Download NUR 155 EXAM 3 (GALEN) 2026 ACTUAL QUESTIONS WITH VERIFIED SOLUTIONS. and more Exams Nursing in PDF only on Docsity!
NUR 155 EXAM 3 (GALEN) 2026
ACTUAL QUESTIONS WITH
VERIFIED SOLUTIONS.
proprioception awareness of posture and movement things to prevent contracture: permanent fixation of a joint splints, braces foot drop permanent plantar flexion isotonic exercise active movement with constant muscle contractions EX: walking, self feeding, turning in bed isometric exercise tension and relaxation of muscles w/o joint movement EX: planks, calf raises aerobic exercise requires oxygen metabolism to produce energy EX: stair climbing, walking anaerobic exercise builds power & body mass, doesn't require oxygen EX: heavy weightlifting if pt has sensory deprivation you do what?
open up blinds orient pt to the day time turn on lights encourage visitors give puzzles and activities to do if pt has sensory overload you do what? dim the lights give them ear plugs cluster care hearing precautions make sure pt has hearing aids on take mask down speak clearly dont yell vision precations orient pt to placement of items (clock) keep things within reach ensure pts have their glasses braille if needed taste precautions may not know what they are eating give highly aromatic food oral hygiene to keep oral cavity pleasant tasting encourage pt to eat variety of foods dont serve spicy foods smell precautions eliminate odors that arent pleasant stimulate environment w/ pleasant odors pt rely on expiration dates
encourage use of hearing aids, minimize background noise, speak clearly, face the pt when speaking equilibrium instruct pt to call for help, keep lights dim, floor clear of any obstacles, keep basin at bedside for nausea and vomiting vision orient pt to placement of things in room, call light within reach risk factors for skin breakdown
- diabetes (loss of sensitivity, may not know they have a wound)
- cardiovascular disease (COPD, heart failure)
- malnutrition (decreased protein intake)
- age (older people are more at risk)
- friction and shear, sliding, tearing <- this tears the skin risk factors affecting wound healing
- oxygen & tissue perfusion
- diabetes
- nutrition (protein, vit C/A/E, zinc copper)
- age
- infection (affects ability to heal)
- fecal & urinary incontinence risk factors for developing pressure injury
- boney prominence
- decreased lean body mass
- decreased pain perception
- hyperthermia (fever)
- age phases of wound healing inflammatory, proliferative, maturation
Phases of Wound Healing: Inflammatory Phase bodys initial response to wounding of the skin, lasts about 3 days, bleeding occurs which is known as coagulation cascade and formation of clot begins, which stops the bleeding, includes process of homeostasis, there is an increase of pain, swelling, & redness Phases of Wound Healing: Proliferative phase repair the defect, filling the bed with granulation tissue (new tissue, beefy red, granular, bumpy, fragile), lasts several weeks Phases of Wound Healing: Maturation phase known as the remodeling phase, usually lasts up to a year, scar tissue is formed and strengths (avascular mass of collagen) eschar unstageable, cant see underneath determine pus colors yellow, green, blue What should you NOT see in a pressure injury arteries What is usually visible within a pressure wound tissue, muscles and bones dehiscence occurs in connection with surgical incisions, partial or incomplete separation of tissue layers during the healing process (obesity, poor nutrition) evisceration total separation of the tissue layers, organs are coming out
readily available, can be moistened, absorbent, not an effective barrier, removing often results i pain and damage to wound bed Dressing: Transparent film prevent bacteria and fluids from entering wound, allow oxygen and water vapor to move through it, it is not absorbent, used for wounds that have minimal or no drainage Dressing: hydrocolloids, occlusive, adessive dressing absorb small to moderate amount of drainage, provide a moist wound, long wear time makes this dressing inappropriate for infected wounds Dressing: Foams pulls fluid away from the wound bed, but maintains a moist wound, should not be used for wounds with small amount of drainage Dressing: Alginates highly absorbent, can be combined, decreases the frequency of dressing changes, avoid in dry wounds, use on bleeding wounds Dressing: gels add moisture to wound, not absorbent, used for wounds that have minimal drainage S closing of the tricuspid and mitral valve S closing of the aortic and pulmonic valves hypoxemia
reduced oxygen in the blood dyspnea difficulty breathing (have pt sit up) incentive spirometry steps pt should be sat up in upright position, see steady rise of marker, instruct pt to inhale slowly with mouth on the mouthpiece, inhale as much as possible, hold for 3-5 seconds, then remove the mouthpiece and exhale slowly, repeat 5- 12 times with 2 controlled coughs, do it every 1-2 hours while pt is awake, see the rise of the cylinder in the chamber Oxygen safety No candles, cigarettes in the area, AVOID USE OF ELECTRIC RAZORS , hairdryers, electric blankets, electric heaters that may cause a spark
