Understanding Coping Mechanisms and Stress Management in Nursing, Exams of Nursing

Download Understanding Coping Mechanisms and Stress Management in Nursing and more Exams Nursing in PDF only on Docsity! Test 3 Nursing 101Exam Questions with Answers Latest Update 2024 100% Accuracy B (Rationale: the number of beats per minute is 12 beats slower than the apical rate of 80 beats per minute. This indicates weak contractions of the left ventricle and could lead to alterations in perfusion. The other assessment findings are within normal limits.) - Correct Answers Which of the following assessment findings would suggest to the nurse that a patient is at risk for alterations in perfusion? A. BP of 110/68 mmHg B. Apical HR of 80; Radial beats per minute of 68 C. RR - 20 D. Temp - 98.8 A (Rationale: hematocrit is the percentage of the blood that is erythrocytes, which contain the hemoglobin that carries oxygen. Long-term hypoxia may result in the body's attempt to increase oxygen-carrying capacity by increasing erythrocyte production. This can lead to an alteration in the patient's perfusion. BUN is a measure of blood urea nitrogen, not oxygen-carrying capacity. Increases in blood sugar and sedimentation rate are not directly a measure of oxygenation.) - Correct Answers A patient is admitted with complaints of shortness of breath of 2 weeks duration. Which of the following lab findings would support the finding that the patient is at risk for an alteration in perfusion? A. Increased hematocrit B. Decreased BUN C. Increased blood sugar D. Increased sedimentation rate A (Rationale: the one intervention that would help the client prevent the onset of cardiovascular disease would be to avoid cigarette smoking. The other instructions are not known to prevent cardiovascular disease.) - Correct Answers A patient tells the nurse that he does not want to develop the same heart problems that his parents experienced. Which of the following should the nurse instruct this client? A. avoid smoking cigarettes B. limit fluid intake C. wear elastic hose D. limit exercise to 15 minutes a day B (Rationale: swelling in one leg with pitting edema is suggestive of DVT in the vein of the affected leg because the clot is obstructing the venous return from the leg. Bilateral calf tenderness may be a normal reaction to the exercise of climbing stairs. SOB that subsides after activity and 2+ palpable pulses are normal.) - Correct Answers The nurse would suspect deep venous thrombosis in a patient with which of the following assessment findings? A. Bilateral calf tenderness after walking up a flight of stairs B. Swelling in one leg with pitting edema C. Shortness of breath after activity D. 2+ palpable pedal pulses B (Rationale: an absence of bleeding is a priority outcome for any client receiving anticoagulant therapy. Disturbing the IV line could relate to bleeding, but this does not directly correlate with heparin. Dietary restrictions are important but not as high a priority as an absence of bleeding. Elevation of the affected extremity is important but not as high a priority as an absence of bleeding.) - Correct Answers A patient diagnosis with DVT is receiving IV Heparin. The nurse would identify which of the following as being the priority outcome for this patient? A. The patient will not disturb the IV infusion B. The patient will not experience bleeding C. The patient will comply with dietary restrictions D. The patient will keep the right leg elevated on 2 pillows. A (Rationale: A reduction in arterial oxygen saturation level and dyspnea indicate the client is experiencing impaired gas exchange. This would be the priority for the client at this time. The other possible nursing diagnoses would not be considered a priority at this time.) - Correct Answers A patient diagnosed with a pulmonary embolism has a reduction in arterial oxygen saturation level and dyspnea. The nurse would identify which of the following diagnoses as being a priority problem for this patient? A. Impaired gas exchange B. Ineffective tissue perfusion C. Anxiety D. Impaired physical mobility C (Rationale: the hemoglobin level affects the amount of oxygen that can be carried in the blood. The low level suggests the client does not have enough red blood cells to provide adequate oxygen for the body. The blood pH is WNL. Serum sodium does not impact the oxygen capacity of the body. Oxygen saturation is WNL.) - Correct Answers The blood sugar levels have been excellent for the last 6 months." The patient is using the defense mechanism: A. denial B. conversion C. dissociation D. displacement B - Correct Answers When doing an assessment of a young woman who was in an MVA 6 months ago, the nurse learns that the woman has vivid images of the crash whenever she hears a loud, sudden noise. The nurse recognizes this as: A. conversion B. PTSD C. dissociation D. displacement C - Correct Answers A grandfather living in Japan worries about his two young grandsons who disappeared after a tsunami. This is an example of: A. a situational loss B. a maturational loss C. ambiguous loss D. a developmental loss B - Correct Answers During the assessment of an older woman experiencing a developmental crisis, the nurse should ask which of the following questions? A. how is this flood affecting your life? B. since your husband died, what have you been doing in the evening when you feel lonely? C. how is having diabetes affecting your life? D. I know this must be hard for you. Let me tell you what might help. Actual loss - Correct Answers The loss of a person or object that can no longer be felt, heard, known or experienced Perceived Loss - Correct Answers