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A comprehensive set of questions and answers covering fundamental concepts in nursing. It explores the origin of the word 'nurse', the interrelated roles of nurses, coping with disability and death, the nursing process, nurse practice acts, vital signs, and the criteria for recognizing nursing as a profession. It also delves into the history of nursing, sources of knowledge, types of knowledge, goals of nursing research, reasoning, health, illness, wellness, nursing theory, evidence-based practice, human dimensions, acute and chronic illnesses, stages of illness behaviors, health promotion, maslow's hierarchy of needs, ethical principles, nurse-patient relationships, discharge planning, and vital signs measurements. A valuable resource for students and professionals seeking to enhance their understanding of fundamental nursing concepts.
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origination of the word "nurse" - CORRECT ANSWER-from the latin word "nutrix" meaning to nourish Interrelated roles of nurses - CORRECT ANSWER- communicator, teacher, counselor, leader, researcher, advocate, collaborator coping with disability and death - CORRECT ANSWER-nurses use optimal function of maximum strengths and potentials, refer to community support systems; provide care to families and patients during end-of-life care, hospice The Nursing Process - CORRECT ANSWER--one of major guidelines for nursing practice
Nursing is recognized as profession based on what criteria - CORRECT ANSWER--well defined body specific and unique knowledge
goals of nursing research - CORRECT ANSWER--improve care in clinical setting
steps in implementing EBP - CORRECT ANSWER-Step 1: ask a question about a clinical area of interest or an intervention Step 2: collect the most relevant and best evidence Step 3: Critically appraise the evidence Step 4: integrate the evidence w/ clinical expertise, patient preferences, and values in making a decision to change Step 5: evaluate the practice decision or change human dimensions that compose the whole person - CORRECT ANSWER-physical, intellectual, environmental, spiritual, sociocultural, and emotional acute illness - CORRECT ANSWER-rapid onset of symptoms and lasts only a short time; examples: cold, diarrhea, pneumonia, appendicitis chronic illness - CORRECT ANSWER-slow onset, characteristics: permanent change, caused by change in anatomy, requires special patient education, long period of care or support; examples: heart disease, diabetes, lung diseases, and arthritis stages-of-illness behaviors - CORRECT ANSWER-Stage 1: experiencing symptoms Stage 2: assuming the sick role Stage 3: assuming a dependent role Stage 4: achieving recovery and rehabilitation primary health promotion - CORRECT ANSWER-directed towards PROMOTING health and PREVENTING the development of disease processes or injury; example: immunization clinic, family planning services, accident prevention education secondary health promotion - CORRECT ANSWER-focus on SCREENING for early detection of disease with prompt
diagnosis and treatment of any found; example: assessing children for normal growth and development and encourage regular medical, dental and vision exams tertiary health promotion - CORRECT ANSWER-after an illness is diagnosed and treated; example: teaching a patient with diabetes how to recognize and prevent complications, refer woman to support group after removal of breast due to cancer maslow hierarchy of needs - CORRECT ANSWER-provides a framework for nursing assessment and for understanding the needs of patients at all levels; many nursing interventions are aimed at meeting patients' basic human needs Maslows level 1: physiologic needs - CORRECT ANSWER- oxygen, food, water, sex, rest, physical activity; physiologic needs are highest priority Maslows level 2: safety and security needs - CORRECT ANSWER-both physical and emotional components; being protected from potential or actual harm Maslows level 3: love and belonging needs - CORRECT ANSWER-often called higher-level needs; understanding and acceptance of others in both giving and receiving love; feeling of belonging; unmet needs produce loneliness and isolation Maslows level 4: self-esteem needs - CORRECT ANSWER- need for a person to feel good about oneself, to feel pride and a sense of accomplishment, and to believe that others also respect and appreciate those accomplishments; positive self- esteem facilitates the person's confidence and independence Maslows level 5: Self-Actualization - CORRECT ANSWER- acceptance of self and others as they are; each lower level must be met; focus of interest on problems outside oneself;
respect for all people; focus on strengths and possibilities vs problems autonomy - CORRECT ANSWER-respect rights of patients to make health care decisions nonmaleficence - CORRECT ANSWER-avoid causing harm beneficence - CORRECT ANSWER-benefit the patient; balance benefits against risks and harms nurse practice acts - CORRECT ANSWER-each state has its own; protects public with legal scope of nursing practice standards - CORRECT ANSWER-used as guidelines for peer review (ANA) establishing an effective nurse-patient relationship - CORRECT ANSWER--reduce anxiety through therapeutic communication, teaching, and acceptance
