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NUR 2356 / NUR2356 Multidimensional Care I (MDC 1)
Exam 1 (Latest 2026/2027 Update) | Rasmussen |
Complete Study Guide | Verified Questions & Answers |
100% Correct Solutions | Grade A
What does Maslow believe about the hierarchy of needs? a person could not meet the needs of love and belonging and self-esteem without meeting basic physiological needs. herbal supplements & their usage Ginko Biloba: Depression, memory Ginseng: depression Kava: Depression, anxiety Echinacea: common cold Chamomile: calming and soothing properties. Goldenseal: Stimulates immune system and bile secretion Melatonin: sleep Kava Herbal Antianxiety Agent and Depression Name the pain scales 1 - 10 FACES FLACC
CRIES
FLACC pain scale F:face L:legs A:activity C:cry C:consolability Things to know about pain assessment PQRST If treatment works It's subjective Ginko Biloba Depression and memory (dementia) Ginseng fatigue and depression Echinacea common cold
Examples of self actualization (e.g., extent to which goals are achieved, role performance, Personal growth, reaching one's highest potential) Catholic End-of-Life indviduals may be brought to hospitalized patients by a priest, deacon, or designated lay Eucharis- tic minister A Roman Catholic who is seriously ill might wish to receive the sacrament of anointing the sick. (last rites) Last Rites Anointing of the Sick (Catholic) Mormons follow a strict health code, known as the Word of Wisdom Word of Wisdom (Mormon Culture) advises healthful living and pro- hibits the use of tea, coffee, alcohol, and tobacco Mormons believe in life before and after death; thus, death repre- sents the passage into another life phrase
(Mormon) Nurses may remove garments before surgery, but it must at all times be considered intensely private and be treated with respect Mormons wear garments at all times except for hygiene, elimination, or being intimate in marriage Nursing Interventions to achieve self actualization Provide art supplies Esteem Met when a person feels a sense of accomplishment and are recognized by others for that achievement. Esteem tier consists of? (Maslow Hierarchy of needs)
- Feeling of accomplishment
- Body image
- Pride in achievements
- Admiration from others Self-Actualization tier consists of? (Maslow Hierarchy of needs)
- Temperature regulation
- Elimination
- Rest
- Sleep effects
- Sex
- Physical Activity
- mobility assessment
- Blood flow (perfusion) is necessary to meet other basic needs Nursing Interventions to achieve safety and security Prevent falls & Communicating concerns Love and belonging needs are met when the person seeks personal relationships with others. Love/Belonging tier consists of? (Maslow Hierarchy of needs)
- Intimate relationship
- Friends
- Social supports Nursing Interventions to achieve love & belonging Referring a patient to a support group
Physiological needs are essential for maintenance of life Examples of physiological needs (e.g., oxygen, water, food, air, water, shelter, sleep and rest, elimination, activity, temperature regulation) Nursing Interventions to achieve physiological needs
- Helping patient to eat dinner 2.Changing a patients oxygen tank 3.Ensure patient is getting enough rest Basic physiological needs (needs that are essential for the maintenance of life) Air, Food (Nutrition), water, temp regulation, elimination, rest (sleep effects), sex, physical activity (mobility assessment), blood flow (perfusion) is necessary to meet other basic needs One of the most critical nursing interventions the nurse has is the ability to monitor and interpret the client's? vital signs. Interventions for elevated/decreased vitals continue to monitor patient
v. Infuse warm solutions vi. Remove wet clothing Hyperthermia temperature above the normal range that may be related to exercise or exposure to an abnormally hot environment
- Temp is greather than 104 degrees What is perfusion? Adequate arterial blood flow to the peripheral tissue. What does peripheral and central perfusion relate to? Peripheral=peripheral tissue Central=major organs Definition of pulse? rhythmic expansion of an artery produced when a bolus of oxygenated blood is forced into it by contraction of the heart. Bradycardia pulse rate less than 60 bpm
Tachycardia pulse rate beats higher than 100/min Influences for pulses? o Exercise o Age o Gender o Anxiety o Pain Documentation for pulse? o Rhythm - even tempo o Strength (0-4+, absent, weak or thready, normal, strong, bounding) o Regular rhythm: 30 seconds x 2- or 15-seconds x 4o Irregular rhythm (regular/irregular); full minute; apical. o •Amplitude is what is measured o •Rate, rhythm (regular or irregular), and quality (strong, weak or bounding) Quality of pulse strong, weak or bounding Strength of pulse 0 = absent
expiration expulsion of air from the lungs (diaphragm relaxes > lungs recoil); breathing out systolic blood pressure ventricles contract, 90-120, maximum pressure on the arteries Pain assessment before and after treatment Scale of 0-10(0 being no pain 10 being the worst pain you have ever felt) Assessment of pain history · P: Provocation and Palliati o no What causes it? o What makes it better? o What makes it worse? · Q: Quality and Quantity o How does it feel, look, or sound? o How much of it is there? · R: Region and Radiationo Where is it? o Does it spread? · S: Severity and Scale o Does it interfere with activities? o How does it rate on a severity scale of 1-10? · T: Timing and Type of Onseto When did it begin?
