NUR 111 (1-5) Final Exam Questions With 100% Correct Answers |Verified |Latest Update 2024, Exams of Advanced Education

Download NUR 111 (1-5) Final Exam Questions With 100% Correct Answers |Verified |Latest Update 2024 and more Exams Advanced Education in PDF only on Docsity! NUR 111 (1-5) Final Exam Questions With 100% Correct Answers | Verified | Latest Update 2024 Describe the communication process - Correct Answer-Stimulus, source (seder/encoder), message, channel, receiver (decoder), feedback/communication Identify factors that influence communication - Correct Answer- Developmental level, gender, sociocultural differences, roles and responsibilities, space/territoriality, physical/mental/emotional state, values, environment Discuss types of communication used in healthcare and the role of the nurse in each type. - Correct Answer-Verbal, nonverbal, electronic - Correct Answer- Define therapeutic communication and helping relationships. - Correct Answer-the face-to-face process of interacting that focuses on advancing the physical and emotional well-being of a patient. Involves: listening, conversation skills, silence, touch, humor, interviewing techniques Discuss and utilize SBAR communication technique when communicating with physicians and other nurses. - Correct Answer-S (Situation), B (Background), A (Assessment), R (Recommendation) Discuss role of documentation in healthcare and demonstrate appropriate documentation techniques. - Correct Answer-"If you continue data collection, modify plan of care as needed, document), evaluating (measure how well the patient has achieved the desired outcomes, identify factors contributing to the patients success or failure, modify the plan of care if indicated) Describe and demonstrate the steps in concept mapping care planning - Correct Answer- Altruism - Correct Answer-The selfless giving of others Autonomy - Correct Answer-The patient has the right to determine their own course of healthcare Human Dignity - Correct Answer-The person has dignity just because they are human Integrity - Correct Answer-Admit when you make a mistake. You wont try to cover it up or blame someone else Social justice - Correct Answer-Protecting the rights of everyone Reflective journaling - Correct Answer-A tool used to clarify concepts through reflection by thinking back or recalling situations Concept mapping - Correct Answer-A visual representation of patient problems and interventions that illustrates an interrelationship Cues - Correct Answer-Information obtained through use of the senses Inferences - Correct Answer-Judgment or interpretation of cues Subjective data - Correct Answer-Must be provided by client. Subject to be different from each patient Objective data - Correct Answer-Factual information that is provable for all patients Medical diagnosis - Correct Answer-Identification of a disease condition based on physical signs, symptoms, PMH, and results of diagnostic (dx) tests and procedures. Physicians, PAs, and NPs can write medical diagnoses, and treat diseases described therein Nursing Diagnosis - Correct Answer-the domain of nursing. Clinical judgment about patient's responses to actual and potential health problems, that the nurse is licensed and competent to treat. **Different from medical dx by individualizing dx to each patient and involving the patient in the process as much as possible.** Collaborative Problem - Correct Answer-Actual or potential physiological complication that nurse's monitor to detect the onset of changes. Requires working with other disciplines NANDA - Correct Answer-North American Nursing Diagnosis Association NANDA-I - Correct Answer-North American Nursing Diagnosis Association International Components of a Nursing diagnosis - Correct Answer-Nursing diagnosis label (problem), related factors (etiology), Defining characterisitics (symptoms) How to write out a nursing diagnosis - Correct Answer-Problem (nursing diagnosis lavel), etiology (related to ...), symptoms (as evidenced by ...) *Nursing diagnosis label* *related to ....* *as evidenced by...* Maslow's hierarchy of care - Correct Answer- How to be SMART when writing patient outcomes - Correct Answer- Specific, Measurable, Attainable, Realistic, Time bound caregivers to another to ensure the continuity and safety of that patient's care. Define HIPPA and it's impact on professional nursing practice. - Correct Answer-Health Insurance Portability and Accountability Act passed in 1996, finished in 2002, two objectives: ensure individuals could maintain health insurance between jobs, ensure security/confidentiality of patient health information Discuss the nursing process for maintaining safety including necessary assessment data and nursing interventions to maintain safety while caring for clients across the lifespan. - Correct Answer-Assess/Identify safety risks in the home, demonstrate safety measures, education. Falls (from young children or older adults), injuries from toys/sharp objects (more common in young children), infection (young children and older adults), Ingestion (young children and toddlers), MVAs (young children and adolescence), Child/Elder abuse (includes money abuse), Drug/alcohol abuse (more common in adolescent and young adults) Discuss safe and appropriate use of restraints and the nursing implications when using restraints. - Correct Answer-Nurse must chart a restraint assessment for behavioral restraints every 15 minutes and PRN while the restraints are on. New order must be provided every 4 hours. For non-behavioral restraints the nurse must chart a restraint assessment every 2 hours and PRN while the restraints are on, a new order must be obtained every 24 hours. If any restraint is discontinued for any length of time a new order must be obtained Describe and demonstrate appropriate isolation precautions and their indications. - Correct Answer-Standard precautions (used to care for all hospitalized patients regardless of their diagnosis. Includes gloves and possibly gown and mask and PPE and N95 respiratory or clean air respirator), transmission based precautions including: airborne (diseases which are transmitted by smaller air particles, has a negative isolation room, PPE, Mask, gloves), droplet (diseases which are transmitted by smaller air particles, use mask), contact (gown and gloves, direct and indirect patient contact could transmit disease) Discuss the principles of sterility - Correct Answer-1. A sterile object remains sterile only when touched by another sterile object, 2. only sterile objects may be placed on a sterile field, 3. A sterile object or field out of range of vision or an object held below a persons waist is contaminated, 4. A sterile object or field becomes contained by prolonged exposure to air, 5. When a sterile surface comes into contact with a wet, contaminated surface, the sterile object or field becomes