MULTIDIMENSIONAL CARE 1 EXAM 2 QUESTIONS AND CORRECT ANSWERS, Exams of Nursing

Download MULTIDIMENSIONAL CARE 1 EXAM 2 QUESTIONS AND CORRECT ANSWERS and more Exams Nursing in PDF only on Docsity! MULTIDIMENSIONAL CARE 1 EXAM 2 QUESTIONS AND CORRECT ANSWERS What position would the nurse utilize to prevent aspiration for a client while eating? - ANSWER>>>>- Sit them up right on a bed or chair - for seizure patients feed through unaffected side Cutaneous Pain - ANSWER>>>>arises from burning your skin like on a hot iron or from touching a hot pan on the stove Visceral Pain - ANSWER>>>>caused from deep internal disorders such as menstrual cramps, labor pains, or gastrointestinal infections Deep Somatic Pain - ANSWER>>>>Ø originates from ligaments, tendons, nerves, blood vessels and bones - Ex: fractures or sprains Radiating Pain - ANSWER>>>>Ø starts at an origin but extends to other locations - Ex: pain from a sore throat may extend to ears and head Referred Pain - ANSWER>>>>Ø occurs in an area distant from the site of origin - Pain from a heart attack might be felt in the left arm or jaw Phantom Pain - ANSWER>>>>Ø pain that is perceived from an area that has been surgically or traumatically removed - Pain from an amputated limb Neuropathic Pain - ANSWER>>>>Ø results from an injury of one of more nerves Acute Pain - ANSWER>>>>short duration, rapid onset, and associated with some kind of injury Chronic Pain - ANSWER>>>>last 6 months or longer and interferes with activities of daily living What is the most reliable source used to measure pain? - ANSWER>>>>PQRST/ pain scale What does PQRST stand for? - ANSWER>>>>Provokes (what causes it?) Quality (How does it look like/feel?) Radiates (Where is it? Does it spread?) Severity(Pain scale) Time(When did it begin? How often does it occur?) Location of pain - ANSWER>>>>Where is the pain? Where is it hurting? Intensity of pain - ANSWER>>>>refers to the strength of the amount of pain experienced rated mild to excruciating Quality of pain - ANSWER>>>>The words the patient uses to describe their pain. Such as cramping, burning, pins and needles, sharp, dull or achy, tingling, stabbing and so on Onset and duration of pain - ANSWER>>>>When did the pain start Is it constant or intermittent What are Maslow's hierarchy of needs? - ANSWER>>>>physiological, safety, love/belonging, esteem, self-actualization Basic psychological needs of Maslows - ANSWER>>>>physiological safety love/belongingesteem Air, food, water, temperature regulation, blood flow, rest, sex, physical activity Growth needs of Maslows - ANSWER>>>>self actualization Factors that interfere with sleep? - ANSWER>>>>Stress, anxiety, pain SBAR - ANSWER>>>>S: Situation B: Background A: Assessment R: Recommendation SBAR: Situation - ANSWER>>>>What is the situation you are calling about? • Identify self, unit, patient, room number. termination phase - ANSWER>>>>occurs at the end of a relationship - review and summarize shared information successfully Therapeutic Communication Techniques - ANSWER>>>>1) ACTIVE LISTENING - Shows clients that they have your undivided attention 2) OPEN-ENDED QUESTIONS - Used initially to encourage clients to tell their story in their own way. Ask questions in a language that a client can understand 3) CLARIFYING - Questioning clients about specific details in greater depth or directing them toward relevant parts of the history. 4) SUMMARIZING - Validates the accuracy of the story. Therapeutic Characteristics - ANSWER>>>>Empathy Respect Genuineness (ability to respond truthfully) Concreteness (ability to respond using specific terms) Confrontation (clarify message if you are unclear to avoid risk for error) Social distance - ANSWER>>>>3ft - 6ft Barriers to communication - ANSWER>>>>Ø Don't ask too many questions all at once Ø Changing the subject rapidly Ø Expressing approval or disapproval Ø Offering advice Ø Providing false reassurance Ø Stereotyping Ø Using patronizing language Socialization - ANSWER>>>>the process by which individuals internalize the values, beliefs, and norms of a given society and learn to function as members of that society Acculturation - ANSWER>>>>The adoption of cultural traits, such as language, by one group under the influence of another. Assimilation - ANSWER>>>>interpreting our new experiences in terms of our existing schemas Actions with response to Fire on unit - ANSWER>>>>R - rescue A - alarm C - contain (get patient out of room and closet the door) E - extinguish How to use a fire alarm - ANSWER>>>>P - pull A - aim S - squeeze S - sweep wheelchair safety - ANSWER>>>>brakes locked during all transfers, swing away footrests during transfers if possible Fall risk safety measures - ANSWER>>>>Ø Place patient close to nurse station Ø Never let a patient stay in the bathroom by themselves Ø Keep bed at low level Ø Offer regular opportunities to go to the toilet Ø Check on them every 2hrs never events - ANSWER>>>>Serious but preventable errors that should never occur leading cause of accidental death - ANSWER>>>>motor vehicle accidents Mission of OSHA - ANSWER>>>>- Occupational safety and health administration - Congress created OSHA through the occupational safety and health act of 1970 - Assures safe and healthful working conditions for working men and women by setting and enforcing standards and by providing training, outreach, education, and assistance National Patient Safety Goals - ANSWER>>>>Identify patients correctly Improve staff communication Use medicines safely Use alarms safely Prevent infection Identify patient safety risks Prevent mistakes in surgery Purpose of incident report - ANSWER>>>>- to memorialize in writing any unusual event at the time of its occurrence by a person who was a direct personal witness - to LEARN from the mistakes and how to eliminate, reduce and manage the risks on a daily basis Risk for toddlers - ANSWER>>>>choking Risk of falls in geriatrics - ANSWER>>>>Ø Higher risk inpatients older then 75 Ø Poor vision, low bp, dizziness, alcohol use, polypharmacy, arthritis, etc Ø Adults 65 and old history of falls, lives alone, use assistive devices, wheelchair use Risk of violent behaviors - ANSWER>>>>Ø Anxiety, angry, acute illness they don't understand, treats Ø Never close the door behind you Risk mitigation with poison control - ANSWER>>>>Ø Always call poison control center Ø Gastric lavage (tube that goes into the mouth and washed the stomach) Ø Dialysis Ø Administration of antidotes - Ex: opioids = Narcan Ø NEVER INDUCE VOMITING Risk related to needle stick injury - ANSWER>>>>Ø Tired or fatigue Ø Low skill level Ø Lack of using protecting devices Motor vehicle mitigation - ANSWER>>>>Ø Wearing seatbelts Ø Not texting and driving Types of pollution - ANSWER>>>>air, water, soil contamination What is a sentinel event? - ANSWER>>>>an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof fluid overload symptoms - ANSWER>>>>increase BP, increased urine output, dependant edema, lung crackles, neck vein distension Fluid-Deficient Symptoms - ANSWER>>>>Decreased urine output, decreased skin turgor, dry mucous membranes, hypotension, tachycardia, weight loss Physiological needs - ANSWER>>>>Nutrition assessment Mobility Assessment