.36-0.44 sec
premature atrial contractions (PACs) - Answer underlying rate and rhythm usually regular,
P wave is premature and abnormal in size, shape or direction perhaps inverted or hidden in
preceding T wave; PR normal or prolonged, QRS normal
atrial flutter - Answer flutter waves in the shape of "saw teeth" before each QRS; PR not
measurable; normal QRS
atrial fibrillation - Answer no distinct P wave; PR immeasurable; normal QRS with irregular
rate
Supraventricular tachycardia - Answer rhythm is regular, P waves hidden in preceding
QRS, narrow QRS, rate 100-280 bpm
atrial fibrillation ecg - Answer
atrial fibrillation characteristics - Answer - regularity: irregular
- rate: variable, atrial rate greater than ventricular rate
maturational crisis - Answer Developmental stages crisis
situational crisis - Answer crisis based on distressing events
adventitious crisis - Answer crisis based on traumatic external events (hurricane,
terrorism, etc.)
Phase 1 of crisis - Answer person is exposed to the serious stressor they try usual coping
methods to deal with the stressor
Phase 2 of crisis - Answer usual coping mechanisms fail, they attempt to try new coping
mechanisms by using trial and error attempts at problem solving
Phase 3 of crisis - Answer anxiety reaches severe and panic levels. Resolution may occur
at this stage by compromising needs or redefining the situation
Phase 4 of crisis - Answer anxiety overwhelms the person and leads to serious personality
disorganization, depression, confusion, violence against others, or suicidal behavior
primary crisis intervention - Answer promotes mental health and reduces mental illness to
decrease the incidence of crisis
secondary crisis intervention - Answer interventions that promote safety, reduce anxiety
(facility-based)
tertiary crisis intervention - Answer Provides support for those who have experienced
severe crisis, and now recovering from a disabling mental status
Plan of care for a client in acute crisis - Answer - assess for SI or HI thoughts or plans
- take initial steps to make patient feel safe and less anxious
- listen carefully
- assist patient with tasks as they will be unable to do them
- identify social supports
- identify needed coping mechanisms
- involve patient in identifying realistic, acceptable interventions
- plan regular follow-ups to assess progress
foundations for crisis intervention - Answer - goal of any patient in crisis is to return them to
the pre-crisis level of functioning or higher
- crisis intervention is here and now oriented
- early intervention increases the chance for positive outcomes
- crisis has a limited duration and usually resolves within 4-6 weeks
,assessing patients perception of the crisis event - Answer - what leads you to seek help
now?
- has anything upsetting happened recently?
- describe how you are feeling right now.
- how does this situation affect your life?
assess patients coping skills - Answer - what have you been doing to relieve anxiety
- what has helped you in the past to relieve anxiety?
- what have you tried this time?
Robert's Seven-Stage Crisis Intervention Model - Answer - plan and conduct crisis
assessment
- establish rapport
- identify major problems
- deal with feelings and emotions
- generate and explore alternatives
- develop and form an action plan (crisis resolution)
- follow-up plan and agreement
Normal infant temperature - Answer 37.5C (99.5F)
Normal infant heart rate - Answer 120-150 bpm (1 week- 3 mo)
(up to 180 bpm-- neonate)
normal infant respiratory rate - Answer 25-30 breaths per minute
Normal infant systolic BP - Answer 65-78 (1 yr: 80-114)
normal toddler temperature - Answer 37.2-37.7C (99.0-99.9F)
normal toddler heart rate - Answer 70-130
normal toddler respiratory rate - Answer 21-30 breaths per minute
normal toddler systolic bp - Answer 86-120
normal preschooler temperature - Answer 37-37.2C (98.6-99.0F)
normal preschooler heart rate - Answer 60-110
normal preschooler respiratory rate - Answer 21-25 breaths/minute
normal preschooler systolic bp - Answer 91-125
normal school age temperature - Answer 36.7C (98.1F)
,normal school age heart rate - Answer 60-110 bpm
normal school-age respiratory rate - Answer 12-21 breaths/min
normal school age systolic bp - Answer 97-130
adolescent normal temperature - Answer 36.6C (97.9F)
normal adolescent heart rate - Answer 50-90 bpm
normal adolescent respiratory rate - Answer 16-19
normal adolescent systolic bp - Answer 111-145
P wave - Answer atrial depolarization
QRS complex - Answer ventricular depolarization
steps for ECG interpretation - Answer 1. Determine rate
2. assess for regularity
3. assess P wave
4. measure PR interval
5. Measure QRS
6. examine ST segment
7. assess T waves
8. measure QT interval
determining rate - Answer Counting the rate from the top of the QRS and counting the P
waves to make sure that they are equal
assessing regularity - Answer - Atrial regularity→ P wave to P wave
- Ventricular regularity→ R wave to R wave
assess P wave - Answer - Present?
- Consistent shape?
- Upright?
- One before every QRS?
measure PR interval - Answer - Measure from beginning of the P wave to end of the PR
segment
- Should be 0.12-0.20s
- Is the PR interval the same throughout the strip?
- Want the PR to be same throughout the strip
- Could indicate heart block
, measure QRS interval - Answer - Measure from the beginning of the Q wave to the end of
the S wave
- Should be 0.04-0.10
- Do they all look the same throughout the strip?
assess ST segment - Answer Has to be more than 1 small box (higher or lower) in different
leads
ST segment should be in a straight line
assess T wave - Answer Is it peaked or inverted?
measure QT interval - Answer - Measure from the beginning of the QRS to end of the T
wave
- Ventricular depolarization & repolarization
- Should be equal to or less than half the distance of the RR interval (0.36-0.44 seconds)
arrhythmia - Answer Abnormal rhythms of the heart's electrical activity system that can
affect its ability to effectively pump oxygenated blood to throughout the body
Depolarization - Answer leads to contraction of the heart
repolarization - Answer relaxation of the heart
PR interval - Answer 0.12-0.20 sec
QRS interval - Answer 0.04-0.10 sec
QT interval - Answer 0.36-0.44 sec
premature atrial contractions (PACs) - Answer underlying rate and rhythm usually regular,
P wave is premature and abnormal in size, shape or direction perhaps inverted or hidden in
preceding T wave; PR normal or prolonged, QRS normal
atrial flutter - Answer flutter waves in the shape of "saw teeth" before each QRS; PR not
measurable; normal QRS
atrial fibrillation - Answer no distinct P wave; PR immeasurable; normal QRS with irregular
rate
Supraventricular tachycardia - Answer rhythm is regular, P waves hidden in preceding
QRS, narrow QRS, rate 100-280 bpm
atrial fibrillation ecg - Answer
atrial fibrillation characteristics - Answer - regularity: irregular
- rate: variable, atrial rate greater than ventricular rate