contaminated, 6. The edges of a sterile field or container are considered to be contaminated, 7. As much as possible do not lean over or reach across your sterile field Surgical asepsis - Correct Answer-An object is considered sterile when all micro-orgamisms, including pathogens and spores, have been destroyed Order of putting on PPE - Correct Answer-Hand hygiene, gown, mask, eyewear, gloves Order of taking off PPE - Correct Answer-Gloves, eyewear, gown, mask, hand hygiene Medical asepsis - Correct Answer-Considered contaminated if they bear or are suspected of bearing pathogens Types of non-behavioral restraints - Correct Answer-Side rails (only when all 4 rails are up and when used to help prevent a confused patient from falling out of bed), wrist restraint, vest restraint, mittens, arm immobilizer Types of behavioral restraints - Correct Answer-Leather wrist restraints Permitted disclosures of Personal Health Information - Correct Answer-Public health, law enforcement/judicial proceedings, deceased Incidental disclosures (breaks HIPPA but you wont get in trouble for it) - Correct Answer-Sign-in sheets, overheard conversations, charts outside rooms, white boards, waiting rooms Referred pain - Correct Answer-Perceived in an area that is distant from its point of origin Incident pain - Correct Answer-Predictable pain, precipitated by an event or activity such as coughing, changing, position or being touched Cancer pain - Correct Answer-Acute/chronic pain, referred pain is common, 90% of patient shave pain controlled Neuralgias pain - Correct Answer-Damage to a peripheral nerve, caused by infection or disease Phantom pain - Correct Answer-Simulation of severed nerves at site of amputation Breakthrough pain - Correct Answer-Exceeds the analgesic effect of long-acting meds Psychogenic pain - Correct Answer-Pain in the absence of any physiological event or diagosis Central pain - Correct Answer-High-frequency bursts of impulses, perceived as pain, usually caused by brain lesions Pain is assessed as... - Correct Answer-The fifth vital sign 0-10 pain scale - Correct Answer- Faces Scale - Correct Answer- Pseudoaddiction - Correct Answer-Desperately drug seeking because of under treatment of pain Pain in older adults - Correct Answer-Pain tolerance decreases, respond to pain in atypical ways, acute and chronic pain in older adults, certain types of visceral pain may be less severe in older adults COLDERR method - Correct Answer-Character (describe sensation), Onset (when it start, how it has changed), Location (where it hurts), Duration (constant versus intermittent in nature), Exacerbation (factors that make it worse, Relief (factors that make it better), Radiation (pattern of shooting/spreading/location of pain away from its origin) PQRSTU method - Correct Answer-Provoke/palliate, Quality, Region, Severity, Timing, U (how does it affect YOU the patient) Sedation Scale - Correct Answer-S= sleep, easy to arouse, 1= awake and alert, 2= slightly drowsy, easily aroused, 3= frequently drowsy and drifts off to sleep during conversation (monitor, maybe decrease opioids) , 4= somnolent, minimal or no response to physical stimulation (stop opioids, maybe administer Narcan) Non-pharmacological Interventions - Correct Answer-Cognitive behavioral (change perceptions of pain, distraction prayer, relaxation, guided imagery, music, biofeedback), Physical (provide pain relief, correct physical dysfunction, alter physiological responses, therapeutic touch, chiropractic, cutaneous stimulation) Pharmacological Interventions for pain management - Correct Answer-Mild pain (step 1) - non-opioid analgesics. Persists (step 2) moderate pain- weak, opioid combination of opioid and non-opioid. Persists (step 3) severe pain - strong opiates administered around the clock, titrated until pain relieved, respiratory effects Types of pharmacological interventions - Correct Answer-Analgesics (three types- non-opioids, opioids, adjuvants) Adjuvants - Correct Answer-Drugs originally created to treat conditions other than pain Common opioid side effects - Correct Answer-Constipation, N/V, sedation, respiratory depression, pruritus, urinary retention Review the anatomy and physiology of the upper and lower respiratory system and how it interacts with body systems - Correct Answer- Discuss alterations in respiratory functioning and risk factors across the lifespan - Correct Answer-Hyperventilation- increased rate and depth of ventilation; above body's normal metabolic requirements. Hypoventilation- decreased rate or depth of air movement into the lungs; inadequate to meet the body's oxygen demand or eliminate carbon dioxide. Dyspnea- Difficulty breathing Hypoxia- Inadequate oxygen available to the cells Cyanosis-Blue discoloration of the skin and mucous membranes Discuss the nursing assessment of the respiratory system. - Correct Answer-In depth history of a patient's normal and present cardiopulmonary function, Past impairments, Methods that a patient uses to optimize oxygenation, Review of drug, food, and other allergies, Physical examination, Laboratory and diagnostic testing Describe diagnostic tests that are commonly used to assess alterations in the respiratory system. - Correct Answer-Blood tests: CBC, Cardiac enzymes, Serum electrolytes Imaging: Chest X-ray, cardiac catheterization, chest CT, chest MRI Noninvasive: TB skin test, Holter Monitor, ECG, PFT, Pulse oximetry Discuss nursing interventions to promote optimal respiratory functioning, including the care of artificial airways - Correct Answer- Health promotion (stopping a problem before it starts), Promoting comfort (positioning, adequate fluid intake, humidified air), chest physiotherapy, postural drainage, Promoting proper breathing, percussion, oropharyngeal and nasopharyngeal suctioning, orotracheal and nasotracheal suctioning, tracheal suctioning Differentiate among various oxygen delivery devices and their appropriate uses. - Correct Answer-Oral airway (prevents obstruction of the trachea by displacement of the tongue into the oropharynx), endotracheal and tracheal airways (short-term use o ventilate, relieve upper airway obstruction, protect against aspiration, clear secretions), tracheotomy (surgical incision into the trachea to establish an airway- for emergencies), tracheostomy (long-term assistance), nasal cannula, oxygen mask, oxygen tent Pulmonary circulation - Correct Answer-Moves blood to an from the alveolar capillary membranes for gas exchange If a patient is on room air what % oxygen are they receiving? - Correct Answer-21% oxygen Ventilation - Correct Answer-The process of moving gases into and out of the lungs Perfusion - Correct Answer-The process by which oxygenated capillary blood passes through body tissues Respiration - Correct Answer-Exchange of respiratory gases in the alveoli and capillaries Work of breathing - Correct Answer-The effort