NURS171 Final Exam Questions With Complete Solutions, Exams of Nursing

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NURS171 Final Exam Questions With Complete Solutions 0.45% NaCl, 0.33 NaCl Correct Answers Hypotonic solutions 0.9% NaCl, LR (lactated ringer's) Correct Answers isotonic solutions A Correct Answers night and color vision; cellular growth and maturity; maintaining healthy skin and mucous membranes; growth of skeletal and soft tissues; reproduction; fish liver oil, liver, butter, cream, egg yolk, yellow fruit, green leafy vegetables, fortified milk A Delta Fibers Correct Answers large, transmit fast pain impulses; inhibit pain; "blocks" painful stimulus coming up the C fibers transmit pleasurable stimuli to skin receptors Abdomen Characteristics Correct Answers IAPP: inspect, auscultate, percussion, palpate; RLQ, RUQ, LUQ, LLQ; bowel, bladder patterns; soft, relaxed, free of tenderness; normal: clicks/gurgles every 3-20 seconds and bruits (absence of pulsations) Acceptance (Kubler-Ross) Correct Answers comes to terms with it; The final stage brings a feeling of peace regarding the loss that has occurred. It is a time of quiet expectation and resignation. The focus is on the reality of the loss and its meaning for the individuals affected by it. Acid-Base Regulation Correct Answers respiratory: remove CO2 (acid) through rapid, deep breathing, shallow breathing when pH is too alkaline; renal: last line of defense (slow)... can take 3 days to return pH to normal; kidneys regulate the concentration of plasma bicarbonate (buffer) Active Euthanasia Correct Answers someone administer the agent of death Active Immunity Correct Answers A form of acquired immunity in which the body produces its own antibodies against disease-causing antigens.; after infection is acquired; immunizations; passive: mother to baby Active Transport Correct Answers requires energy ATP; occurs when molecules (particles such as electrolytes) move; across cell membranes from area of low concentration to area of high concentration; sodium reabsorption results in passive reabsorption of water; increases plasma volume and kidney perfusion; occurs when fluid volume is low Allergic Transfusion Reaction Correct Answers S/S: flushing, itching, wheezing, urticaria (hives), anaphylaxis; stop transfusion, assess pt, take VS; replace with IV 0.9% NaCl; notify physician immediately; administer prescribed antihistamine Anabolism Correct Answers requires energy; building up Anesthesia Correct Answers used to obtain analgesia, muscle relaxation or paralysis, and amnesia; general, conscious sedation, regional and local Anger (Kubler-Ross) Correct Answers "Why me?" and "It's not fair!"; Envy and resentment toward individuals not affected by the loss are common; may be directed at the self or displaced on loved ones, caregivers, and even God; There may be a preocupation with an idealized image of the lost entity. Angiotensin II Correct Answers retains sodium and water in kidneys and directs release of aldosterone Anthropometric Measurements Correct Answers measures the body composition (proportion of fat in the body); noninvasive physical examination techniques to determine body dimensions; height and weight; assess growth rate in children; indirectly assess adults' protein and fat stores; assess overweight, obesity and underweight Anticipatory Grief Correct Answers grief experienced prior to a loss; during death process caregiver can detach from who the person "used to be" Antidiuretic Hormone (ADH) Correct Answers pressure sensors in the vascular system that stimulate or inhibit release; kidneys will retain or excrete more fluid Anxiety Correct Answers emotional response; anticipation of danger; psychological conflict rather than physical; related to a future/anticipated event; source may not be identified worry, nervous, uneasy, fearful, tearful or physical symptoms, nausea, trembling, sweating APTM Correct Answers Z; aortic valve, pulmonic, tricuspid (right), mitral (left) S2 dub AP; S1 lub TM Arabs Correct Answers show direct eye contact, but only bw same sex; stand close in space Archetypes Correct Answers something recurrent, based on facts; dark skin, blue eyes of culture members Arterial Blood Gases (ABGs) Correct Answers directly measures the partial pressures of oxygen, carbon dioxide, and blood pH in the arterial blood; invasive blood draw; requires the puncture of an artery followed by lab testing of the sample; comprehensive, but invasive, painful, time consuming, expensive Arteries Correct Answers oxygenated blood to the tissues; away from the heart onto the peripheries Asepsis Correct Answers Absence of pathogens; absence of contamination by disease causing organisms Asians Correct Answers does not make eye contact; can't view circumstances as something to be controlled so will accept pain stoically; extended family, respect for elders, group oriented, subordination to authority, self-respect and self-control; health is a state of physical and spiritual harmony; illness is the disharmony of basic principles: yin and yang; Obesity = >30; varies for athletes, pregnant and post partum women BMR Correct Answers amount of energy required at rest for major organ function (heart, liver, brain); factors affecting: body composition, growth periods, body temperature, environmental temperature, disease processes, prolonged physical exertion, person's age, weight, type of activity BNP Correct Answers brain natriuretic peptide; measured in the serum to help determine presence of heart failure with fluid excess; increased levels determine CHF Braden Scale Correct Answers sensory perception, moisture, activity, mobility, nutrition, friction and shear; total score less than 18 = risk Brain Stem Correct Answers regulates involuntary control of respirations Bronchial Correct Answers loud, high-pitched, hollow, tubular sounds; longer expiration than inspiration Bronchovesicular Correct Answers medium, low, pitched hollow sound with equal inspiratory and expiratory phase; 1st and 2nd ICS adjacent to sternum on anterior chest; bw scapulae on posterior chest Bruxism Correct Answers grinding and clenching of the teeth in NREM sleep; can erode tooth enamel and loosen the teeth BUN (blood urea nitrogen) Correct Answers 