A loss uniquely defined by the client, less obvious to others Example: best friend getting married -- feel like you are losing your friend Maturational Loss - Correct Answers A loss that is a result from a developmental process that is normally expected Example: daughter leaves home for college Situational Loss - Correct Answers A loss that is a result of a sudden unexpected external event Example: MVA leaves physical disabilities Grief - Correct Answers The emotional response to a loss Mourning - Correct Answers Outward social expression of a loss Bereavement - Correct Answers Grief + mourning Inner feelings and outward reaction of a loss Anticipatory Grief - Correct Answers uncomplicated; grief experienced by a loss you knew was coming; implies "letting go" before the loss Chronic Grief - Correct Answers Ongoing grief; can't get past Delayed Grief - Correct Answers something that keeps you from grieving at that time Example: Family gets into car accident -- father dies, but daughter is in ICU -- wife's attention is on daughter and unable to grieve her husband Exaggerated Grief - Correct Answers Grief that impairs level of functioning Masked grief - Correct Answers Not able to grieve, pick up negative coping patterns Example: picks up drinking to mask pain/cope Disenfranchised Grief - Correct Answers experienced loss that cannot be publicly shared or is not socially acceptable Ex: pets; loss of significant other that was not approved of, suicide, abortion Ambiguous Grief - Correct Answers Example: someone goes missing and remains are not found Kubler-Ross' Behavioral Theory - Correct Answers 5 stages of grief - denial - anger - bargaining - depression - acceptance Bowlby's Attachment Theory - Correct Answers - shock + numbness - yearning and searching - disorganization and despair - reorganization Worden's Grief Task Model - Correct Answers Task 1: to accept the reality of the loss Task 2: to experience and work through the pain of grief Task 3: to adjust to an environment in which the deceased is missing Task 4: find an enduring connection with the deceased while embarking on a new life ** not linear; believed you cannot fully grieve unless you are able to complete all 4 tasks ** Factors that affect loss and grief - Correct Answers - developmental stage - personal relationships (how long did you know them) - nature of the loss (public vs. private) - coping strategies - socioeconomic status (availability of resources) - culture and ethnicity - spiritual beliefs - hope (did you get closure?) Grief & Loss Nursing Diagnosis - Correct Answers - anticipatory grieving - dysfunctional grieving - hopelessness - compromised family coping - spiritual distress Physical manifestations of end-of-life - Correct Answers - periods of unresponsiveness (sensory) - coolness and color changes in extremities, nose and fingers (circulatory) - altered breathing patterns -- apnea, labored, Cheyne stokes (respiratory) - weakness and fatigue (musculoskeletal) - decreased urine output, dark colored urine, decreased ability to eat/drink (GI/GU) - color changes, blue spots (skin) - brain death End of life comfort - Correct Answers fluids and fiber 1990 Omnibus Reconciliation Act - Correct Answers Patient self-determination act: able to decide what type or extent of medical care you want Advanced directives - Correct Answers legal documentation that direct end-of-life issues Full Code - Correct Answers All life saving measures are initiated DNR - Correct Answers do not resuscitate Palliative care - Correct Answers - focus is on caring interventions not curative treatment - conversion - denial - displacement - identification - dissociation - regression Compensation - Correct Answers act of making up for something you viewed as lost Conversion - Correct Answers unconsciously converting an emotional stressor into a physiological symptoms Example: you are so anxious, you lose your appetite Denial - Correct Answers avoid things that cause pain; avoid emotional conflict Displacement - Correct Answers displacing feelings towards someone else example: mad at husband, but yell at your child Identification - Correct Answers example: husband gains weight when wife is pregnant Dissociation - Correct Answers decreased awareness; subject to a sense of numbing Regression - Correct Answers regress to earlier development stage example: abused child regresses to wetting the bed Traumatic Stress Disorders - Correct Answers - acute stress disorder (ASD) - post traumatic stress disorder (PTSD) Anxiety - Correct Answers - is often non-specific; vague, uneasy feeling - may occur with clients who are hospitalized when pain, fear of death, surgery, treatments, coping with outcomes of treatments and their ability to return to normal life Crisis - Correct Answers - an upset in the balance of the stable state - coping mechanisms no longer work Types of crisis - Correct Answers - developmental - situational Developmental crisis - Correct Answers unable to complete a task for a specific developmental level -- can occur at any stage Situational crisis - Correct Answers - physically or psychologically hazardous situation - not anticipated - not prepared to handle Role of the Nurse (in crisis) - Correct Answers - help the client problem solve - help identify situational support - help the client understand the relationship between the event and their reaction to the event **assist in identifying new methods of coping** Nursing Assessment: Stress - Correct Answers - subjective findings: what the patient reports (i.e. "i feel tired; I feel worthless") - objective findings: nurse observations (i.e. patients change in weight or vitals; sleep