required to expand and contract the lungs Atelectasis - Correct Answer-Collapse of the alveoli that prevents the normal exchange of oxygen and carbon dioxide Accessory muscles - Correct Answer-Abdomen, neck and back- only used to facilitate when breathing is difficult Compliance - Correct Answer-How easy it is for the lungs to obey the order to breathe Airway resistance - Correct Answer-If they are choking on something they have a lot of airway resistance Oxygen transport - Correct Answer-Lungs and cardiovascular system Carbon dioxide transport - Correct Answer-Diffuses into red blood cells and is hydrated into carbonic acid Factors influencing respiratory gas exchange - Correct Answer-Change in surface area available (alveoli), thickening of alveolar-capillary membrane, partial pressure, solubility and molecular weight of the gas Physiologic factors affecting oxygenation - Correct Answer-Decreased oxygen carrying capacity, hypoventilation, decreased inspired oxygen concentration, increased metabolic rate (as with hyperventilation), conditions affecting chest wall movement, influences of chronic diseases Developmental factors affecting oxygenation - Correct Answer- Infants, toddlers, school-aged children, adolescents, young/middle- aged adults, older adults Lifestyle factors affecting oxygenation - Correct Answer-Nutrition, exercise, smoking, substance abuse, stress Cardioprotective nutrition - Correct Answer-Diets rich in fiber; whole grains; fresh fruit and vegetables; nuts; antioxidants; lean meats; and omega-3 fatty acids Environmental factors affecting oxygenation - Correct Answer- Occupation, where they live Hypoxia - Correct Answer-Condition of insufficient oxygen anywhere in the body. Causes: rapid pulse, rapid shallow respiration and dsypnea, increased restlessness and lightheadedness, flaring nares, substernal or intercostal retractions, cyanosis Tachypnea - Correct Answer-Fast breathing Bradypnea - Correct Answer-Slow breathing Apnea - Correct Answer-No breathing Kyssmauls breathing - Correct Answer-Very deep, regular but rapid respirations. This is seen in metabolic acidosis, they're having a hard time getting rid of CO2 Cheyne-Stokes respirations - Correct Answer-Deep, rapid breathing followed by long periods of apnea, irregular respirations. A sign a patient is actively dying or overdose Biots respirations - Correct Answer-Very irregular, rates normal but varying depths and long periods of apnea. A sign of severe brain damage Physical Examination: Inspection - Correct Answer-Overall appearance, level of consciousness, skin/mucous membranes (for pallor, cyanosis, clubbing), chest structures, rate, rhythm, depth Pallor - Correct Answer-Pale Clubbing - Correct Answer-A sign of long term hypoxia Physical examination: Palpation - Correct Answer-Skin temperature, chest expansion, masses, edema, tenderness, tactile fremitus Physical Exam: Percussion - Correct Answer-Position of lungs, density of lung tissue, change in tissue Physical exam: Auscultation - Correct Answer-Assess air flow through respiratory passages and lungs Diagnostic tests - Correct Answer-Blood tests (CBC, cardiac enzymes, serum electrolytes), imaging (chest x-ray, cardiac catherterization, chest CT, chest MRI), Noninvasive (TB skin, Holter monitor, ECG, PFT, breathe on their own but you're worried their airway may be compromised at some point. Measure from tip of lip to tip of ear Endotracheal and tracheal airways - Correct Answer-Short-term use to ventilate, relieve upper airway obstruction, protect against aspiration, clear secretions, extremely invasive and only done in emergency. Out of nursing scope of practice to put these in but you may assist, to check placement use an ambu bag and first listen for air sounds in the stomach (they should not be there), then listen in the left side (you want to hear lung sounds in the left), confirm with a chest x-ra Tracheotomy - Correct Answer-surgical incision into the trachea to establish an airway, still for emergency situations. Tracheostomy - Correct Answer-Long-term assistance. Obturator is what is used to put it in and as soon as it is in take it out but leave it in the room, metal ones do not have cuffs and are long term Nasal trumpet - Correct Answer-Someone who is breathing all right on their own but you're worried something might happen to their airway Precautions for tube replacement - Correct Answer-Tube of equal or smaller size kept at bedside for emergency reinsertion, ties not changed for at least 24 hours after insertion, first change by physician no sooner than 7 days after tracheostomy How often should a tracheostomy be cleaned? - Correct Answer-Once every shift What is the first thing you do if a patient accidentally dislodges their tracheostomy? - Correct Answer-Assess the patient How do you help someone who is in minor dyspnea? - Correct Answer-Place them in semi-fowlers position How often should you change the outer cannula? - Correct Answer- Once a month unless its metal How often should you change the inner cannula? - Correct Answer- Every shift If patient dislodges tracheostomy and it cannot be replaced what do you do? - Correct Answer-Assess level of respiratory distress, minor dyspnea may be alleviated with semi-fowlers position, severe distress may progress to respiratory arrest, cover stoma with sterile dressing and ventilate with bag-mask until help arrives With the patient at home doing their own care what technique should be used? - Correct Answer-Clean technique In the hospital with medical professionals doing the care what technique is used? - Correct Answer-Sterile technique Passy-Muir Speaking Tracheostomy Valve - Correct Answer-You can deflate the cuff and put the valve over the trachea so they are able to speak but it does cover an airway so if they cough or are short of breath they need to take it off Decannulation - Correct Answer-When a patient can exchange air and expectorate and does not need the tracheostomy anymore. Soma is closed with take and covered with an occlusive dressing, patient should splint stoma with fingers when coughing, speaking or swallowing, tissue will form in 24-48 hours, opening will close in several days without surgical intervention Maintenance and promotion of lung expansion - Correct Answer- Ambulation, positioning, incentive spirometry, noninvasive ventilation, chest tube Incentive spirometry - Correct Answer-Encourages voluntary deep breathing. Helps bring fevers down, usually the goal is to breathe in 1000mL Noninvasive ventilation - Correct Answer-Maintains positive airway pressure and improves alveolar ventilation Bilevel Positive Airway Pressure - Correct Answer-Has a certain pressure set for inspiration and certain pressure set for expiration, usually used with oyxgen Manual resuscitation bag - Correct Answer-Used for clients in respiratory arrest or distress. Self inflating bag, attached to