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Nursing Fundamentals 121 Final Exam
Questions With Correct Answers
assessment findings indicating pts see spirituality as a source of strength - ANSWER -Religious symbol or book in the room -Religious service televised in room -Prayer before meals, reading religious material -Verbalization of religion, fear of death, asking for clergy -Minister or spiritual mentor visitor manifestations of different types of spiritual distress, including treatment- related, situational, physiologic, and psychologic - ANSWER Psychologic: Fear, loss of connection with god, depression Physiologic: Disturbed sleep pattern r/t spiritual distress, fatigue, weakness Treatment-related: Decisional conflict between treatment plan and religious belief Situational: Inability to practice one's spiritual rituals ex: "why god" Feelings of embarrassment interventions to support client's specific religious practices - ANSWER - Respect beliefs affecting diet Jews: kosher diet (no shellfish/pork) Catholics: avoid meat on Fridays -Respect beliefs related to healing -Respect beliefs related to dress Do not cut pts body hair (for IV/surgery) if they have vowed to never cut body hair for Khalsid Sikh -Respect beliefs related to birth -Respect beliefs related to death -Allow time, privacy for worship, prayer, meditation -Assess how pts religious needs can be met FICA assessment model - ANSWER F: faith or beliefs "What spiritual beliefs are most important to you?" I: implications or influence "How is your faith affecting the way you cope now" C: community "Is there a group of like-minded people that you meet with regularly" A: address How can we support you spiritually
spiritual well-being assessment findings - ANSWER Trusting relationships, inner strength, meaningfulness, motivation, commitment to higher values such as hope, truth, trust, feeling alive, purposeful and fulfilled spiritual distress assessment findings - ANSWER Lack of hope, meaning, purpose, forgiveness, intimacy w the divine, anger or lack of interest about spiritual nurturing people relationship between religious views and stress and coping - ANSWER Negative religious coping is associated w poor adjustment and outcomes "God is punishing me" or "God/my church isn't there for me anymore" Make appropriate referral, chaplain, if it is observed specific rituals for various religions in regard to death and dying, such as Muslim beliefs, Catholic beliefs, Protestant beliefs, etc. - ANSWER Pts fam may need to observe their dying loved one get a ritual performed to feel spiritually comforted catholics and death/dying - ANSWER Receive "anointing of the sick" when very sick or nearing death Free of pain in order to die with comfort muslims and death/dying - ANSWER Want to face Mecca and say a prayer to be loyal to Allah Bathe and prepare the body, Bury, (forbidden to cremate) within 24hrs after death jews and death/dying - ANSWER Burial w/in 24hrs of death except in the Sabbath nuclear family - ANSWER Mother, father and their offspring (traditional family usually married) binuclear family - ANSWER When two biological parents divorce but continue to raise their children in partnership with one another Children spend significant time w both parents, going from one house to the other on a schedule Special consideration: ensure health promotion guidance and education for care of child w acute/chronic condition are communicated effectively to both biological parents Extended family: - ANSWER Grandparents, aunts, uncles, cousins; relatives of nuclear family May live w or away from fam May be source of emotional, financial support May share household and childrearing responsibilities
Intergenerational family - ANSWER More than two generation living together Children may continue to live w parents after having children Grandparent may move in Cohabiting (communal) family - ANSWER Unrelated individuals/families living under one roof May include never-married individuals, divorced or widowed Nursing consideration: non biological parent does not have legal authority for child; not being able to seek medical care for child LGBTQ families - ANSWER Can have all structures outlined previously May be born from a previous hetero relationship, adopted, artificial insemination, surrogate, donor egg One parent may not have legal parental status Single adults living alone - ANSWER Young adults who have recently moved out of fam house Older adults who may be widowed, divorced or never married Internal resources - ANSWER The family will demonstrate knowledge, skills, effective communication patterns, and family roles that facilitate problem solving External resources: - ANSWER