10-20 mg/dL; elevations seen with impaired kidney function, dehydration, excessive protein breakdown/intake; low levels seen with low protein intake Burnout Correct Answers cannot cope with physical or emotional demands of the workplace C Correct Answers collagen synthesis; capillary wall support; antioxidant; iron absorption; immune function; citrus fruits, tomatoes, potatoes, green vegetables, cauliflower C Fibers Correct Answers small, transmit slow pain impulses (dull, diffuse, achy); produce pain, gate is at the brain; stimulation is non painful = blocked to feeling pain; noxious stimuli = keeps the gate open from mechanical thermal and chemical stimuli Calcium Correct Answers most abundant electrolyte in the body; promotes transmission of nerve impulses; catalyst for many cellular activities; important in bone and teeth health; regulates muscle contraction; essential in blood clotting; insufficiency leads to osteoporosis; absorption stimulated by vitamin D; inverse relationship with phosphorus (one rises, other falls) Calcium (Ca) Correct Answers mineral; bone and teeth formation; blood clotting; nerve conduction; muscle contraction; cellular metabolism; heart action; dairy products, sardines, green leafy vegetables, broccoli, whole grains, egg yolks, legumes, nuts, fortified products Cardiac Output (CO) Correct Answers SV x HR; volume of blood pumped from the left ventricle throughout the circulation in one minute Cardiomyopathy Correct Answers heart muscle disorder that results in heart enlargement and impaired cardiac contractility Carriers Correct Answers carry pathogens without displaying active disease Catabolism Correct Answers releases energy; breaking down Categories of Stress Correct Answers situational (random, unpredictable, hurricane, accident); functions as the client's advocate, maintains sterile field, maintains a safe, comfortable environment Circulatory Overload Transfusion Reaction Correct Answers S/S: persistent cough, crackles (lung sounds), hypertension, distended neck veins; slow or stop transfusion, assess pt; monitor VS; place the client upright; notify physician, treat symptoms as ordered Classification of Surgery Correct Answers body system; purpose; degree of urgency; degree of risk Clean Catch Urine Specimen Correct Answers cleanse genitalia b4 voiding and collect sample in midstream Clean Wound Correct Answers uninfected, minimal inflammation; face lift, cataract surgery, joint replacement, breast biopsy Clean-Contaminated Wound Correct Answers not infected but increased risk; surgery that involves GI, GU or respiratory tract Closed Wound Correct Answers no break in the skin (bruises) Cognitive Learning Correct Answers involves "knowing"; includes storing and recalling information in the brain; lectures, one to one instruction, print and online materials, panel discussions, webinars Cold Therapy Correct Answers used for therapeutic purposes, can cause tissue damage; produces local anesthesia; decreases muscle tension; decreases blood flow; slows bacterial growth; used to prevent or limit edema and reduce inflammation, pain, oxygen requirements and bleeding Coma Correct Answers deep prolonged unconsciousness caused by disease, poison, or a severe blow lasting days or even years Complete Blood Count (CBC) Correct Answers red blood cells (RBC), hemoglobin (Hgb), hematocrit (HCT), white blood cells (WBC), platelets (PLT) Complicated Grief Correct Answers a type of grief that impedes a person's future life, usually because the person clings to sorrow or is buffeted by contradictory emotions; dysfunctional; length of time and intensity of emotion Comprehensive Assessment Correct Answers health history and complete physical examination, usually conducted when a patient first enters a health care setting; provides a baseline for comparing later assessment; building a patient's data base Comprehensive Physical Examination Correct Answers health history interview plus complete head-to-toe examination Conscious Sedation Correct Answers an alternative form of anesthesia that provides intravenous sedation and analgesia without producing unconsciousness; pt may feel sleepy but is aware of surroundings, can easily be aroused by touch or speech and can talk to surgical team; monitoring of vitals and pulse ox, O2 given via nasal cannula, quick recovery, used for bronchoscopy, cosmetic surgery; not recommended for highly anxious patients, Contaminated Wound Correct Answers not infected but carry high risk; trauma or open wounds Convalescence Stage of Infection Correct Answers tissue repair, return to health Cordotomy Correct Answers surgical procedure that severs a nerve tract within the spinal cord to relieve intractable pain Crackles Correct Answers fine: clears when coughing; coarse: not cleared when coughing; discontinuous, low bubbling sound due to air being forced through narrow airway or alveoli; heard on inspiration the most Creatinine Correct Answers 0.6-1.2 mg/dL; Delirium Correct Answers an acutely disturbed state of mind that occurs in fever, intoxication, and other disorders and is characterized by restlessness, illusions, and incoherence of thought and speech; in response to medical or mental illness, drug toxicity, or other cause; potentially reversible Dementia Correct Answers An abnormal condition marked by multiple cognitive defects that include memory impairment; irreversible decline in mental status Denial Correct Answers refusing to acknowledge thoughts, feelings, desires, or impulses Denial (death) Correct Answers People characteristically feeling, "No not me; this cannot happen to me" Depression Correct Answers can be unresolved anger and may result from stress; more than just feeling of sadness or "the blues"' flat affect, hollow, unendurable; sense of emptiness; may lead to withdrawal from social contacts Depression (Kubler-Ross) Correct Answers the full impact of the loss is experienced; the sense of loss is intense, and feelings of sadness and depression prevail; this is a time of quiet desperation and disengagement from all association with the lost entity; may linger beyond what is expected Dermis Correct Answers middle layer of skin; lies below epidermis and above subq Diaphragm (stethoscope) Correct Answers flat end piece of