oxygen source (turn it all the way up), cover nose and mouth and apply a good seal, gentle squeeze of bag delivers a "breath" Cardiopulmonary rehabilitation - Correct Answer-Controlled physical exercise, nutrition counseling, relaxation and stress management, medications, oxygen, compliance, systemic hydration Evaluation (ask about) - Correct Answer-Degree of breathlessness, if distance ambulated without fatigue has increased, rating the breathlessness from 0 to 10, which interventions reduced dyspnea, frequency of cough and sputum production What order should you perform tracheal and pharyngeal suctioning? - Correct Answer-Perform tracheal suctioning before pharyngeal suctioning whenever possible Discuss focused nursing assessment of the lungs and thorax including inspection - Correct Answer-Inspection: observe skin color, inspection of anterior/posterior thorax, inspect fingers for clubbing-sign, respirations Identify pertinent landmarks relevant to nursing assessment of the lungs and thorax (lines) - Correct Answer-Anterior sternal, midclavicular, anterior axillary lines. Posterior vertebral, scapular, posterior axillary lines. Lateral anterior, posterior, midaxillary lines Identify pertinent landmarks relevant to nursing assessment of the lungs (lobes) - Correct Answer-Three lobes on the right side, two lobes on the left side (because the heart is there) Identify normal lung/thorax assessment findings across the lifespan - Correct Answer-Infant/child: louder/harsher sounds on auscultation, more rapid respiratory rates, use abdominal muscles. AP diameter is normally 1:1 Older adult: increased anterior-posterior diameter, increased kyphosis, decreased thoracic expansion, use of accessory muscle, increased secretions, decreased compliance Common respiratory disorders - Correct Answer-Asthma, atelectasis, chronic bronchitis, Emphysema, Lobar pneumonia (pneumonia), pleural effusion, pneumothorax Discuss focused nursing assessment of the lungs and thorax including palpation - Correct Answer-palpation: palpate anterior: trachea, sternum, ribs, intercostal spaces, palpate posterior: ribs, intercostal spaces, respiratory expansion, tactile fremitus, palpate for respiratory expansion Discuss focused nursing assessment of the lungs and thorax including percussion - Correct Answer-Lungs: assess aeration, density and presence of fluid. Anterior chest percussion has to have patient semi- sitting or supine. Posterior chest percussion has to have patient sit leaning forward with arms folded, diaphragmatic excursion Discuss focused nursing assessment of the lungs and thorax including inspection auscultation - Correct Answer-8- anterior, 6- lateral, 10- posterior. Normal sounds: bronchial, broncho-vesicular, vesicular. Abnormal sounds: crackles (rales), rhonchi, wheezing, stridor, friction rub Asthma - Correct Answer-Obstrutive airway disease, hypersensitive response results in bronchospasm. Symptoms: episodic wheezing, dyspnea, nighttime cough. Diagnosed with spirometry, quick relief and long term medications Atelectasis (as a condition) - Correct Answer-Incomplete expansion of lung or portion of lung. Symptoms: tachypnea, tachycardia, dyspnea, hypoxemia. Diagnosed with radiology studies. Ambulation, deep breathing and body positioning will help to resolve Broncho-vesicular sounds - Correct Answer-Hear around the sternum around the center. Inspiration = expiration, mixed blowing sounds Vesicular sounds - Correct Answer-What you hear in the periphery of the lung fields. Inspiration> expiration. Rustling/soft.low pitched Crackles - Correct Answer-Bubbling/crackling, low- high pitched discontinuous. Fluid causes this and is heard on inspiration and expiration. It is crackles if the sound does not clear with coughing Rhonchi - Correct Answer-Typically heard over trachea/bronchi on inspiration and expiration. Loud/coarse sounds. Rough. Caused by mucus. If the sound improves or clears with coughing then it is rhonchi Wheezes - Correct Answer-Heard over all lung fields. Musical/squeaking sound. High-velocity airflow through narrow/obstructed airways. Caused by narrowed/obstructed. Mostly heard on expiration. Usually an issue of the lower respiratory system Stridor - Correct Answer-Harsh, loud, high pitched. Heard on inspiration. Indicative of narrowed airway or foreign body. Usually an issue of the upper respiratory system Friction Rub - Correct Answer-Rubbing/grating sound. Loudest over lower lateral anterior surface. Indicative of inflamed pleura rubbing against chest wall. Resonance - Correct Answer-Normal lung sound Aeration - Correct Answer-How much air is in their lungs Scoliosis - Correct Answer- Funnel Chest - Correct Answer- Pigeon Chest - Correct Answer- Define cognition and components of cognition - Correct Answer- Cognition: The process of thought that embodies perception, attention, visual/spatial cognition, language, learning, memory, and executive function; as well as the higher-order thinking skills of comprehension, insight, problem solving, reasoning, decision making, creativity, and metacognition. Differentiate between dementia and delirium. - Correct Answer- Dementia: Various organic disorders that progressively affect cognitive functioning. Occurs over a period of months to years. Impaired memory, judgment, attention, span and abstract thinking Delirium: An acute illness that results in a temporary state of confusion. Lasts hours or weeks, resolves with treatment. May be the first sign of a medical complication. The most common complication of hospitalization for the elderly Discuss risk factors for impaired cognition. - Correct Answer-Personal behaviors: Chemical exposure, activities that predispose someone to a traumatic brain injury, high-risk behaviors Environmental exposures: lead, pesticides Congenital and genetic conditions: chromosomal abnormalities, downs syndrome, fragile X syndrome Maternal Issues: Fetal alcohol syndrome, illegal drug exposure Discuss nursing assessment tools for impaired cognition. - Correct Answer-Mini-mental examination: A standardized cognitive assessment tool, provides II cognitive tasks Confusion Assessment Method (CAM) Mini-Cog Discuss nursing interventions when caring for clients with impaired cognition - Correct Answer-Pharmacotherapy, predictable routine, consistent caregivers, simple instructions, eye contact, presence of familiar items/people, sensory aids, allowed to be involved in decision making, promote general health and comfort, reorientation, pain Decorticate Posture - Correct Answer-Their legs are extended but their arms are bent and their fists are clenched. Due to severe brain injury Decerebrate - Correct Answer-When the upper arms and limbs are extended, toes are pointed down, head and neck may be arched back and the muscles are rigid. Caused by brain injury Mental Retardation - Correct Answer-developmental disorder Delirium - Correct