Coping, adaption, and include extended family, friends, community organizations, religion, healthcare settings Family Ecomap - ANSWER Visually represents how a family interacts w community Healthcare, education, family, recreation and social networks Communication patterns including verbal/nonverbal comm, listening and how disagreements are managed. Family Genogram - ANSWER Visualize familial relationships and patterns of chronic conditions occurring within the family unit Visual representation of gender showing lines of birth descent through the generations Family APGAR - ANSWER Rapid assessment of family function/dysfunction (psychosocial) Consist of 5 items adaptation, partnership, growth, affection and resolve Ask the questions to all family members above the age of 10 Concern for responses noted in the "hardly ever" category
Home observation for measurement of the environment - ANSWER observation for measurement of the environment Assess the quality of support and stimulation in the home of the children Age-specific tool separated into subscales Responsivity of parent Acceptable of child Physical environment and organizational learning materials Variety in experience Parental involvement Friedman family assessment tool - ANSWER Used to understand family structure, influences, strengths and weaknesses What factors might indicate problems with family communication? - ANSWER Clear communication, problem solving and sharing feelings associated with events within the family can help families achieve a high level of functioning and increase self-efficacy among children and other family members. Anything opposite of this might indicate problems w communication ex: family leader ignores disagreements Identify indicators that successful wellness care was provided to a family. - ANSWER Healthy behaviors/Lifestyle: smoking cessation, healthy diet, exercise, stress relief All families have up to date immunizations and are physically active in sports weekly Facilitating appropriate referrals will improve family's quality of life, reduce risk of illness Establishing therapeutic relationship with family ( connection with pt, fam, and RN) Environment: home safety What tasks by a mother show the role of caring, nurturing, and educating children - ANSWER high level parenting attribute parental control parental warmth affection/caring, nurturing, comfort, teaching healthy lifestyles and skills Parental warmth - ANSWER Warm, nurturing Expressing affection, smiling at children frequently Limiting criticism, punishment Expressing approval of child Parental control - ANSWER Restrictive control of behavior Surveying and enforcing compliance w rules Encourage children to fulfill responsibilities Sometimes limiting freedom of expression
Kubler-Ross 5 stages of grief - ANSWER Denial, anger, bargaining, depression, acceptance characteristics of complicated grief - ANSWER prolonged/intensified grief Inability to proceed w daily activities/ isolate self Avoidance of things that remind of the deceased/ visual hallucinations may occur Anger, distrust, depression, meaninglessness Loss of identity Usually diagnosed after 6 month of grief is grief has not diminished due to increase risk of suicide interventions for complicated grief - ANSWER Support groups (talk therapy) Support pts right to grieve the loss Facilitate pts spiritual and cultural needs Antidepressants Cognitive therapy characteristics of disenfranchised grief - ANSWER Hiding grief from others (ex: "married" boyfriend died) Not seeking support after a loss because of feelings of shame, guilt, lack of recognition of the loss Intensified emotions More pronounced feelings of anger and depression due to resentment over the unacknowledged loss interventions for a grieving adolescent? - ANSWER Encourage, not force, to voice feelings about loss Encourage pt to talk to close friends Encourage healthy coping mechanisms, therapy, bereavement group autonomy of the client experiencing terminal illness - ANSWER Advanced directive can be used If pt is capable and communication is possible, autonomy can be exercised Dying person's bill of rights Physical comfort, emotional support, personal autonomy, respect for individual and family interventions for an elderly client who has lost a spouse - ANSWER Group therapies, individual therapy; explain benefits Allow pt to discuss concerns w/o judgment Complicated grief treatment Teach about complicated grief reactions Referral to support group Antidepressants w monitoring closely for any side effects Healthy coping mechanisms