the stethoscope used for hearing relatively high-pitched heart sounds Diastole Correct Answers trough or resting phase of the heart; minimum pressure exerted against arterial wall Diffusion Correct Answers passive transport of molecules; solutes move from an area of higher concentration to area of lower concentration until equilibrium Disenfranchised Grief Correct Answers A situation in which certain people, although they are bereaved, are prevented from mourning publicly by cultural customs or social restrictions; loss that is not socially supported or acknowledged; miscarriage, mistress, gay partner in family that don't support gay partner Disinfecting Correct Answers removes pathogens on inanimate objects by physical, chemicals, steam, gas, ultraviolet light Disorders that are Provoked by Sleep Correct Answers coronary artery disease: dreams may increase HR and provke angina and ECG changes; asthma: bronchospasm, attacks as esophageal sphincter relaxes and reflux results COPD: lower oxygen tension and increased CO2 retention during sleep; diabetes: blood glucose levels vary during the night; gastric and intestinal ulcers: duodenal ulcers secrete up to 20 times more gastric acid; peptic ulcers: increased acid producing nocturnal epigastric pain and sleep loss Displacement Correct Answers psychoanalytic defense mechanism that shifts sexual or aggressive impulses toward a more acceptable or less threatening object or person, as when redirecting anger toward a safer outlet; kick the dog Distal Correct Answers away from the point of attachment; further away from the midline Dyssomnia Correct Answers a sleep disorder in which one has difficulty falling asleep, staying asleep, or avoiding sleep E Correct Answers antioxidant; protects red blood cells and muscle tissue cells; vegetable oils, nuts, milk, eggs, muscle meats, fish, wheat and rice germs, green leafy vegetables Evisceration Correct Answers protrusion of organs or tissues through the separated incision; use binder Exhaustion Stage Correct Answers final stage; if adaptive mechanisms become ineffective/nonexistent; ends in injury, illness, death External Loss Correct Answers actual losses of objects that are important to the person because of their cost or sentimental value; lost through death, destruction or disasters Extracellular Correct Answers outside of cells; interstitial, intravascular, transcellular; sodium, chloride, bicarbonate; albumin (can be found here) Facilitating Grief Work Correct Answers expressing feelings (encourage questions and respond timely, expect wide range of feelings, DO NOT COMPARE OWN LOSS); recalling memories (photo albums); finding meaning Factors Affecting Grief Correct Answers significance of the loss; amount of support for the bereaved; conflict existing at the time of death; circumstances of the loss (sudden, expected, suicide, homicide, person in pain?, feel responsible?); previous loss; developmental stage; spiritual/cultural background; timeliness of death; sense of potential Factors Affecting Grief for Adolescence Correct Answers conflicted in life stage; depends on relationship with lost person; Factors Affecting Grief for Adulthood Correct Answers perceive loss as a normal part of living; depends on person's self esteem and availability of supports Factors Affecting Grief for Childhood Correct Answers believe death is temporary Factors Affecting Grief for Older Adults Correct Answers many losses; loss of physical and function and independence; cumulative effects may be devastating Factors Affecting Skin Integrity Correct Answers nutrition/hydration; protein intake; cholesterol; calorie intake; vit c, zinc, copper intake; sensation level; cognition level; circulation; medication; moisture; fever; contamination/infection; lifestyle Factors Affecting Sleep for Adolescence Correct Answers increased school demands, TV, social networking, staying out late with friends, drugs, alcohol, caffeine Factors Affecting Sleep for Middle Aged Correct Answers insomnia related to stress, change, depression, anxiety, tension Factors Affecting Sleep for Older Adults Correct Answers nocturia, side effects of medications, discomfort or pain, partner's sleep habits (snoring, restlessness) Factors Affecting Sleep for Older Children Correct Answers anxiety, stress, depression, social concerns Factors Affecting Sleep for Young Adults Correct Answers studying all night, driven to succeed, late work nights, stress, parents of young children with sleep disturbances Factors Affecting Sleep for Young Children Correct Answers trouble falling asleep, frequent awakenings, nightmares, heavy snoring, environmental stimuli; trouble winding down, bad dreams, imaginary figures Fat Soluble Vitamins Correct Answers ADEK; stored primarily in the liver and adipose tissue; Food Record Correct Answers most accurate food diary; identifies quantity and type of food eaten; requested of client in advance; requires high level cognitive and psychomotor functioning of clients and commitment to complete task Full Thickness Wound Correct Answers the dermis, epidermis, and subcutaneous tissue are penetrated; muscle and bone may be involved Gastrointestinal Suction Correct Answers used intermittently or continuously to suction/collect excess fluid and gas; continued until peristalsis resumes, bowel sounds audible, and pt is passing flatus; pt remains NPO Gastrostomy Tube (G Tube) Correct Answers long term feeding tube placed surgically or endoscopically through the skin and the abdominal wall into the stomach or jejunum Gate-Control Theory Correct Answers the theory that the spinal cord contains a neurological "gate" that blocks pain signals or allows them to pass on to the brain. The "gate" is opened by the activity of pain signals traveling up small nerve fibers and is closed by activity in larger fibers or by information coming from the brain. General Adaptation Syndrome Correct Answers Selye's concept of the body's adaptive response to stress in three phases —alarm, resistance (adaptation), exhaustion or recovery. General Anesthesia Correct Answers produces rapid unconsciousness and loss of sensation; inhaled or intravenous medication that depress the pt's CNS and relax muscles; mechanical ventilation is needed, predisposed to