Answer-global cognitive disorder Dementia - Correct Answer-global cognitive disorder Focal Cognitive Disorders - Correct Answer-amnesia, aphasia, executive function disorders, etc... Aphasia - Correct Answer-loss of ability to understand or express speech. Caused by brain damage Amnesia - Correct Answer-Some loss of memory. Caused by brain damage Primary Dementia - Correct Answer-- irreversible and is not caused by a secondary disease Secondary Dementia - Correct Answer-irreversible and occurs as a result of another disease process Agnosia - Correct Answer-inability to process sensory information Delusions - Correct Answer-are false beliefs that misinterpret the environment or experiences Diagnostic tests for cognition - Correct Answer-Lab tests: to rule out medical problems Neuropsychometric: Standardized/formal testing Brain imaging techniques: MRI or PET scanning SPICES tool - Correct Answer-S= Sleeping disorders P= Problems with eating or feeding I= Incontinence C= Confusion E= Evidence of Falls S= Skin breakdown Pharmacotherapy for cognition - Correct Answer-Hypnotics, anxiolytics, antidepressants, antipsychotics, cholinesterase inhibitors (AD), memantine (Namenda) (AD) Irreversible Health Related Conditions for risk factors for impaired cognition - Correct Answer-Stroke, brain tumor, CVD (cardiovascular disease), Chronic Pulmonary Disease, Depression Reversible Health Conditions for risk factors for impaired cognition - Correct Answer-Fluid and electrolyte balance, systemic or intracranial infection, fever, pain, hypoglycemia, anoxia, some medications, heart conditions Anoxia - Correct Answer-Absence of oxygen Risk factors for females for impaired cognition - Correct Answer- Overall poor health, dependency, lack of social support, insomnia Risk factors for males for impaired cognition - Correct Answer-History of stroke, history of diabetes What interacts to help produce sensation and perception? - Correct Answer-Sensory receptors and the nervous system The 5 senses are: - Correct Answer-Vision, hearing, taste, smell, touch Vision is also called: - Correct Answer-Visual Hearing is also called: - Correct Answer-Auditory Taste is also called: - Correct Answer-Gustatory Smell is also called: - Correct Answer-Olfactory Touch is also called: - Correct Answer-Tactile Who is at the highest risk for impaired sensory/ perception - Correct Answer-Elderly Presbyopia - Correct Answer-Inability to focus on near objects Medications that can cause vision problems - Correct Answer-some of the most common issues w/certain meds...blurred vision, pupillary constriction, retinal toxicity, halo effects & dry eyes Medications that can cause ototoxicity problems - Correct Answer- Sometimes permanent inner ear problems that can also affect balance Can be temporary or permanent Parasthesias (numbness/tingling in the hands and feet) Cancer drugs (antineoplastics) can cause numbness/tingling in hands & feet Parasthesias - Correct Answer-Numbness/tingling in the hands and feet Medications that can cause taste and smell problems - Correct Answer-Chemotherapy is big culprit Up to half of all cancer patients exhibit taste problems Meds are the most common cause of impaired taste Antihypertensives Antibiotics Antivirals Diuretics Calcium channel blockers The pain pathway - Correct Answer-1. Site of injury, 2. spinal cord, 3. Brainstem, 4. Cerebrum Somatomotor cortex - Correct Answer-Receives all motor import from the body Somatosensory cortex - Correct Answer-Receives all sensory import from the body Anatomy of the brain - Correct Answer- Sclera - Correct Answer-White thickness that protects the eye Cornea - Correct Answer-Allows light to come into the eye and only covers the iris Iris - Correct Answer-Regulates the amount of light that comes in Eye Anatomy - Correct Answer- Conjunctivitis - Correct Answer-infection, inflammation of the conjunctiva which lines the eye and the surface of the eye. Highly contagious so do not share towels and wash cloths, clean eye as prescribed and they'll get eyedrops from the pharmacy and they will be administered as ordered, good infection education External ear - Correct Answer- Middle ear - Correct Answer-An air-filled space, located in the temporal bone, connects to the throat by the eustachian tube, eustachian tube opens to allow air flow when chewing/swallowing. Vibrations of the tympanic membrane (eardrum) cause the auditory ossicles to move and send sound waves to the oval window Once the waves reach the oval window, they have been amplified greatly What is the purpose of the eustachian tube? - Correct Answer-To equalize air pressure on both sides of the eardrum Inner ear - Correct Answer-Bony labyrinth surrounding a membrane, cochlear, vestibular system, the physical vibrations that we feel int he ear get transmitted to the brain and that is how we hear Cochlea - Correct Answer-Hearing ability Vestibular system - Correct Answer-Helps control balance Taste - Correct Answer-Digestion starts in the mouth, directly related to the ability to swallow and chew, transmitted to medulla in the brain, visceral sensory fibers from esophagus, stomach, intestines and liver allow taste signals to initiate digestive activity Smell - Correct Answer-Controlled by cranial nerve I (olfactory) Critical to the desire to eat...therefore to stay healthy Sensory receptors in the nose that respond to airborne chemicals Chemicals bond to cilia receptors in the nose Cascade of reactions that eventually leads to the olfactory nerve Brain processes and determines what type of smell it is Touch - Correct Answer-Somatosensory system Controlled by large network of touch receptors and nerve endings in the skin Receptors transmit the senses of pain, temperature, pressure, itching, etc... Examination of the sensory system for taste and smell - Correct Answer-Taste and smell Inspect tongue and oral cavity Have your patient open their mouth and look inside Inspect nose Look at the inside and outside of their nose Check for patency of nasal airway Test tasting ability Have them move to food around in their mouth to make sure they are really tasting that food Test smell What is put in newborns eyes to prevent infection from STDs? - Correct Answer-Silver nitrate What is secondary prevention? - Correct Answer-Screening Screening vision - Correct Answer-Recommended across the lifespan starting in the newborn period Visual acuity charts starting after age 3 Adults up to age 60 should receive an eye exam at least every 2 years and PRN Special attention should be paid to those w/chronic diseases such as DM Yearly exams for those older than 60 Eye dilation during exams Tonometry Tonometry - Correct Answer-A procedure testing for glaucoma. Covered probe gently touches the surface of the cornea several times to register the IOP (intraocular pressure)...cornea is first anesthetized...normal is 10-22...consistent