average blood pressure for healthy adult - CORRECT ANSWER-120/ intermittent fever - CORRECT ANSWER-temperature returns to normal at least once every 24 hours remittent fever - CORRECT ANSWER-temperature does not return to normal and fluctuates a few degrees up and down sustained or continuous fever - CORRECT ANSWER-temp remains above normal with minimal variations relapsing or recurrent fever - CORRECT ANSWER-temp returns to normal for one or more days with one or more episodes of fever, each as long as several days rectal temp - CORRECT ANSWER-37.5 C, 99.5 F axillary temp - CORRECT ANSWER-36.5 C, 97.7 F tympanic temp - CORRECT ANSWER-37.5 C, 99.5 F forehead temp - CORRECT ANSWER-34.4 C, 94.0 F heat production - CORRECT ANSWER--primary source is metabolism
factors affecting body temp - CORRECT ANSWER--circadian rhythms
tachypnea - CORRECT ANSWER-increased respiratory rate; may occur in response to increased metabolic rate bradypnea - CORRECT ANSWER-decreased respiratory rate; occurs in some pathologic conditions apnea - CORRECT ANSWER-periods when no breathing occurs dyspnea - CORRECT ANSWER-difficult or labored breathing orthopnea - CORRECT ANSWER-changes in breathing when sitting or standing assessing blood pressure - CORRECT ANSWER--listening for korotkoff sounds w/ stethoscope
ACE inhibitors - CORRECT ANSWER-to prevent vasoconstriction by angiotensin II and decrease circulatory fluid volume by reducing aldosterone production RACE - CORRECT ANSWER-R: rescue anyone in immediate danger A: activate the fire code and notify appropriate person C: confine the fire by closing doors and windows E: evacuate patients and other people to a safe area jaundice causes - CORRECT ANSWER-yellowish, itchy skin; bilirubin problem and liver not functioning properly eczema - CORRECT ANSWER-red, itchy inflammation of the skin; usually develops in early childhood, more common in people w/ family history; treatment involves avoiding soap and other irritants and applying creams or ointments if prescribed psoriasis - CORRECT ANSWER-common skin condition that speeds up the life cycle of skin cells, cells build up rapidly on surface of skin and extra skin cells form scales and red patches that are itchy and sometimes painful; chronic, comes and goes wound - CORRECT ANSWER-a break or disruption in the normal integrity of the skin and tissues intentional wound - CORRECT ANSWER-the result of planned invasive therapy or treatment ex. surgery, intravenous procedure unintentional wound - CORRECT ANSWER-are accidental; occur from unexpected trauma open wound - CORRECT ANSWER-occurs from intentional and unintentional trauma; skin surface is broken, providing a portal of entry for microorganisms
closed wound - CORRECT ANSWER-results from a blow, force, or strain caused by trauma such as a fall, an assault, or motor vehicle crash acute wound - CORRECT ANSWER-usually heal within days to weeks chronic wound - CORRECT ANSWER-do not progress through stages of healing; healing impeded albumin normal lab values - CORRECT ANSWER-3.5- 5 vitamin c and zinc - CORRECT ANSWER-important in wound healing phases of wound healing - CORRECT ANSWER--hemostasis- vessels constrict and clotting begins
across wound, thin layer of epithelial cells form across wound, granulation tissue forms a foundation for scar tissue to develop maturation phase - CORRECT ANSWER-final stage of healing, begins 3 weeks to 6 months after injury, collagen remodeled, new collagen tissue is deposited, scar becomes thin white line desiccation - CORRECT ANSWER-dehydration maceration - CORRECT ANSWER-overhydration trauma - CORRECT ANSWER-physical injury edema - CORRECT ANSWER-swelling caused by excess fluid trapped in your body's tissues necrosis - CORRECT ANSWER-death of tissue wound complications - CORRECT ANSWER--infection
measurement of pressure ulcer - CORRECT ANSWER--size of wound
purulent drainage - CORRECT ANSWER-thick, musty or foul odor, varies in color open drainage system - CORRECT ANSWER-penrose drain; promotes drainage passively closed drainage system - CORRECT ANSWER--Jackson-pratt drain
6 classes of nutrients - CORRECT ANSWER-supply energy: carbs, proteins, lipids regulate body processes: vitamins, minerals, water carbs - CORRECT ANSWER--sugars and starches
minerals - CORRECT ANSWER--inorganic elements found in all body fluids and tissues
visual or optic reflexes - CORRECT ANSWER-visual impressions contribute to posture by alerting the person to spatial relationships with the environment extensor or stretch reflexes - CORRECT ANSWER-when extensor muscles are stretched beyond a certain point, their stimulation causes a reflex contraction that aids a person to reestablish erect posture isotonic exercises - CORRECT ANSWER-muscle shortening and active movement isometric exercise - CORRECT ANSWER-muscle contraction without shortening isokinetic exercise - CORRECT ANSWER-muscle contraction with resistance paresis - CORRECT ANSWER-impaired muscle strength or weakness paralysis - CORRECT ANSWER-absence of strength secondary to nervous impairment hemiparesis - CORRECT ANSWER-weakness of half of the body hemiplegia - CORRECT ANSWER-paralysis one half of the body paraplegia - CORRECT ANSWER-paralysis both legs quadriplegia - CORRECT ANSWER-paralysis of both arms and both legs