o How often does it occur? o Is it sudden or gradual? What is communication? Two-way process of sending & receiving messages Diastolic Blood Pressure (DBP) ventricles relax, 60-80, minimum pressure on the arteries Hyperthermia Preventions ii. Wear lightweight, loose-fitting clothing. iii. Avoid excessive sun exposure. iv. Stay indoors with fans or air conditioning when outside v. temperatures are elevated. vi. Limit consumption of alcohol and caffeine. vii. Apply sunscreen of at least 30 SPF. viii. If overheated, take a cool water shower or bath. Pulse Pulse allows the nurse to assess the how adequate the heart is pumping the blood to the body Normal Pulse Values
cuff size the length needs to be 80% of the arm circumference width of the cuff should be 40% of the arm circumference What can occur if you have the wrong cuff size? false reading Hypotension related to dehydration from inadequate fluid intake, from diarrhea, elevated temp fits well with this unit. Hypotension Nursing interventions · Vital signs Initially increase HR and BP · Discuss other signs and symptoms associated with fluid loss · Identify high-risk populations · I & O, daily weights as examples Normal Resp Values 12 - 20 breaths per minute
Resp Rate, Rhythm, and depth Normal, deep, or shallow Determine clients Respiratory effort (nasal flaring; use of accessory muscles, and body positioning) Pulse Ox measures the oxygen level in the blood Hypoxia is a low oxygen level in the blood, which leads to symptoms that may affect the client's basic care and comfort needs. Interventions to treat hypoxia i. Monitor for manifestations of respiratory depression, such as decreased respiratory rate and decreased level of consciousness. Notify the provider if findings are present. Respiratory distress interventions iii. Position the client for maximum ventilation (Fowler's or semi-Fowler's position). iv. Complete a focused respiratory assessment. v. Promote deep breathing, and use supplemental oxygen as prescribed. vi. Stay with the client, and provide emotional support to decrease anxiety.
Dry crackles the sound one might hear when rubbing several hairs together close to the ear are associated with small airway collapse and lung disease. Moist crackles sound wet on auscultation and are related to the accumulation of alveolar fluid. Pleural rubs sounds of inflamed pleural surfaces rubbing over each other, they are loud, low pitched and localized Grunting is a short, deep, guttural sound heard during expiration. Grunting is caused when the child exhales against a partially closed glottis in an attempt to keep the bronchioles open and prevent closure of the alveoli. Grunting can be associated with pulmonary edema, pneumonia or atelectasis, a partially expanded lung.
Crepitus is a crinkly, crackling or grating sound or feeling in the subcutaneous tissue. It can be an indication that free air has entered the tissue. Review signs and symptoms of hypoxia Hypoxia is a low oxygen level in the blood, which leads to symptoms that may affect the client's basic care and comfort needs. Hypoxia S/S Dyspnea Elevated blood pressure Increase respirations Increased pulse Pallor/pale skin Cyanosis/blue-tinged lips or oral cavity Anxiety Restlessness Confusion Drowsiness Hypoxia Interventions · Oxygen therapy (O2 delivery methods, amount of O2 delivered per device, safety education) · Incentive spirometry · Turn, Cough and Deep Breath