pneumonia and thrombophlebitis, risk for death, MI, stroke, hyperthermia, sore throat, nausea, vomiting, headache, shivering, confusion General Survey Correct Answers first contact, overall impression of client; appearance/behavior, grooming/hygiene, body type/posture; mental state; speech; vital signs; height/weight Germans Correct Answers want far space (looking into room equals invasion of privacy) Greatest Determinant of Intracellular Osmolality Correct Answers Potassium Greatest Determinant of Serum Osmolality Correct Answers Sodium Grief Correct Answers psychological, physical, and spiritual healing after loss; with significant loss; intensity depends on the meaning the person attaches to the loss tends to come and go Hand Hygiene Correct Answers the single most important activity for preventing and controlling infection; 15 seconds, warm water, rinse soap completely HDL Correct Answers removes cholesterol from bloodstream, returns to liver to produce bile Heart-lung Death Correct Answers the irreversible cessation of spontaneous respirations and circulation Hematocrit Correct Answers M: 42-52% F: 37-47% a measure of the percentage of RBCs in whole blood; as fluid decreases, % of cells in ratio to blood increases; as fluid increases, % of cells decreases; Hemoglobin Correct Answers M: 14-18 g/dL F: 12-16 g/dL the iron-containing pigment of red blood cells that carries oxygen from the lungs to the tissues Hemolytic Transfusion Reaction Correct Answers S/S: fever, chills, dyspnea, chest pain, tachycardia, hypotension, can be fatal; stop transfusion, assess pt, take VS; replace with IV 0.9% NaCl; notify physician immediately; send blood including tubing and filter along with sample of venous blood and first voided urine to lab for analysis; to a wound site to stimulate growth of new blood vessels and enhances WBC action; Hypercalcemia Causes Correct Answers hyperparathyrodism, malignant bone disease, prolonged immobilization, excess intake, thiazide diuretics Hypercalcemia S/S Correct Answers muscle weakness, constipation, anorexia, nausea, vomiting, polyuria, polydispia, kidney stones, bizarre behavior, bradycardia Hypercalcemia Treatment Correct Answers monitor I/O and eliminate calcium intake; encourage fluid intake (prevent stones), encourage fiber to prevent constipation, renal dialysis Hyperkalemia Causes Correct Answers K+ >5.0 mEq/L; renal failure, potassium sparing diuretics, hypoaldosteronisms, high potassium intake couple with renal insufficiency, acidosis, major trauma, false level: hemolyzed serum level Hyperkalemia S/S Correct Answers muscle weakness, dysrhythmias, flaccid paralysis, intestinal colic, Tall T waves on ECG Hyperkalemia Treatment Correct Answers monitor I/O and potassium level; caution about potassium-rich food intake in patients with elevated creatinine levels (kidney insufficiency) Hypermagnesemia Causes Correct Answers renal failure, adrenal insufficiency, excess replacement Hypermagnesemia S/S Correct Answers flushing, warmth of skin, hypotension, drowsiness, lethargy, hypoactive reflexes, depressed respirations, bradycardia Hypermagnesemia Treatment Correct Answers monitor VS, airway and reflexes; avoid magnesium based intake Hypernatremia Causes Correct Answers Na+ >145 mEq/L; excessive sodium intake, water deprivation, increased water loss through diaphoresis, heat stroke of DI. Administration of hypertonic tube feeding Hypernatremia Treatment Correct Answers monitor I/O and sodium level; monitor VS and LOC; restrict oral sodium intake; increase water intake; administer IV solutions that do not contain sodium Hyperphosphatemia Causes Correct Answers renal failure, hyperthyroidism, chemotherapy, excess use of phosphate based laxative Hyperphosphatemia S/S Correct Answers short term symptoms (tetany: tingling of extremities and cramping); long term: calcification in soft tissue Hyperphosphatemia Treatment Correct Answers if severe, administer aluminum hydroxide with meals to bind phosphorus; monitor phosphorus level and I/O Hyperresonance Correct Answers a long, low-pitched hollow sound heard over areas with trapped gas, of increased air such as pneumothorax or emphysema Hypersomnia Correct Answers excessive sleeping (especially during daytime); can be related to depression, disorders of the CNS, kidney, liver, metabolic disorders Hypertonic Solution Correct Answers when a fluid has higher osmolality (solutes) than blood; water moves by osmosis from cells into the extracellular fluid (vascular system); D10W, D5W w/ 0.9% NaCl, D5W w/ 0.45 NaCl; give when fluids need to move out of the cell and into ECF to maintain fluid balance bw ICF and ECF CELLS SHRINK; >375 mOsm/L; IV fluid has higher osmolalility than blood; pulls (fluid) water and electrolytes into blood vessels from interstitial space and intracellular space; D5 0.9% NaCl, D5 0.45% NacL, D5RL, and volume expanders; purpose: stabilize blood pressure, increase urine output, reduce edema Hypervolemia Correct Answers excess fluid volume; Hyponatremia Treatment Correct Answers monitor I/O and sodium level; increase oral sodium intake; administer IV saline infusion (0.9% Sodium Chloride); seizure precautions if severe Hypophosphatemia Causes Correct Answers refeeding after starvation, alcohol withdrawal, diabetic ketoacidosis, respiratory acidosis Hypophosphatemia S/S Correct Answers paresthesia (tingling/numbess of skin or hands, joint stiffness, seizures, cardiomyopathy, impaired tissue oxygenation Hypothalamus Correct Answers regulates fluid intake; thirst center (stimulates urge to drink) Hypotonic Solution Correct Answers when a fluid has lower osmolality (solutes) than blood; 0.45% NaCl and 0.33 NaCl water moves by osmosis from vascular system into the cells; give when cells are dehydrated and fluids need to be replenished intracellularly CELLS SWELL; <250 mOsm/L; IV fluid has lower osmolality than cells; pull water out of blood vessels and into cells; D5W and 0.45 NaCl (half normal saline); not intended for patient's at risk of increased intracranial pressure; purpose: hydrate the cell (diabetic ketoacidosis) Hypovolemic Shock Correct Answers continued fluid loss (bleeding); rapid heart rate, weak pulse, orthostatic hypotension, decreased skin turgor, decreased urine output, flat neck