disturbance) - focused interview ("have you noticed any changes? Any suicidal thoughts?) Ineffective Individual Coping (nursing diagnosis) - Correct Answers Defining characteristics: - change in person's usual pattern of behavior - signs/symptoms: tension headache, fatigue, sleep disturbance, poor concentration, ineffective problem solving, poor hygiene - self destructive behaviors: drinking, smoking, drug abuse, self-harm, etc. Interventions for Ineffective Individual Coping - Correct Answers - establish rapport - educate on impact of ineffective coping on health - educate on effective coping skills - provide caring presence - encourage counseling Health Promotion - Correct Answers - you may not be able to change the stressors, but you can change how you react to them - time management, exercise, humor, rest, support, etc. Ways to relieve stress - Correct Answers 4-7-8 breathing Emotional Freedom Technique (acupuncture, energy medicine) Transcendental Meditation Spirituality - Correct Answers - another type of mind/body relatedness - a process and sacred journey, the experience of a radical truth of things, and a belief that relates a person to the world and gives meaning to existence - quest for purpose and meaning in life; connection with mystery and a higher power Spirit - Correct Answers the essence that connects a person to others and all living things unifies the whole person Spirituality and Health - Correct Answers Health is affected by our spirituality - effects include decreased anxiety, decreased depression, helps balance the need for control, placebo effect, gives meaning to life Hope - Correct Answers - something to lie for and look forward to - a determination to endure - is energizing giving motivation to achieve - an invaluable personal resource when faced with loss - must be present for a client to effectively cope Recent research in spirituality/health - Correct Answers - religious faith and spiritual meaning as a positive predictor of survival in CABG surgery - prayer can decrease BP - meditation and relaxation techniques help manage chronic pain, anxiety, depression and may improve immune function Spiritual Health - Correct Answers - sense of personal fulfillment - sense of peace with self and world - sense of fulfillment in life - ability to articulate a purpose in life - part of holistic nursing often overlooked - older nurses, as they become more conscious of their own death, become more comfortable in this area of care Holistic Assessment: spirituality - Correct Answers - ask about faith/belief, religious preferences, practices - need for visit by minister, rabbi, etc. - observe for behaviors/objects including bible, praying, head covering - ask focused/open ended questions such as "is God important to you? Is prayer helpful?" Nursing diagnosis: spiritual distress - Correct Answers an impaired ability to integrate or experience meaning/purpose in life through a person's connectedness to self, others, nature, music, and/or power greater than oneself may be expressed both verbally and behaviorally (i.e. inability to sleep, crying, worried) Spiritual distress: patient outcomes - Correct Answers - client will develop an inner spiritual peace and sense of well-being - client will express a greater sense of meaning - client will express purpose and hope in living Spiritual distress: interventions - Correct Answers - establish a caring presence - talk with client about spiritual needs Goal of ventilation - Correct Answers produce a normal PaCO2 Hyperventilation - Correct Answers excessive alveolar ventilation Hypoventilation - Correct Answers ventilation inadequate to meet body's demands for O2 and elimination of CO2 Hypoxia - Correct Answers inadequate tissue oxygenation at cellular level First sign of hypoxia** - Correct Answers change in LOC/altered mental status/confusion COPD + Hypoventilation - Correct Answers **in most of us, an increase in CO2 is a trigger for us to breathe faster** COPD patients: - chronic CO2 retainers - have adapted to increase CO2 - CO2 receptors do not function - stimulus to breathe is the decrease in PaO2 - if excessive O2 is delivered, the stimulus to breathe may be negated causing hypoventilation Cardiac Anatomy - Correct Answers function is to deliver oxygen, nutrients and other substances to tissues and to remove waste products of cellular metabolism Myocardial Pump - Correct Answers - stroke volume - cardiac output - systole - diastole - pre/afterload Stroke volume - Correct Answers volume of blood ejected by the ventricles with each stroke Cardiac output** - Correct Answers amount of blood ejected from the left ventricle each minute Systole - Correct Answers contraction chambers empty and blood is pumped to the body Diastole - Correct Answers relaxation heart rates and cavities fill with blood Preload - Correct Answers the amount of blood in the left ventricle at the end of the diastolic filling Afterload** - Correct Answers the resistance to left ventricle ejection that the heart must overcome to fully eject blood **concerned with afterload for Pt's with HTN -- overtime, LV will get hyperatrophied/stretched (heart failure)** Myocardial conduction - Correct Answers SA Node --> AV Node --> Bundle of His --> Bundle Branches --> Parkinjie Fibers SA Node - Correct Answers natural pacemaker 60-100 normal sinus rhythm AV Node - Correct Answers mediator of impulse between atria and ventricles 40-60 **can act as standby pacemaker if SA node fails** Bundle of His - Correct Answers fire the impulse from the AV node to the Purkinje fibers 20-40 Bundle Branches - Correct Answers L/R contract in synchrony Perkinje Fibers - Correct