pressures >27, high risk for glaucoma Cochlear Implants - Correct Answer-Surgically implanted devices Provide direct electrical stimulation to the auditory nerve May work for children & adults with whom hearing aids do not work Risk factors for otitis media - Correct Answer-Recent upper respiratory infections Exposure to household smoke Bottle feeding as an infant Daycare attendance Signs and symptoms of otitis media - Correct Answer-Crying, fussy, irritable Might rub or pull ear Loss of appetite Difficulty sleeping Adaptive methods for hearing and vision - Correct Answer-Braille: Raised up bumps that assist patients with reading by touching Guide dogs Sign language Closed-caption TV Assistive listening Amplifies sound for the patient Common for patients who are hard of hearing Conductive hearing loss - Correct Answer-Obstruction of the external ear canal Perforated tympanic membrane Fluid Scarring Common in children who have recurrent ear infections Sensorineural hearing loss - Correct Answer-Damaged inner ear or auditory CN Lost or damaged receptor cells Congenital, genetic, or acquired Most common type of hearing loss Not usually "fixable" but hearing aids generally work well Risk factors in children for sensorineural hearing loss - Correct Answer-Family history Positive titer for TORCH Toxoplasmosis Rubella HIV Cytomegalovirus Herpes Craniofacial abnormalities Very LBW (Low birth weight) Bilirubin >16 mg/dl Meningitis Ototoxic drugs - Correct Answer-aspirin furosemide (Lasix) aminoglycosides antibiotics (gentamicin, streptomycin, tobramycin) Chemotherapy agents Tinnitus - Correct Answer-Perception of sound or noise in the ear without stimulus from the environment Described as a buzzing, roaring, or ringing Associated with noise induced hearing loss or ototoxicity A disorder that involves the inner ear Procedure for cognition, hearing, vision assessment - Correct Answer- Introduce self Verify patient's identity Explain the procedure to the patient Wash hands Assess ability to follow commands - Correct Answer-Asking your patient to follow commands is a good indicator of how much damage remains and where the damage is. Occipital lobe - Correct Answer-Vision Cerebellum - Correct Answer-Movement, coordinated balance Temporal lobe - Correct Answer-Memory, emotions, hearing, language, learning Frontal lobe - Correct Answer-Judgement, planning, complex intellectual processes Parietal lobe - Correct Answer-Interpretation of sensory information Broca area - Correct Answer-Motor speech area so it is where movements required to produce speech are from Wernickes area - Correct Answer-How we comprehend language and it is the sensory speech area and helps us use the correct words to express ourselves Expressive Aphasia - Correct Answer-Patient knows what he/she wants to say but has trouble communicating it Usually not much difference between reading or writing Broca's area damaged Receptive Aphasia - Correct Answer-Patient hears the voice but does not understand it These patients will many times take language literally Their own speech may become disturbed because they do not understand it Wernicke's area damaged Assessing eyes - Correct Answer-Inspect: color size shape symmetry of eyes and pupils PERRLA - Correct Answer-Pupils Equal Round React to light Accommodation (use a pencil and bring it in closer to them and their pupils should get smaller and their eyes should cross) Neuro assessment for pupils - Correct Answer-Assess that both pupils are the same size ...Equal or unequal -Assess for regularity/irregularity -Assess for reaction to light ...Brisk, sluggish, flaring, nonreactive Inspecting the conjunctiva of the lower lid - Correct Answer- What does a cataract look like? - Correct Answer- What does acute glaucoma look like? - Correct Answer- Neuro assessment eye response - Correct Answer-Opens eyes to voice Spontaneous Opens eyes to touch Opens eyes to pain Lifting brows Pt attempts to open eyes No response Drifts to the right Drifts to the left Neuro assessment seizure activity - Correct Answer-Yes/no Neuro assessment extremity reflex/sensation strength assessment - Correct Answer-Normal power: 5 Moves against resistance: 4 Moves against gravity: 3 Moves with gravity eliminated: 2 Palpable/visible contraction: 1 Flaccid: 0 Mini mental assessment - Correct Answer-Use when you suspect they have delirium or dementia or any neuro deficits that you suspect. The highest number you can get is a 30 and if you are less than a 24 you are at risk for delirium and dementia Assessing the nose - Correct Answer-Inspect shape, size, color, nasal flaring Lightly palpate for tenderness Determine patency of nares Inspect nasal cavity Visual Inspection - Correct Answer-Inspect the head and face (eyes & ears) - Size & shape - Symmetry - Edema (swelling) - Hair distribution - Drainage (out of any spots in their body) What is the only effect of hypoxia that infants might show? - Correct Answer-Nasal flaring Assessing the ears and hearing - Correct Answer-Inspect for symmetry, size, & position Inspect external auditory canal If you palpate the tragus and there is pain what does that indicate? - Correct Answer-An infection of the outer ear (otis externa) How do you activate a tuning fork? - Correct Answer-Strike it against the heel of your hand and it will start to vibrate What will happen during the Webber test for a patient with conductive hearing loss? - Correct Answer-problems conducting sound waves. During the Webber test they will hear vibration louder in the affected ear Could be obstruction What will happen during the Webber test for a patient with sensorineural hearing loss? - Correct Answer-damage to hearing nerves or hair cells in the cochlea. During the Webber test they will hear louder in the unaffected ear Webber test - Correct Answer-you put the tuning fork on the top of their head after it is activated and they should be able to hear equally in each ear In a normal person they hear equally in both ears Glasgow coma scale - Correct Answer-The highest score you can get is 15 and the lowest is 3. Higher scores are better Cranial nerve I - Correct Answer-Olfactory. Sense of smell. Sensory nerve. Cranial nerve II - Correct Answer-Optic. Vision. Sensory nerve. Cranial nerve III - Correct Answer-Oculomotor. Pupillary reflex, extrinsic muscle movement of eye. Motor nerve Test near vision - Correct Answer-They test both eyes at the same time. They can wear their glasses Testing visual fields by confrontation - Correct Answer-You have to be eye level with your patient and close to them. You as the nurse cover one eye and the patient covers the eye across from you and you are standing or sitting and you hold a pen or something like that equally distant between both you and the patient and the patient says when they see the the pen or thing come into sight How to test for CN III - Correct Answer-Testing PERRLA