veins, increased temperature (not in elderly), muscle weakness and fatigue; fluid shifts from ICF and interstitial space to intravascular system resulting in dry skin, dry mucous membranes; Illness Stage of Infection Correct Answers signs and symptoms present Impact (crisis) Correct Answers anxiety and confusion increase; trouble organizing personal life; may feel the stress but minimize its severity Impaired Arterial Circulation Correct Answers restricts activity, produces pain, and leads to muscle atrophy and thin tissue that can lead to ischemia and necrosis Impaired Venous Circulation Correct Answers results in engorged tissues containing high levels of metabolic waste products that make the tissue susceptible to edema, ulceration, and breakdown Incubation Stage of Infection Correct Answers from time of infection until manifestations of symptoms; can infect others Infected Wounds Correct Answers evidence of infection (drainage or necrotic tissue/bacteria present); post op incision with evidence of infection Infection Correct Answers invasion of and multiplication in the body by a pathogen (microorganisms capable of causing disease); can be local or systemic; agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host Inflammatory Phase Correct Answers the initial phase of wound healing in which bleeding is reduced as blood vessels in the affected area constrict; 1 to 5 days; bleeding is slowed/stopped; migration of WBC into wound tissue; phagocytosis clears debris; plasma proteins and fibrin form a scab to prevent microbial invasion Initial Assessment Correct Answers comprehensive nursing assessment resulting in baseline data that enables the nurse to make a judgment about a patient's health status, ability to manage one's own health care, and need for nursing, and to plan individualized, holistic health care for the patient; -Admission when client enters healthcare system -Purpose to evaluate health status and identify health needs that are unmet 250 to 375 mOsm/L; remain in the blood vessels (0.9% NaCl = normal saline, lactated ringers); purpose: hydration (hypovolemia, hypotension) Judaism Correct Answers orthodox, conservative, reform, reconstructionist K Correct Answers synthesis of clotting factors; bone development; green leafy vegetables, liver, intestinal bacteria synthesizes a form of this) Ketones Correct Answers chemical substances that the body produces when it does not have enough insulin in the blood; an alternative fuel when glucose is not available Kidneys Correct Answers principal regulator of fluid and electrolyte balance; Korotkoff Sounds Correct Answers series of sounds that correspond to changes in blood flow through an artery as pressure is released, 5 sounds; 1 - first sound as you deflate BP cuff (systolic) 2 - soft swishing sound caused by blood turbulence 3 - begins midway and is sharp, rhythmic tapping sound 4 - similar to third sound, but softer and fading 5 - silence (diastolic) Kubler-Ross Correct Answers five stage of death; denial, anger, bargaining, depression, acceptance; people tend to experience one or more of the five stages during the period from terminal diagnosis to the actual death; may not go through every stage; not the nurse's responsibility to move people on to the next stage; it is our responsibility to accept and support people wherever they are in the process and help them verbalize their feelings Kussmaul Correct Answers type of resp that is rapid, deep, sighing breaths that occur in pt with metabolic acidosis, especially when associated with diabetic ketoacidosis Laboratory Data for Wounds Correct Answers WBC, serum protein, albumin, prealbumin, wound cultures; WBC may increase; low serum protein may delay wound healing Latent Infections Correct Answers never completely eliminated; microbe exists in host tissues without causing symptoms LDL Correct Answers transports cholesterol to body cells Local Adaptation Syndrome Correct Answers short term response to restore homeostasis on a localized scale; reflex, inflammation Local Anesthesia Correct Answers regional anesthesia that produces loss of pain sensation at the desired site (wound to be sutured); used for minor procedures - sutures, skin growth, can be topical or injected Loss Correct Answers the undesired change or removal of a valued object, person or situation; begins at birth and continues through death; losing a job, loved one, growing older Loss of Aspects of Self Correct Answers Physical losses, body organs, limbs, body functions, body disfigurement Macrominerals Correct Answers needed in amounts of >100mg/day; calcium, magnesium, phosphorus, potassium, sodium Magnesium Correct Answers second most abundant cation (+) in the ICF; maintains normal intracellular levels of potassium; involved in protein and CHO metabolism; needed for protein and DNA synthesis; loss may be due to diuretics, poorly controlled diabetes mellitus, excess alcohol intake; involved in electrical activity in nerve and muscle membranes Maladaptive Coping (ineffective) Correct Answers does not promote adaptation, considered unhealthy; overeating, working too much, oversleeping, substance abuse; temporarily relieves anxiety, but may have harmful effects Morse Scale Correct Answers fall risk assessment; questions with point value to assess a pt's risk for falling; score > 50 considered high risk Mourning Correct Answers the act of showing sorrow or grief; wearing black, crying Naloxone (Narcan) Correct Answers reversal of CNS depression and respiratory depression because of suspected opioid overdose; competitively blocks the effects of opioids, including CNS and respiratory depression, without producing any agonist (opioid- like) effects; Narcolepsy Correct Answers genetic defect of the CNS in which REM sleep can not be controlled; chronic disorder caused by the brain's ineffectiveness in regulating sleep-wake cycles normally; sudden, uncontrollable episodes of sleep during the day; sleepiness, slurred speech, slackening of facial muscles, feeling of impending weakness of the knees, paralysis, and hallucinations, impaired performance, awaken feeling refreshed; trtmnt: with CNS stimulants such as methylphenidate (Ritalin) Nasoenteric Tube Correct Answers longer than an NG tube, extending through the