Answers disperses impulse to myocardial muscle of LV Cardiac Function Alteration - Correct Answers Affected by: - conduction disturbance - increased/decreased cardiac output (normal: 4-6L/min) - heart failure - valvular disease - angina - MI - HTN Normal Cardiac Output - Correct Answers 4-6 L/min Angina - Correct Answers decrease in oxygen to heart muscle Cardiopulmonary functioning - Correct Answers any condition that affects cardiopulmonary functioning directly affects the body's ability to meet oxygen demand - decreased Hgb - decreased inspired O2 concentration - hypovolemia - increased metabolic rate Factors which impact oxygenation/perfusion - Correct Answers - developmental: premature, school age, adult, older adult - lifestyle: HTN, diet, smoking, DM, obesity - Environmental: stress, anxiety, smoking, dust/mold, pollutants Assessment: Cardiac History - Correct Answers - risk factors - culture -pain -dyspnea (clinical sign of hypoxia) - fatigue - peripheral circulation - intermittent claudication (pain) 6 P's of Peripheral Circulation - Correct Answers 1. Pain 2. Pallor 3. Pulse 4. Parasthesia 5. Paralysis 6. Poikothermia (coldness) Assessment: Respiratory History - Correct Answers - cough - SOB/dyspnea - orthopnea - wheezing - smoking - environmental factors - hemoptysis - pain - culture 1st sign of cardiovascular dysfunction - Correct Answers a change in vital signs such as the increase/decrease in HR and/or BP Respiratory Diagnostic Tests - Correct Answers - TB skin tests - treat the underlying cause - oxygen therapy (may not be 1st intervention) - medication - physical techniques (tripod position) - psychosocial airway maintenance - Correct Answers secretions: - hydration - humidification - nebulization - coughing - chest PT (i.e. vibrating vest) - postural drainage - artificial airway - nasotracheal and tracheal suctioning - CPAP/BiPAP - avoid milk with increased secretions - apply humidity to O2 if Pt is on 3-4L (can cause drying) - Nebulization = breathing treatment + moisture - Chest PT is contraindicated for patient with pulm. embolism Lung Expansion - Correct Answers Positioning: - Pneumothroax: good lung down - Hemothorax: affected lung down IS/Flutter valve Chest tube: used for a variety of reasons but typically to remove fluid or air from pleural space chest tube maintenance - Correct Answers - do not milk** - do not clamp** - keep below level of chest** - watch for air leaks** - location (pleural vs mediastinal) - suction vs water seal/gravity drainage - closed system (don't empty until full)** - occlusive dressing - keep vaseline gauze and hemostats at bedside Oxygen therapy - Correct Answers - does not promote airway clearance, but improves gas exchange if airway is clear - prevents or relieves hypoxia - treat as a drug (need MD order) - continuously monitor Oxygen delivery - Correct Answers - fraction of inspired O2 (FiO2): given percent of inspired concentration - equipment is categorized as low flow and high flow Low Flow O2 Devices - Correct Answers - differes with respiratory pattern - cannula, simple face mask, trache collar High Flow O2 Devices - Correct Answers - delivers high concentration of O2 regardless of respiratory pattern - venturi mask, 24-50% FiO2 - Correct Answers fraction of inspired oxygen - 1-2L = 24-28 FiO2 - 3L = 32-36 FiO2 Home O2 therapy - Correct Answers Indicated when: - pulse ox is 88% or less - arterial PaO2 is 55Hg or less **teach safety, regulation, signs of hypoxia** Restorative therapy - Correct Answers - respiratory muscle training - pursed lip breathing: assists by decreasing air trapping and resistance - diaphragmatic breathing Cardiac Medications - Correct Answers - vasodilators - CA channel blockers - beta blockers - anti arrhythmic - chronotropics - inotropics - ACE inhibitors** - diuretics - statins - anticoagulants** - platelet de-aggregators ACE inhibitors - Correct Answers block angiotensin I-II; lower BP Anticoagulants - Correct Answers should not be given to vegetarians --> reaction with potassium diets What medication would be contraindicated with a BP of 90/60? - Correct Answers adrenergic or cholinergic Chronotropics - Correct Answers affect heart rate per minute - negative chronotropic: decreases HR - positive chronotropic: increases HR Inotropic - Correct Answers affecting the contractility of cardiac muscle - Negative inotropic: decrease contraction force - Positive inotropic increases contraction force Respiratory medications - Correct Answers - Antitussives (cough) - bronchodilators - corticosteroids - decongestants - antihistamines - expectorants - leukotriene receptor antagonists (block inflammation - combo inhalers Oxygen/Perfusion Nursing Diagnosis - Correct Answers - anxiety - ineffective airway clearance - ineffective breathing pattern - cardiac output decreased - impaired gas exchange - altered tissue perfusion - inability to sustain spontaneous ventilation - altered health maintenance - ineffective coping - knowledge deficit - risk for infection - activity intolerance Coping - Correct Answers describes how an individual deals with problems, such as illness and stress. Factors involved in coping - Correct Answers - family dynamics - adherence to treatment - the role an individual can play in important relationships - number/duration/intensity of stressors - past experiences - available resources - A basic assumption is that a client can either advance or regress in the face of a situational role change Temporary Role Change - Correct Answers the client will resume the role when illness resolves Permanent Role Change - Correct Answers illness has altered the level of the client's health to