Recognize factors that place a client at risk for safety issues. - ANSWER Age, dizziness when walking/mobility, cognitive and sensory awareness, emotional state, lifestyle, antihypertensive and pain medications, HAIs interventions for prevention of safety issues - ANSWER Non skid socks, remove hazardous materials, utilize mobility devices, side rails, bedside table and call light within reach, 5 rights of med admin, PPE, reposition, Wear seat belt, avoid driving when sleepy or tired, exercise daily role of clients in engaging in their own safety. - ANSWER Infection control, fall precautions, nutrition, smoking cessation, stress management, exercise, injury prevention, help pt engage in their own safety restraint use in the health care setting. - ANSWER Order for restraint must be in chart When placing restraints, immediately notify the provider then document Chemical or physical restraints The joint commission: - ANSWER quality and safety through accreditation and certification NIOSH - ANSWER evidence supported recommendations on prevention of worker injuries OSHA - ANSWER ensures safe and healthy working conditions for workers; enforces standards by providing training, outreach, education and assistance. Unsafe working conditions are reported to OSHA QSEN - ANSWER prepares nursing students w knowledge, skills and attitudes needed to improve quality patient care Board of nursing: - ANSWER this agency should be contacted if nurse delegates CNA work that is out of her scope of practice What can nurses do to protect themselves from injury? - ANSWER Hand hygiene, PPE Self-care Appropriate disposing of sharps Safe pt handling; proper form Use mobile assistive devices Ask for help to move pt when pt is over 200lbs fall risk interventions - ANSWER Have pt use side rails, glasses, shower seats, have frequently used items with in reach of pt, clear pts areas from clutter, nonskid socks
development of Alzheimer's disease, including risk factors. - ANSWER Early onset familiar: inherited disease Sporadic AD No clear pattern of inheritance 65+ (age) Environmental factors Gender (women 3x more likely than men) Family hx Genetics Ethnicity (hispanics and african americans) Lifestyle factors (unhealthy diet, HTN, DM, obesity, HDL, smoking Health hx (TBI, hypertension, depression, education level, sleep disorders, psychotic meds Not a normal part of aging interventions to protect against the development of Alzheimer's - ANSWER Obesity (exercise) Lifestyle (Remaining socially active, keeping mind active; sudoku, puzzles, reading ) Review in class activities r/t to cognition concepts - ANSWER Stress and coping Safety Tissue integrity Elimination, nutrition Oxygenation Impaired communication What kind of dietary modifications could help decrease risk factors for heart disease? - ANSWER Exercise, avoid smoking, and ETOH Low sodium diet/ bal. meals/ cal. control Lean red meats/ limit fat intake DO NOT eliminate all fat Fruit and vegetables What category of client's may be appropriate for bariatric surgery? - ANSWER Morbid obesity (BMI 40 or higher) who are unable to lose weight through diet, exercise, health problems like metabolic syndrome, hypertension, or heart disease What are priority nursing concepts of concern/ nursing diagnosis for bariatric clients? - ANSWER Activity intolerance Knowledge deficient in nutrients obesity and interventions - ANSWER an accumulation of fat that is abnormal or excessive
-healthy diet -exercise -meal portion control malnutrition and interventions - ANSWER individuals who do not eat sufficient types and amounts of food may experience malnutrition -scheduled meals -nutritional supplements -weight control Review labs you might see in the presence of a UTI - ANSWER Urinalysis Elevated WBC 10- Gram stain positive Urine culture and sensitivity test independent interventions might be provided for a client who is incontinent?
- ANSWER Teach hygiene care Normal fluid intake Toilet schedule ( always at same times) Skin must be kept clean and dry Replace soiled clothing and linen/ change brief What are risk factors for developing constipation? - ANSWER Immobility Lack of privacy Chronic laxative use Suppressing the urge to defecate What assessment findings are typical with a bowel obstruction? - ANSWER Abdominal distention ( high pitched tinkling, rushing, or growling sounds) Constipation or diarrhea Vomiting Inability to pass gas nursing diagnoses for a bedbound older pt - ANSWER Risk for constipation Supplement fiber - ANSWER laxitive increases bulk to promote passage of stool. -take 2 hours before or after other medications Always take with sufficient water Stool Softeners: - ANSWER Hold water and moisten the stool and help prevent constipation. -suggested for use in patients who should avoid straining -Prolonged use may cause an electrolyte imbalance.