nose down into the duodenum or jejunum; used for pt at risk for aspiration with decreased level of consciousness, absent or diminished gag reflex or severe gastroesophageal reflux Nasogastric Tube (NG Tube) Correct Answers for short term use (less than 6 weeks) for feeding or drainage of stomach contents; can be used for feedings Native Americans Correct Answers do not make eye contact; present in time (may forget appointments); respect of elders; bonding to family/group; acceptance of nature; belief in spiritual power; health means living in harmony with nature, surviving under difficult circumstances, body treated with respect; illness associated with disharmony or evil spirits, caused by an action that should not have been performed; rituals/ceremonies, chanting, purification, meditation, herbs Negative Pressure Wound Therapy Correct Answers uses suction to remove drainage and speed wound healing; by secondary and tertiary intention; creates a vacuum; improves wound healing by reducing edema from tissues, promotes granulation tissue formation, removes exudate and infectious material Neurectomy Correct Answers surgical removal of a nerve to eliminate intractable localized pain Neuropathic Pain Correct Answers injury to one or more nerves; repeated transmission of pain signals even in absence of painful stimuli; feels burning, numbness, tingling, "pins and needles" Never Events Correct Answers serious but preventable surgical errors (that should never occur); foreign object left in patient; air embolism; wrong type of blood; pressure injuries; falls and traumas; infections (urinary and IV catheters); complications from poorly controlled blood sugar; infections at surgical site; DVT or PE after joint replacement Niacin Correct Answers B vitamin; cellular metabolism to produce energy; enriched breads and cereals, chicken, tuna, liver, peanuts, dairy products Non-essential amino acids Correct Answers can be synthesized by body North Americans and Northern Europeans Correct Answers want 18 inches of personal space; future in time; independence, individuality, wealth, comfort, cleanliness, achievement, youth and beauty; health is a state of physical and emotional well-being; do not have to be actively dying; holistic comfort care, treat symptoms (nausea) support families and caregivers, ensuring continuity of care, ensuring respect for persons, ensuring informed decision making, attending to emotional and spiritual concerns, supporting duration of function and survival, managing symptoms Panic Level of Anxiety Correct Answers level of anxiety where pt is unreasonable, irrational, unable to focus on even one detail; may lose contact with reality; may react wildly (shouting, screaming, running about, clinging to something); cannot function or communicate effectively; may feel terror and impending doom; S/s: dilated pupils, labored breathing, severe trembling, sleeplessness, palpitations, diaphoresis, pallor and muscular incoordination Pantothenic Acid Correct Answers B vitamin; cell metabolism of fat and cholesterol; amino acid activation; heme formation; meats, whole grain cereals, legumes, occurs in most foods Parasomnias Correct Answers Abnormal behaviors such as nightmares or sleepwalking that occur during sleep. Paroxysmal Nocturnal Dyspnea Correct Answers sudden awakening due to shortness of breath that begins during sleep; the pt feels panic and extreme dyspnea and must sit upright to ease breathing Partial-Thickness Wound Correct Answers extend through the epidermis but not through the dermis Passive Euthanasia Correct Answers lack of action (withholding medications or food); honoring the refusal of treatments Passive Transport Correct Answers osmosis, diffusion, filtration; requires no energy Pathogens Correct Answers microorganisms that invade the body and are capable of causing disease; most common are bacteria, viruses and fungi; protozoa, helminths (worms), prions; require nutrients, moisture, temperature control (ideal 95), oxygen, pH (5 to 8) and electrolytes, light (grow best in dark) Penetrating Wound Correct Answers an open wound that breaks the skin and enters a body area, organ, or cavity Perceived Loss Correct Answers is felt by person but intangible to others; aging- feeling loss of youth; STD patient - is unpure Perfusion Correct Answers the continuous supply of oxygenated blood to all body; cells; blood flow to a capillary bed to provide nutrients and oxygen to tissues and organs peripheral nerve block Correct Answers regional anesthesia; the injection of an anesthetic into and around a nerve or group of nerves pH Correct Answers death <6.90; acidosis >6.90 <7.35 neutral 7.35 - 7.45; alkalosis >7.45 <7.80 death >7.80 measured by ABGs Phagocytosis Correct Answers process in which extensions of cytoplasm surround and engulf large particles and take them into the cell; by macrophages and neutrophils Phantom Pain Correct Answers area surgically removed; burning, itching, deep pain Phosphate (Phosphorus) Correct Answers major anion (-) in the ICF; catalyst for many intracellular activities; promotes muscle and nerve action; bound with calcium in teeth and bones (inverse relationship); Prealbumin Correct Answers 15-36 mg/dL; acute changes (in nutrition) Precrisis Correct Answers after event, person uses usual coping strategies, has no symptoms, denies any stress Preoperative Correct Answers begins with decision to have surgery, lasts until patient is transferred to operating room or procedural bed; explain what to expect before surgery, in the operating room, and after surgery; education: tests to be done, skin preparation, medications, NPO, bowel prep, time to arrive, remove jewelry, routine, deep breathing/incentive spirometer, anti-embolism stockings, length of stay, who may be present in OR room (surgeon, circulating nurse, scrub nurse, tech), assessments, pain management, dressings, equipment, monitoring devices Primary (first) Intention Healing Correct Answers minimal or no tissue loss; edges well approximated (closed); little scarring is expected use of adhesive strips, sutures, surgical staples/glue Primary Defenses Correct Answers Anatomical features, limit pathogen entry Intact skin Mucous membranes Tears Normal flora in GI tract Normal flora in urinary