and you bring your pen light out and go in on each eye How to test for CN III, IV, VI - Correct Answer-Eye movement with muscle and nerve coordination. Ask patient not to move head. The patient is looking at the object and not moving their head but they are moving their eyes. How to test for CN V - Correct Answer-Ask the patient to close their eyes and grit their teeth and you are going to feel their jaw line to feel that it is evenly clenching. Have the patient close their eyes and you touch them on the right side and they say where you are touching them and then do the other side and then do both sides and the patient needs to say where and when you touched them How to test for CN VII - Correct Answer-Ask your patient to smile and show teeth and then have your patient close their eyes tightly. Or have them puff out their cheeks and then after that raise their eyebrows. They can have their eyes open or closed for these two How to test for CN VIII - Correct Answer-Stand behind your patient and you test one ear at a time and so the patient coves one of their ears and you stand on the side of the ear that is not covered and you whisper something while standing 6 inches away and then step back and stand 2 feet away and say something else and then do the same thing on the other side How to test for CN IX, X - Correct Answer-To test this you have the patient stick out their tongue and say "ahhh" and then you look in their mouth and see if their palate elevates and if you cant see it have them stick out their tongue further Vagus is checking the gag reflex you put a tongue depressor in the back of their throat to test the gag reflex. ONLY done when it needs to be done How to test for CN XI - Correct Answer-Put your hands on their shoulders and apply light resistance and turn their head against resistance by putting your hand on their cheek How to test for CN XII - Correct Answer-To test this nerve have the patient stick their tongue out and have them forcefully move it from side to side or cheek to cheek Definition of perfusion - Correct Answer-Supply oxygen and nutrients needed for metabolic processes to the tissues. Who gets the most perfusion if there is not enough fluid circulating? - Correct Answer-Head, heart and kidneys get the most perfusion and perfusion is decreased to extremities Central Perfusion - Correct Answer-Force of blood movement generated by cardiac output Requires adequate cardiac function, blood pressure, and blood volume Cardiac function (the heart) How much is getting out of the heart itself Tissue or Local Perfusion - Correct Answer-Volume of blood that flows to target tissue Requires patent vessels, adequate hydrostatic pressure, and capillary permeability When the blood is actually getting out to the tissue itself Blood pressure usually relates to what? - Correct Answer-Volume and kidney control pressure. With COPD and other issues this becomes a high pressure system and that causes lots of issues Systemic Circulation - Correct Answer-High pressure system. Pumps blood out and all the way to the toes and that force of blood that is pumped out drives the blood back from the toes to the heart again Circulation system diagram - Correct Answer- Cardiac cycle - Correct Answer-Contraction (systole) and relaxation (diastole) of the chambers of the heart constitutes one heart beat What is a normal heart rate - Correct Answer-60-100 Normal blood pressure is what - Correct Answer-120/80 but studies are showing that that may be hypertensive Who has abnormally high heart rates? - Correct Answer-Children have heart rates above 100 and neonates have normal heart rates of 140 but by the time the child is 8 they start to normalize Why do children have higher heart rates? - Correct Answer-It is normal for children to have an irregular heart rate (an arrhythmia) because kids have a respiratory pattern irregularity (called a sinus arrhythmia) Consequences of impaired tissue (local) perfusion - Correct Answer- Impairment of tissue perfusion is associated with loss of vessel patency or permeability, or inadequate central perfusion Results in impaired blood flow to the affected body tissue (localized effect) Leads to ischemia and, ultimately, cell death if uncorrected The cardiac cycle - Correct Answer- Heart rate changes - Correct Answer-Increase HR = Increase CO except: Sustained Rapid HR = decrease filling time = Decreased CO Decreased HR = Decreased CO Factors affecting heart rate - Correct Answer-Autonomic nervous system: Sympathetic nervous system, parasympathetic nervous system Vagal nerve response - Correct Answer-Can be good or bad. It activates the vagal nerve which activates the parasympathetic response and decreases the heart rate People sometimes pass out when they are bearing down to poop or feel light headed due to N/V Sometimes can be good to help get heart rate under control Coughing stimulates the vagus nerve and can slow the heart Ejection Fraction (EF) - Correct Answer-Stroke Volume divided by end- diastolic volume Represents the percent of volume ejected from the heart during contraction Normal is 50-70% Individuals with damaged hearts will have a reduced EF and decreased perfusion to the body systems People who have EF in the 30's-40's are going to show symptoms of: -Fatigue -Restless (more about oxygenation more than anything else) -Swelling in ankles Cardiac Output (CO) - Correct Answer-Stroke Volume (SV) X HR Amount of blood pumped into the pulmonary and systemic circulation in 1 minute. The volume that is hitting the body ever minute Average Adult CO is 4-8L/min With poor functioning heart CO decreases = poor tissue perfusion Contractility - Correct Answer-Ability of heart muscle fibers to shorten -Enlarging uterus causes stasis of blood in lower extremities = edema & varicose veins Orthostatic hypotension - Correct Answer-When a patient goes from a lying position to a standing position they get dizzy because their blood pressure drops Cardiovascular changes with aging - Correct Answer-Myocardial hypertrophy Stiffened heart valves (fibrosis & calcification) Stenosis or incompetence of Valves -Sometimes older adults have decreased pain sensation For heart attack: -Men have crushing pain in their chest, pain in their left law and left arm -Women tend to have midsternal back pain, estrogen is a heart protectant and once women meet menopause their cardiac disease risk is equal to men -Older adults have general fatigue, and sometimes complain of some pain, indigestion Preload - Correct Answer--Stretch of cardiac muscle fibers -Starling's law - The greater the volume, the greater the stretch, and the greater the force of the contraction to accomplish emptying. -Too much volume (Renal disease, CHF) cause overstretch and ineffective contraction -Too little volume (fluid volume deficit) cause to little stretch and decreased CO Afterload - Correct Answer-Force the