a point that previous roles are no longer available Self concept - Correct Answers is the way individuals feel and view themselves. Involves conscious and unconscious thoughts, attitudes, beliefs, and perceptions Self-esteem - Correct Answers how a person feels about self Health issues that affect self concept and self esteem - Correct Answers - loss of health - disability - chronic illness - disfigurement Development of self-concept - Correct Answers - complex and lifelong - Erikson's psychosocial theory maybe a guide and defines key tasks individuals face in development - successful mastery of each stage leads to a strong sense of self - self esteem varies in life rising in childhood, waning in adolescence, rising again in adulthood and decreasing in old age Components of self-concept - Correct Answers - identity - body image - role performance Identity - Correct Answers internal sense of self; critical for the achievement of intimate relationships common stressors: job loss, neglect, societal norms, gender identification concerns Body image - Correct Answers attitudes or self perceptions about body including physical appearance, sexuality, youthfulness and strength common stressors: stroke, colostomy, obesity, chronic illness, aging, scarring, rape Role performance - Correct Answers perceptions of self's ability to carry out various roles with competence common stressors: life-career imbalance, empty nest, caring for aging parent Effects of others on self-concept - Correct Answers - Family plays a primary role in the development and maintenance of self concept - The nurse can have an important influence on a patients self concept and can influence a positive change in a patient with altered self concept Assessment of self-concept - Correct Answers Nursing assessment questions may be helpful: - how would you describe yourself? (identity) - what aspects of your appearance do you like? (body image) - what things make you feel good about yourself? (self esteem) - how effective are you at carrying out your roles? (role performance) Nursing diagnosis: self concept - Correct Answers - disturbed body image - caregiver role strain - disturbed personal identity - ineffective role performance - readiness for enhanced self-concept - chronic low self-esteem - situational low self-esteem - risk for situational low self-esteem Nursing interventions: self concept - Correct Answers - develop a therapeutic nurse- patient relationship - encourage health promotion and self care - assist in identification of positive coping skills - remain sensitive and at the patient's level of acceptance of a change and do not force acceptance the patient may not be ready for - encourage independence and decision making - help the patient reframe thoughts and feelings in a positive way - encourage verbalization of thoughts and feelings - accept the patients thoughts and feelings and provide empathy - assist in developing positive coping skills and identifying negative ones - reinforce strengths, and design opportunities that result in success B (Rationale: showing interest in the client is applying the therapeutic communication technique of offering self. Asking more about how the client feels is applying the therapeutic communication technique of encouraging a description of perception.) - Correct Answers A nurse in an ambulatory care clinic is caring for a patient who had a mastectomy 6 months ago. The client tells the nurse that she has not had much desire for sexual relations since her surgery, stating, "My body is so different now." Which of the following responses should the nurse make? A. "Really, you look just fine to me. There's no need to feel undesirable." B. "I'm more interested in finding out about how your body feels to you." C. Consider an afternoon at a spa. A facial will make you feel more attractive." D. "it's still too soon to expect to feel normal. Give it a little more time." B, C, E (Rationale: having a mastectomy involves changes in physical appearance of a woman and can lead to body image disturbances related to femininity and sexuality. Having an above the knee amputation involves a change in physical appearance and can lead to body image disturbances related to function, health and strength. Having right-sided hemiplegia involves a change in physical appearance and can lead to body image disturbances related to function, health and strength.) - Correct Answers A nurse is caring for a group of clients on a medical-surgical unit. Which of the following clients are at risk for body image disturbances? (select all that apply) A. 30 year old male client following a laparoscopic appendectomy B. 45 year old female following mastectomy C. 20 year old female following left above the knee amputation D. 65 year old client following cardiac catheterization E. 55 year old male client following stroke with right-sided hemiplegia D (Rationale: refusing to look at the leg or dressing indicates that the client is having difficulty acknowledging the fact that the leg has been improved. This would imply a distorted body image.) - Correct Answers A nurse is caring for a client who is 3 days post-op following a below the knee amputation as a result of a MVA. Which of the following client statements indicates to the nurse that the client has a distorted body image? A. "I'll be able to function exactly as I did before the accident." B. "I just can't stop crying." C. "I am so mad at that guy who hit us. I wish he lost a leg." D. "I don't even want to look at my leg. You can check the dressing." B (Rationale: the nurse is acknowledging and allowing the client to discuss his concerns regarding sexual