tract Primary Level of Prevention Correct Answers 1. prevent disease; 2. slow onset of disease eating healthy foods, exercising, maintaining healthy weight, wearing sunscreen, wearing seat belts, immunization Prodromal Stage of Infection Correct Answers appearance of vague symptoms; not all diseases have this stage Projection Correct Answers psychoanalytic defense mechanism by which people disguise their own threatening impulses by attributing them to others; blaming others Proliferative phase (regeneration/granulation) Correct Answers stage in the wound-healing process where granulation tissue begins to form; day 5 to 21; clot/scab dissolves and epithelial cells begin to grow and seal the wound Promoting Circulation Correct Answers elevate pt legs above heart level; flexion of hips, legs, knees constricts veins; support frequent ambulation; ted stockings Proximal Correct Answers Closer to the point of attachment; closer to the midline Psychogenic Pain Correct Answers believed to arise from the mind Psychological Loss Correct Answers loss that affects a person's self-image; challenge our belief system; seen in areas of sexuality, control, fairness, meaning and trust; "it's not fair"; also called internal or perceived loss Psychomotor Learning Correct Answers involves "doing"; learning a skill that requires both mental and physical activity; it includes knowing the skill (cognitive) and valuing the skill (affective); demonstration and return demonstration, simulation models, streaming video, journaling and self reflection and printed materials Pulse Correct Answers rhythmic expansion of an artery produced when a bolus of oxygenation blood is forced into it by contraction of the heart; exercise, fever, heat, acute pain, anxiety, medications, developmental level, position changes, hemorrhage, blood loss, pulmonary conditions, stress, food intake, gender Rationalization Correct Answers defense mechanism that offers self-justifying explanations in place of the real, more threatening, unconscious reasons for one's actions; use of logical sounding excuses to cover up or justify Reaction Formation Correct Answers psychoanalytic defense mechanism by which the ego unconsciously switches unacceptable impulses into their opposites. Thus, people may express feelings that are the opposite of their anxiety-arousing unconscious feelings.; acts opposite to what he/she is feeling Reception Correct Answers process of receiving stimuli from nerve endings; converts stimulus to a nerve impulse and transmits along sensory neurons to CNS Recovery Stage Correct Answers final stage; if adaptation is successful Referred Pain Correct Answers occurs distant original site; MI - down left arm Reflexes Correct Answers automatic responses; 0-4 scale, 2 normal, 4 hyperactive with clonus Regenerative/Epithelial Healing Correct Answers involves epidermis and dermis, no scar, partial thickness wounds heal this way Regional Anesthesia Correct Answers prevents pain by interrupting nerve impulses to and from the area of the procedure; pt remains alert but is numb in the involved area Religion Correct Answers ordered system of beliefs regarding the cause, nature and purpose of the universe, related to the worship of god Religion vs. Spirituality Correct Answers religion is a "map" that outlines essential beliefs, values, and codes of conduct into a way of living; many of the world's religions hold common beliefs; spirituality is a "journey" that takes place over time and involves the accumulation of life experiences and understanding; an attempt to find meaning, value, and purpose in life REM Sleep Correct Answers Rapid eye movement sleep, a recurring sleep stage during which vivid dreams commonly occur. Also known as paradoxical sleep, because the muscles are relaxed (except for minor twitches) but other body systems are active; behavior disturbances: violently acts out dream Renin Correct Answers enzyme released in kidneys when fluid volume is decreased; leads to release of Angiotensin which is converted to Angiotensin II Renin-Angiotensin System Correct Answers System that helps to regulate fluid balance and blood pressure through actions in the kidney; Reservoir Correct Answers where organisms live and multiply; where pathogens survive and multiply; living (human body, animals and insects, warm and moist environments); non-living (soil, water, food and environmental surfaces) resident flora Correct Answers Harmless, nonpathogenic microorganisms that normally reside on the skin and usually do not cause disease. Also known as normal flora.; permanent inhabitants, usually not removed by routine handwashing; live in intestine, aid in digestion, synthesize vitamin K and release vitamin B12, thiamine, and riboflavin when they die; limit growth of harmful bacteria by competing with them for available nutrients; resistance (adaptation) stage Correct Answers maintenance of homeostasis; involves use of coping mechanisms Resonance Correct Answers normal sound heard on percussion over healthy lung tissue Respiratory Characteristics Correct Answers assess for rate, tachypnea/bradypnea; depth, shallow/normal/deep; Secondary Intention Healing Correct Answers extensive tissue loss; edges not approximated or should be left open (due to infection); fill with red granulation tissue; heals from inner layer to surface; wounds heal more slowly Secondary Level of Protection Correct Answers detecting illnesses in early stages; screenings/exams regular physical and dental exams; blood pressure screenings; diabetes screening; PPD/QFT testing Sensible Loss Correct Answers measurable fluid output; urine, diarrhea, feces, ostomy, gastric losses; skin can be measured Serosanguineous Correct Answers mix of bloody and straw- colored fluid; common in new wounds Serous Exudate Correct Answers straw-colored, clear, from clean wounds Severe Level of Anxiety Correct Answers level of anxiety where perceptual field is narrow; focuses on one detail and self; may shift to extraneous details; attention span severely limited; person has difficulty completing simple tasks; no problem solving and learning; feelings of dread, confusion and other emotions; S/s: dizziness, nausea, trembling, hyperventilation, urinary frequency, diarrhea Sinoatrial Node (SA