anuria - CORRECT ANSWER- 24 - hour urine output is less than 50mL; complete kidney shut down or renal failure dysuria - CORRECT ANSWER-painful or difficult urination frequency - CORRECT ANSWER-increased incidence of voiding glycosuria - CORRECT ANSWER-presence of sugar in the urine nocturia - CORRECT ANSWER-awakening at night to urinate oliguria - CORRECT ANSWER-scanty or greatly diminished amount of urine voided in a given time; 24-hour urine output is less than 400mL polyuria - CORRECT ANSWER-excessive output of urine (diuresis) proteinurea - CORRECT ANSWER-protein in the urine; indication of kidney disease pyuria - CORRECT ANSWER-pus in the urine; urine appears cloudy suppression - CORRECT ANSWER-stoppage of urine production; normally, the adult kidneys produce urine continuously at the rate of 60 to 120 mL/h urgency - CORRECT ANSWER-strong desire to void urinary incontinence - CORRECT ANSWER-involuntary loss of urine overflow incontinence - CORRECT ANSWER-chronic retention of urine, the involuntary loss of urine associated
functional incontinence - CORRECT ANSWER-urine loss caused by the inability to reach the toilet because of environmental barriers, physical limitations, loss of memory, or disorientation reflex incontinence - CORRECT ANSWER-experience emptying of the bladder w/o sensation of the need to void total incontinence - CORRECT ANSWER-a continuous and unpredictable loss of urine, resulting from surgery, trauma, or physical malformation dialysis - CORRECT ANSWER-a mechanical way of filtering waste from the blood nursing process for bowels - CORRECT ANSWER--inspection
constipation - CORRECT ANSWER-dry, hard stool; persistently difficult passage of stool; incomplete passage of stool laxatives - CORRECT ANSWER-drugs that induce emptying of the intestinal tract enema - CORRECT ANSWER-the introduction of a solution into the large intestine, usually to remove feces suppository - CORRECT ANSWER-a conical or oval solid substance shaped for easy insertion into a body cavity and designed to melt at body temperature ileostomy - CORRECT ANSWER-allows liquid fecal content from the ileum of the small intestine to be eliminated through the stoma colostomy - CORRECT ANSWER-permits formed feces in the colon to exit through the stoma ostomy - CORRECT ANSWER-surgical opening from the inside of an organ to the outside stoma - CORRECT ANSWER-the part of the ostomy that is attached to the skin normal stoma - CORRECT ANSWER-red and moist pale stoma - CORRECT ANSWER-shows signs of anemia ischemia - CORRECT ANSWER-deficiency of blood in a particular area hypoxia - CORRECT ANSWER-inadequate amount of oxygen available to cells
eschar - CORRECT ANSWER-thick, leathery scab or dry crust that is necrotic and must be removed before the stage can be determined accurately scale used for predicting pressure sore risk - CORRECT ANSWER-braden scale debridement - CORRECT ANSWER-removal of devitalized tissue and foreign material negative-pressure wound therapy - CORRECT ANSWER- promotes wound healing and wound closure through the application of uniform negative pressure on wound bed, reduction in bacteria in the wound, and the removal of excess wound fluid, while providing a moist wound healing environment; results in mechanical tension on wound tissues, stimulating cell proliferation, blood flow to wounds, and the growth of new blood vessels body mechanics - CORRECT ANSWER-the use of proper body positions to provide protection from the stress of movement and activity negative nitrogen balance - CORRECT ANSWER-results in muscle wasting and decreased physical energy for movement and work; caused by diseases that are characterized by a larger breakdown of protein than that which is manufactured footdrop - CORRECT ANSWER-the foot is unable to maintain itself in the perpendicular position, heel-toe gait is impossible, and patient experiences extreme difficulty in walking; caused by patients feet being in planter flexion position over extended time fowlers position - CORRECT ANSWER-semi-sitting position; head of bed elevated 45 to 60 degrees; used to promote
cardiac and respiratory functioning; provides max space in thoracic cavity; high fowlers the bed is elevated to 90 degrees supine or dorsal recumbent position - CORRECT ANSWER- patient lies flat on the back with the head and shoulders slightly elevated w/ a pillow side-lying or lateral position - CORRECT ANSWER-patient lies on the side and the main weight of the body is borne by the lateral aspect of the lower scapula and the lateral aspect of the lower ilium sims position - CORRECT ANSWER-patient again lies on the side but the lower arm is behind the patient and the upper are is flexed at both the shoulder and the elbow prone position - CORRECT ANSWER-person lies on the abdomen with the head turned to the side; the body is straight in the prone position because shoulders, head, and neck are in erect position, arms are easily placed in correct alignment w/ the shoulder girdle, hips, knees can be prevented from flexing or hyperextending active exercise - CORRECT ANSWER-the patient independently moves joints through their full range of motion (isotonic exercise) passive exercise - CORRECT ANSWER-the patient is unable to move independently, the nurse moves each joint through its range of motion Aims of Nursing - CORRECT ANSWER-1. To promote health
To promote health - CORRECT ANSWER-State of optimal functioning or wellbeing. not just absence of disease To prevent illness - CORRECT ANSWER-reduce risk for illness. promote good health habits, maintain optimal functioning To restore health - CORRECT ANSWER-Nurse's responsibility to assess & teach levels of prevention To facilitate coping w/ disability or death - CORRECT ANSWER-Nurse's role to provide "comfort" care