- produce a bowel movement in 12-72 hours
Ear infections Damage to ear Genetics Medications Review the process of assessing gait and posture - ANSWER Spinal curvature Observe balance, signs of pain Interview lifestyle; physical activity at work, ability to perform ADLs nursing interventions for clients experiencing acute back pain. - ANSWER HOB elevated, knees flexed when resting in bed Assess pain level 0- Avoid bending and twisting Body mechanics Postural assessment CK levels. - ANSWER Alteration in mobility Increase CK levels indicate muscle damage, muscle inflammation priority nursing diagnosis for a patient experiencing back pain - ANSWER Acute pain (priority) Impaired mobility Activity intolerance Chronic pain Sleep pattern disturbed nursing interventions for patients experiencing difficulty ambulating due to osteoarthritis? - ANSWER Promote comfort; pain meds ROM PT consult for assistive device treatments for osteoarthritis? Are treatments different for elderly clients? - ANSWER Surgery Acetaminophen; first-line therapy NSAIDs for elderly pts (65 years and above) Moist heat packs to affected area 3 times a day Assistive technology Weight reduction Education about disease, exercise and coping techniques Install grab bars in bathroom Review the causes of brown spots as we age - ANSWER The number of melanocytes in aging skin decreases Avoid the sun and use sunscreen to prevent skin damage
patho of the development of contact dermatitis in a client with latex allergy?
- ANSWER Immune response that leads to issues with tissue integrity Inflammation caused by direct contact with an allergen or irritant Manifestations Localized redness Rash Irritation What interventions may be done to slow progression of a stage 1 or 2 pressure ulcer? - ANSWER Positioning: rotate pt to L and R sides to avoid laying on bony prominences HOB 30 degrees Barrier cream Use pillows, waffle mattress, waffle boots to reduce pressure What are interventions for preventing pressure ulcers? - ANSWER Reposition every 2 hours Recognize labs you would see ordered to check for a systemic infection - ANSWER Blood culture; wound culture WBC differential/ WBC count ABGs Urinalysis How do we break the chain of infection? - ANSWER Hand washing PPE Cover mouth when coughing Sterilization; antiseptics, disinfectants Etiologic infection: - ANSWER Infection caused by microorganisms that invade the tissue Latent infection: - ANSWER Infection by an organism that remains inactive in the body Healthcare-associated infection - ANSWER Associated w delivery of healthcare services in a facility (hospital or nursing home) Hospital-Associated infection - ANSWER Infections that take place after hospital admission, usually 48hrs after admit What should discharge instructions include for a client recovering from cellulitis? - ANSWER Educate on proper hand hygiene Educate on wound care Complete antibiotic Monitor for signs of infection (fever,chills, malaise, redness, tenderness)
Cognitive impairments Sleep disturbances Decreased social activities/isolation What would be the drug of choice for acute severe pain, moderate pain, and mild pain? - ANSWER Mild pain: nonopioid +/- adjuvant (ibu/aceto/naprox) Moderate pain: nonopioid +/- nonopioid, +/- adjuvant (ibu/aceto/naprox) Severe pain: opioid for severe pain +/- nonopioid, +/- adjuvant (morphine) appropriate use of nonopioids for chronic back pain. - ANSWER Consider serious side effects Do not take higher than recommended doses Do not combine opioid and nonopioid in order to relieve severe pain Do NOT discontinue medication when you do not feel the need to take meds any longer interventions would be included in a three-step approach for a client with intractable pain? - ANSWER Administer nonopioid analgesic first Administer a nonopioid w an opioid second Administer an opioid analgesic last What is the relationship between risk for injury and pain? - ANSWER Risk for injury is an external risk factor for pain What physiological signs would you see in a terminal client when death is imminent? - ANSWER Hypotension first Cool skin and irregular pulse SOB/confusion Increased sleep Loss of appetite Vision changes Restlessness Urine decrease Review end of life and appropriate nursing actions r/t end of life - ANSWER Place the documents on the chart (we do not deal with that) Wishes of client take priority Comfort Manage physical emotional and spiritual nursing care of dying pt and family
. What are the qualifications for being on hospice and what are the goals of hospice care. - ANSWER Having 6 months or less to live Hospice care is to ease the the burden of primary caregivers Diagnosis for cancer is not required for hospice care Forgo curative treatment Focus on emotional, special , spiritual support
Support for fam up to 1 yr after death of loved one Goal: Comfort (pain management) and dignity