functioning.) - Correct Answers A nurse is caring for client who is recovering from a myocardial infarction and a cardiac catheterization. The client states, "I am concerned that things might be a little, you know, 'different' with my wife when I get home." Which of the following statements should the nurse make? A. "sounds like something you should discuss with her when you get home." B. "It sounds like you are concerned about sexual functioning. Let's discuss your concerns." C. "Oh, I wouldn't be too concerned. Things will be fine as soon as we get you home." D. "Just make sure you take your medication as directed, and you should be fine." B Postmortem Care - Correct Answers - nurses are responsible for following federal and state laws regarding requests for organ or tissue donation, obtaining permission for autopsy, ensuring the certification and appropriate documentation of the death, and providing postmortem care. - after postmortem care, the client's family becomes the nurse's primary focus C (Rationale: allowing the client as much control as possible maintains dignity and self- esteem) - Correct Answers A nurse is caring for a client who has terminal lung cancer. The nurse observes the client's family assisting with all ADLs. Which of the following rationales for self-care should the nurse communicate to the family? A. Allowing the client to function independently with strengthen her muscles and promote healing B. The client needs to be given privacy at times for self-reflecting and organizing her life. C. The client's sense of loss can be lessened through retaining control of certain areas of her life D. Performing ADLs is required prior to discharge from an acute care facility C (Rationale: the client is displaying bargaining by attempting to negotiate more time to live to see his daughter get married) - Correct Answers A nurse is caring for a client who has stage IV lung cancer and is 3 days post-op following a wedge resection. The client states, "I told myself that I would go through with the surgery and quit smoking, if I could just live long enough to attend my daughter's wedding." Based on Kubler-Ross' model, which stage of grief is the client experiencing? A. Anger B. Denial C. Bargaining D. Acceptance A, D, E (Rationale: asking the grieving individual whether she would like spiritual support at this time is an acceptable nursing intervention to facilitate mourning. The nurse should educate the grieving individual on the grieving process and expected emotions at this time. The nurse should encourage open communication of feelings by using therapeutic communication to facilitate mourning.) - Correct Answers A nurse is consoling the partner of a client who just expired after a long battle with liver cancer. The partner is displaying grief and states, "I hate him for leaving me." Which of the following statements by the nurse successfully facilitate mourning for the grieving partner? (Select all that apply) A. "Would you like me to contact the chaplain to come speak with you?" B. "You will feel better soon. You have been expecting this for a while." C. Let's talk about your children and how they are going to react." D. "You know, it is quite normal to feel anger toward your husband at this time." E. "Tell me more about how you are feeling." D (Rationale: muscle relaxation is an expected finding when a client is approaching death) - Correct Answers A nurse is caring for a client who has a terminal illness. Death is expected within 24 hours. The client's family is at the bedside and asks the nurse about anticipated findings at this time. Which of the following findings should the nurse include in the discussion? A. regular breathing patterns B. warm extremities C. increased urine output D. decreased muscle tone C, D, E (Rationale: the body and the environment should be as clean as possible. This includes washing soiled areas of the body and applying fresh linens and a clean gown. The environment should be as clutter-free as possible. The nurse should remove all equipment and supplies from the bedside. Dimming the lights helps to provide a calm environment for the family) - Correct Answers A nurse is assisting a newly licensed nurse with postmortem care of a client. The family wishes to view the body. Which of the following statements by the newly licensed nurse indicate an understanding of the procedure? (select all that apply) A. "I will remove the dentures from the body." B. "I will make sure the body is lying completely flat." C. "I will apply fresh linens and place a clean gown on the body." D. "I will remove all the equipment from the bedside." E. "I will dim the lights in the room." Sleep - Correct Answers - is a cyclical physiological process that alternates with longer periods of wakefulness - sleep-wake cycle influences and regulates physiological function and behavioral responses Rest - Correct Answers is a feeling of physical calm and freedom from worry Circadian Rhythms - Correct Answers 24 hour cycle Sleep regulation - Correct Answers - Reticular activating system (RAS) - Bulbar synchronizing region (BSR) Reticular activating system - Correct Answers - upper brain stem (cerebral cortex) - maintaining alertness and wakefulness - neurotransmitters associated with excitation and sleep inhibition kick in here Bulbar synchronizing region - Correct Answers - pons, medulla - release of serotonin which causes sleep Sleep stages - Correct Answers - Awake: NREM I - Stage 1: NREM II - Stage 2: NREM III - Stage 3: NREM IV - Stage 4: NREM III - Stage 5: NREM II - REM Sleep cycle - Correct Answers consists of 4 stages of nonrapid eye movement (NREM) sleep and a period of rapid eye movement (REM) sleep **after stage 1, people cycle 4-6x through the other stages per night. With each cycle, the length in REM sleep increases.