Node) Correct Answers pacemaker of the heart Skin Correct Answers largest organ of the body; consist of skin, hair, nails, sweat glands, subcutaneous tissue; major functions: protection of internal organs, thermoregulation, metabolism of nutrients and metabolic waste products and sensation; provides unique identification of an individual Sleep Correct Answers cyclical states/altered consciousness; decreased motor activity/perception; selective response to external stimuli; metabolism decreases; unaware of environment and responds selectively to external stimuli (alarm clock, bright light); Sleep Apnea Correct Answers snoring is biggest sign; oxygen level in blood drops and carbon dioxide level rises causing person to wake up; complain of fatigue and morning headache; diagnosed with sleep study; may cause cardiac dysrhythmias and increases in pulse and blood pressure Sleep Talking Correct Answers in NREM sleep just before REM Sleepwalking Correct Answers in NREM sleep 1 to 2 hours after person falls asleep Sodium Correct Answers 135-145 mEq/L; regulates fluid volume; ECF; moves by active transport; interacts with to maintain muscle contraction; stimulates conduction of nerve impulses; excess can lead to high BP; regulated by aldosterone and ADH levels; Sodium (Na) Correct Answers mineral; water balance; acid base balance; muscle action; nerve transmission; convulsions; table salt (NaCl), milk, meat, eggs, baking soda/powder, celery, spinach, carrots, beets Somatization Correct Answers a somatoform disorder when the expression of psychological distress through physical symptoms Stridor Correct Answers a piercing, high-pitched wheezing sound heard primarily during inspiration due to obstruction of airway; disrupted airflow in larynx or trachea Stroke Volume Correct Answers amount of blood ejected from the left ventricle with one heart beat Stupor Correct Answers a state of near-unconsciousness or insensibility; requires vigorous stimulation before responding Subcutaneous Layer Correct Answers innermost layer of the skin, containing fat tissue; primarily connective and adipose tissue with varying thickness Superficial Wound Correct Answers involves only the epidermis; usually a result of friction, shearing or burning Suspected Deep Tissue Injury (DTI) Correct Answers an area of skin that is intact but discolored; might be purplish or deep red; painful, boggy or have a blister Sympathectomy Correct Answers surgical excision of a portion of the sympathetic nervous system; severs the paths to the sympathetic division of the autonomic nervous system Systole Correct Answers peak of the pulse wave, or contraction of the heart; peak pressure exerted against arterial walls Tactile Fremitus Correct Answers a tremor or vibration in any part of the body detected on palpation; 99, feel on both hands bilaterally and equally Tertiary Defenses Correct Answers Humoral immunity; B-cell production of antibodies in response to an antigen Cell-mediated immunity Direct destruction of infected cells by T cells Tertiary Intention Healing Correct Answers Wound is left open for 3-5 days to allow edema or infection to resolve; delayed wound healing; closed by brining two layers of granulation tissue together; risk for infection use of adhesive strips, sutures, surgical staples/glue Tertiary Level of Prevention Correct Answers 1. stopping disease progression; 2. returning to pre-illness state preventing complications, recovering from surgery or accident, rehabilitating after surgery or accident Thermoregulation Correct Answers the process of maintaining a stable temperature by balancing heat production and heat loss; controlled by hypothalamus; heat production = metabolism; heat loss = skin Thiamin Correct Answers B vitamin; cellular metabolism; nervous system function; GI function; CV function; whole grain, enriched cereal, beef, pork, liver, peas, beans, nuts Third Spacing Correct Answers translocation of fluid from the intravascular or intercellular spaces to tissue compartments, where it becomes trapped and useless; not intracellular or extracellular; occurs in illness, trauma or disease; locations include pleural space (pleural effusion), peritoneal cavity (ascites), blisters (vesicles) Three Approaches to Coping Correct Answers alter the stressor (change jobs, lessen responsibilities); adapt to the stressor (changing thoughts/behaviors about the stressor); avoid the stressor (ending toxic relationship) Thyroid Hormone Correct Answers influences cardiac output which results in increased thyroid hormone; increased cardiac output results in increased glomerular filtration rate and urine output; lack or decreased of this results in decreased cardiac output which results in decreased urine output Water Soluble Vitamins Correct Answers B and C; need to be consumed every day (not stored); Weber's Test Correct Answers A therapist places a vibrating tunning fork on top of the head, mid forehead, and ask the patient if sound is heard equally (normal) or if it is heard louder in one ear; tests bilateral hearing to determine if sound is louder in one ear or equal Wellness Promotion to Support Host Defenses Correct Answers adequate nutrition (replace lost stores, manufacture cells of the immune system, repair damaged tissue); hygiene (sufficient to decrease skin bacterial count); rest/exercise (6 - 9 hours); reducing stress (decrease body's immune defenses); immunizations Wheeze Correct Answers high-pitched continuous musical sounds, usually heard on expiration; air is moving through a narrow airway White Blood Cells Correct Answers 5,000-10,000 or 5 - 10 x 10^3/mm^3; help fight/prevent infection Wound Debridement Correct Answers removal of devitalized or dead tissue or foreign material from a wound; helps remove cells that are alive but not functioning (senescent) from the wound bed and edges; helps stimulate wound healing and prepare the wound bed for advanced therapies or biological agents Wound Infection Correct Answers inflammation or drainage from a wound due to growth of microorganisms; fever >100.4, foul smelling drainage or a change in color of drainage; prevent by effective skin prep and surgical scrub, use/teach good hygiene, sterile saline for wound cleansing, encourage sufficient nutrient/fluid intake;