ventricles must overcome to eject blood. Pulmonary Vascular resistance - low pressure (right heart) Systemic Vascular resistance - high pressure (left heart) Systemic resistance causes problems with afterload Clinical indicators of CO changes - Correct Answer-Manifested by changes in organ function - brain - kidneys - Skin integrity/tissue Cardiac Index - CO adjusted for body size - CO divided by BSA (M2) - normal between 2.5-4.2L/min/m2 Changes in the Vascular System - Correct Answer--Lipid deposits and calcification of vessels occur resulting in decreased elasticity or hardening of vessel walls -Blood pressure changes -From the time we are born and start eating we start depositing lipids and the amount we deposit depends on how we eat and genetics -Nicotine causes lipids to deposit faster than anything else Transition from fetal to pulmonary circulation - Correct Answer-First breath expands lungs Pulmonary resistance drops and blood flows to lungs - ductus arteriosus closes (10-15 hours after birth) permanent closure occurs 10-21 days after birth Increased pressure in left atrium stimulates closure of foramen ovale Infant heart - Correct Answer--Cardiac arrest in children is usually due to respiratory issues -Kids have higher fevers than adults -Kids have inexperienced immune systems -Increased oxygen demand due to tachycardia and can cause dehydration -High HR over 100beats/min - due to high metabolic rate and -Oxygen needs -Blood pressure low -Increase Oxygen demand will cause tachycardia - stress, exercise, fever, respiratory distress -Little cardiac reserve Valvular Diseases - Correct Answer--Mitral, aortic, tricuspid, and pulmonic stenosis -Mitral and aortic regurgitation -Mitral valve prolapse General Assessment Findings for Cardiac Issues - Correct Answer-- Chest pain/ discomfort -Shortness of breath -Edema, weight gain -Nocturia (they get up at night to go to the bathroom) -Palpitations or dysrhythmias -Fatigue -Dizziness, syncope (passing out), changes in LOC Cardiac Markers - Correct Answer--Troponin I (cTnl) 0.5-2.3ng/ml suspicious for cardiac injury, >2.3ng/ml positive for myocardial injury Electrocardiography (ECG) - Correct Answer--Electrocardiography (ECG) and continuous monitoring -Hardwire: where they put the leads on you and connect you to the machine. -Telemetry: They are not hardwired to a system they have a small box that records everything and they could be monitored from anywhere in the hospital -Wireless Mobile Cardiac Monitoring: they are wired to a wireless machine so the patient goes home and their heart is monitored in the hospital Atrial Fibrillation - Correct Answer-The real irregular heart rhythm due to electrical impulses that do not originate in the SA node and they are at a huge risk for blood clots Cardiac Catheterization - Correct Answer--Invasive diagnostic procedure -Femoral or brachial approach -Nursing follow-up care -Monitor catheter site access for bleeding -Assessing peripheral pulses, cap. refill, temp., and color in the affected extremity -Screening for dysrhythmias -Bedrest 2-6 hours -Patient is sedated with a local anesthesia with conscious sedation -They go up through some important artery and it is a catheter that they thread up through the artery and into the heart itself Serum Lipid Diagnostic Test - Correct Answer--Consist of triglycerides, cholesterol -Lipoproteins (LDL's & HDL's) - transport triglycerides and cholesterol -LDL's - to the cells -HDL's - away from the cell -Triglycerides main storage of lipids and constitute approximately 95% of fatty tissue -Cholesterol - precursor to corticosteroids, sex hormones and bile salts - absorbed by food and produced by liver -Lipids deposit on the inside of your vasculature and cause turbulent blood flow through that vasculature and if it closes then you don't have any blood flow through the vasculature -For a total cholesterol level we want you to be less than 200 -Triglycerides we want them less than 150 -LDL= Bad so we want them low. They carry triglycerides to your vessels -HDL= Good so we want them high. They carry triglycerides away from your vessels Pharmacotherapy for Impaired Central Perfusion - Correct Answer- Antihypertensives -The key to these are knowing which ones work for you patinets -Side effects can be very severe Antiarrhythmics -Drugs that control the rhythm -Terminated: Desired heart rate is reached, client shows signs of myocardial ischemia, or becomes exhausted. -Monitored: ECG, rhythm, and ischemic changes. -We are trying to see how the heart functions under stress -The goal is to get the patients heart rate up to a certain level -They are on an ECG machine the whole time and we are monitoring their rhythm and ischemic changes Pain of any kind can cause ischemia Echocardiography - Correct Answer--Transthoracic - noninvasive -Used to measure ejection fraction -Examine size, shape, and movement of cardiac structures -Looking from the outside in and looking through the bone structures to the soft tissues -Transesophageal (TEE) - transducer is through the mouth into the esophagus -Topical anesthetic agent and moderate sedation utilized -We are more interested in the back side of the heart -They take a scope to look through the esophagus to look at the atria -This is done to assess that there is not a clot in the atria to avoid a stroke during shocking them to get their heart going correctly again Objectives Outline in Health People 2020 - Correct Answer-Coronary heart disease High blood cholesterol Key Objectives for Coronary Heart Disease - Correct Answer-- Screening for risk factors -Individual, community, culturally linguistically appropriate education and counseling -Education about symptoms and emergency care -Weight reduction programs -Programs to increase physical activity Key Objectives for High Total Blood Cholesterol - Correct Answer-- Education about risks -Education about diet and exercise -Education about screening Why is it important to look at a baby's lips? - Correct Answer-To assess their perfusion and oxygenation Increased temperature means what for perfusion? - Correct Answer- Increased need for perfusion Decreased temperature means what for perfusion? - Correct Answer- Decreased need for perfusion For cardiac assessment assess... - Correct Answer-Color, Temperature, Edema, Pain/Fatigue, Respiration rate, Heart rate/Pulse, Heart sounds, hair growth patterns in legs, clubbing, BP, Veins Acytese - Correct Answer-Build up of fluid Palpitation - Correct Answer-Racing/fluttering of the heart Is type I diabetes genetic? - Correct Answer-No it is an autoimmune disorder Is type II diabetes genetic? - Correct Answer-It can be Physical exam (objective) - Correct Answer-Dependent rubor: -One leg/foot is swollen and discolored -Usually indicates peripheral artery disease -You do not have good blood flow -Peripheral arterial disease -Peripheral vascular disease