- AVOID use of flammable or oil-based products
- no petroleum-based lubricants oxygen delivery systems
- simple nasal cannula
- simple face mask
- partial rebreather mask
- face tent
- venturi mask
- nonrebreather mask simple nasal cannula 24 - 44%, 1-6 L simple face mask 40 - 60%, 5-8 L
increased risk of uti and urinary stones due to the dependent position of the bladder when supine Causes of fecal impaction from being immobile decreased appetite and decreased fluid intake causes hypomotility in the GI tract, constipation and slow peristalsis Causes of skin breakdown from being immobile decreases skin turgor and pressure ulcers, areas most at risk are boney prominences Psychosocial effects of being immobile they can become depressed, bored, have low self-esteem and be irritable from isolation Ways to prevent skin breakdown Q2 turns, getting the PT to ambulate. Passive and active ROM, and the use of SCD's and tedhoses 8===D Hi my names Ryan, you all smell great today. Peace What are SCD's used for immobile patients that are at risk for lower extremity venusstasis, it increases venous return alterations in cardiopulmonary system look at vital signs, including BP in 3 positions
- inspection, palpation, and auscultation of heart and lungs
- cough assessment
- vascular assessment: is there edema in the extremities, how are the pulses, skin color, texture, cap refill?
- pulse deficient:apical pulse minus peripheral pulse 120-
100=20 this is the pulse deficit
- listen to both sides of lungs to see if they sound the same (decreased or constricted airway?)
- apical pulse for full minute complete blood count RBC, hemoglobin, hematocrit RBC: males 4.7-6.1/females 4.2-5. hemoglobin: males 14-18/females 12- 16 hematocrit: males 42-52%/females 37- 47 basic metabolic panel assess renal function, glucose level, and electrolytes arterial blood gas decreased oxygenation or acid base balance lipids used to diagnose hyperlipidemia, measures total cholesterol, LDL, HDL and triglycerides cardiac enzymes released when myocardial necrosis occurs (death of heart muscle cells) Target HPL (men) 345 Target HPL (women) 355 LDL
specifies the treatment a person wants to receive when the pt is unconscious right no longer capable to make decisions healthy care proxy power of attorney, legal document that allows a designated person to make legal and financial decisions on behalf of an individual, can make decisions on health care for the pt if they are unable to ethical principles beneficence, nonmaleficience, respect for autonomy, justice, veracity, accountability, advocacy, confidentiality, fidelity, responsibility beneficence doing good, acting on behalf of others, putting their priority/needs first nonmaleficience do no harm respect for autonomy self determination, ability to make decisions for yourself justice acting fair and equal for all patients, take care of everyone the same veracity obligation to always be truthful accountability willingness to accept responsibility for ones actions
advocacy advocate their rights, meds, procedures, for home health, etc.. confidentiality limits sharing private pt information fidelity keeping promises, keeping your word responsibility being dependable and reliable homeostasis body's regulation of systems to maintain a steady state fight or flight response response to stress by activation of nervous system compensation focusing on strengths rather than perceived weakness denial ignoring aspects of reality that induce anxiety or contribute to a loss of self-esteem displacement redirecting negative emotions perceived as unacceptable to a safer focus intellectualization overthinking a challenging situation to avoid dealing with emotions projection
"anger turned inward", comes from experience of loss, diminished physical health, may feel worthless, tell the pt you are here to help them, acknowledge their needs complementary and alternative therapies relaxation therapy, exercise, sleep, guided imagery, yoga, meditation, mindfulness, biofeedback, energy therapy (reiki), eastern medicine crisis intervention short term assistance provide at a time if physical or emotional upheaval with the goal of helping the person in distress to regain equilibrium stress and nursing
- workplace stress can lead to depression, burnout, decreased job satisfaction, compassion fatigue (taking care of so many ppl, its affecting you)
- take care of yourself FIRST, use healthy coping strategies anger and aggression always try to deescalate a situation, explain what needs to be done, don't lash out at us active ROM get the most benefits, pt is able to do things for themselves passive ROM pt may be to weak to do it, help them with it, NEVER PUT A JOINT PAST NORMAL FUNCTION