** NREM sleep - Correct Answers 75-80% of sleep time Stage 1 NREM - Correct Answers - very light sleep - only a few minutes long - vital signs and metabolism beginning to decrease - awakens easily - feels relaxed and drowsy Stage 2 NREM - Correct Answers - deeper sleep - 10-20 minutes long - vital signs and metabolism continuing to slow - requires slightly more stimulation to awaken - increased relaxation Stage 3 NREM - Correct Answers - initial stages of deep sleep - 15-30 min long - vital signs continuing to decrease but remain regular - difficult to awaken - relaxation with little movement Stage 4 NREM - Correct Answers - called delta sleep - deepest sleep - 15-30 min long - vital signs low - very difficult to awaken - physiologic rest and restoration - are client expectations being met? Sleep duration - Correct Answers sleep averages vary with the developmental stage, with infants and toddlers averaging 9-15 hr/day; this declines gradually throughout childhood, with adolescents averaging 9-10 hr/day and adults 7-8 hr/day Insomnia - Correct Answers - the most common sleep disorder - is the inability to get an adequate amount of sleep and to feel rested - might be difficulty falling asleep, difficulty staying asleep, awakening too early, or not getting refreshing sleep Acute insomnia - Correct Answers Short term (few days); caused by stress, emotional/physical discomfort, environmental factors, medications, interference of normal sleep schedule Chronic insomnia - Correct Answers sleeping troubles that last for a period of more that 3 weeks Intermittent insomnia - Correct Answers sleeping well for a few days and then having insomnia for a few days Who is more prone to insomnia? - Correct Answers Females and older adults Sleep apnea - Correct Answers - sleep disorder characterized by more than five breathing cessations lasting longer than 10 seconds per hour during sleep - results in decreased arterial oxygen saturation levels central sleep apnea - Correct Answers central nervous system dysfunction in the respiratory control center of the brain that fails to trigger breathing during sleep Obstructive sleep apnea - Correct Answers structures in the mouth and throat relax during sleep and occlude the upper airway Narcolepsy - Correct Answers - sudden attacks of sleep or excessive sleepiness during waking hours - it often happens at inappropriate times and increases the risk for injury A, C, D, E (Rationale: daytime sleepiness, which can interfere with functioning, is common during the day when people cannot sleep at night. Caffeinated drinks act as a stimulant and can interfere with sleep. Periods of apnea warrant a prompt referral for diagnostic sleep studies. Emotional stress is the most common cause of short-term sleep problems.) - Correct Answers A nurse in a provider's office is caring for a client who states that, for the past week, she has felt tired during the day and cannot sleep at night. Which of the following responses should the nurse ask when collecting data about the client's difficulty sleeping? (select all that apply) A. "Does your lack of sleep interfere with your ability to function during the day?" B. "Do you feel confused in the late afternoon?" C. "Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?" D. "Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep?" E. "Tell me about any personal stress you are experiencing." A, B, D, E (Rationale: relaxation techniques, especially muscle relaxation, can help promote sleep and rest. Following an exercise routine regularly, at least 2 hour prior to bedtime, can help promote rest and sleep. For example, rather than trying to sleep with a restless pet at the foot of the bed, move the pet to another sleep area. Limiting fluids for a few hours before bedtime helps minimize getting up to urinate.) - Correct Answers A nurse is talking with a client about ways to help him sleep and rest. Which of the following recommendations should the nurse give to the client to promote sleep and rest? (select all that apply) A. practice muscle relaxation techniques B. exercise each morning C. take an afternoon nap D. alter the sleep environment for comfort E. limit fluid intake at least 2 hours before bedtime C (Rationale: when providing nursing care, the nurse should first use the least restrictive intervention. Of these options, allowing the client to follow her usual bedtime routine represents the least change, so it is the first intervention to try.) - Correct Answers A nurse is caring for an older adult client who has been following the facility's routine and bathing in the morning. However, at home, she always takes a warm bath just before bedtime. Now she is having difficulty sleeping at night. Which of the following actions should the nurse take first? A. rub the client's back for 15 min before bedtime B. Offer the client warm milk and crackers at 2100 C. allow the client to take a bath in the evening D. Ask the provider for a sleeping medication A, C, E (Rationale: cognitive and brain tissue restoration occur during REM sleep. In this stage, awakening is difficult. Dreaming does occur in other stages, but it is less vivid and possibly less colorful.) - Correct Answers A nurse is preparing a presentation at a local community center for sleep hygiene. When explaining rapid eye movement sleep, which of the following characteristics should the nurse include? (select all that apply) A. REM sleep provides cognitive restoration B. REM sleep lasts about 90 minutes C. It is difficult to awaken a person in REM sleep D. Sleep walking occurs during REM sleep E. Vivid dreams are common during REM sleep B (Rationale: clients who have narcolepsy should take short naps to reduce feelings of drowsiness.) - Correct Answers A nurse is instructing a client who has a new diagnosis of narcolepsy about measures that might help with self-management. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I'll add plenty of carbs to my meals." B. "I will take a short nap whenever I feel a little sleepy." C. I'll make sure I stay warm when I am at my desk at work." D. "It's okay to drink alcohol as long as I limit it to one drink per day." Transduction - Correct Answers the conversion of painful stimuli to an electrical impulse through peripheral nerve fibers (nociceptors) Transmission - Correct Answers occurs as the electrical impulse travels along the nerve fibers, where neurotransmitters regulate it; help speed the message along Pain threshold - Correct Answers point at which a person feels pain Pain tolerance - Correct Answers the amount of pain a person is willing to bear Perception or awareness of pain - Correct Answers occurs in various areas of the brain, with influences from thought and emotional processes Modulation - Correct Answers occurs in the spinal cord, causing muscles to contract reflexively, moving the body away from painful stimuli Substances that increase pain transmission and cause an inflammation response - Correct Answers - substance p - prostaglandins - bradykinin - histamine substances that decrease pain transmission and produce analgesia - Correct Answers - serotonin - endorphins - imagery - acupuncture and acupressure - reduction of pain stimuli - elevation of edematous extremities Cognitive-behavioral pain management - Correct Answers changing the way a client perceives pain, and physical approaches to improve comfort Cutaneous (skin) stimulation - Correct Answers transcutaneous electrical nerve stimulation (TENS), heat, cold, therapeutic touch, and massage - interruption of pain pathways - cold for inflammation - heat increase blood flow and to reduce stiffness Pain management: distraction - Correct Answers - includes ambulation, deep breathing, visitors, television, games, prayer, and music - decreased attention to the presence of pain can decrease perceived pain level Pain management: relaxation - Correct Answers includes meditation, yoga, and progressive muscle relaxation pain management: imagery - Correct Answers - focusing on a pleasant thought to divert focus - requires an ability to concentrate pain management: acupuncture and acupressure - Correct Answers stimulating subcutaneous tissues at specific point using needles (acupuncture) or the digits (acupressure) Analgesics - Correct Answers the mainstay for relieving pain 3 classes: nonopioids, opioids and adjuvants Nonopioid analgesics - Correct Answers Examples: acetaminophen, NSAIDs Opioid Analgesics - Correct Answers Examples: morphine sulfate, fentanyl, and codeine Is essential to monitor and intervene for adverse effects of opioid use: sedation, respiratory depression, orthostatic hypotension, urinary retention, nausea/vomiting, constipation adjuvant analgesics - Correct Answers enhance the effects of nonopioids, help alleviate other manifestations that aggravate pain (depression , seizures, inflammations), and are useful for treating neuropathic pain Examples: anticonvulsants, antianxiety agents, tricyclic antidepressants, anesthetics, antihistimines, glucocorticocoids, and antiemetics A (Rationale: the nurse should attempt to identify manifestations that occur along with the client's pan, such as nausea, fatigue, or anxiety.) - Correct Answers A nurse at a clinic is collecting data about pain from a client who reports severe abdominal pain. The nurse asks the client whether he has nausea and has been vomiting. Which of the following pain characteristics is the nurse attempting to determine? A. presence of associated manifestations B. location of the pain C. pain quality D. aggravating and relieving factors C (Rationale: the nurse should use a pain rating scale to help the client report the intensity of his pain. The nurse should use a numeric, verbal, or visual analog scale appropriate to the client's individual needs.) - Correct Answers A nurse is collecting data from a client who is reporting pain despite taking analgesia. Which of the following actions should the nurse take to determine the intensity of the client's pain? A. ask the client what precipitates the pain B. Question the client about the location of the pain C. Offer the client a pain scale to measure his pain D. Use open-ended questions to identify the client's pain sensations D (Rationale: a client who reports pain that lasts more than 6 months and continues beyond the time of tissue healing is experienced chronic pain. The nurse should identify this client's pain as chronic and assist with planning interventions to relieve manifestations associated with the pain.) - Correct Answers A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain? A. a client who has a broken femur and reports hip pain B. a client who has incisional pain 72 hours following pacemaker insertion C. a client who has food poisoning and reports abdominal cramping D. a client who has episodic back pain following a fall 2 years ago C, D, E (Rationale: opioid analgesia can cause respiratory depression, which causes respiratory rates to drop to dangerously low levels. The nurse should monitor the client's respiratory rate and administer naloxone if indicated. Opioid analgesia can also cause orthostatic hypotension and the nurse should monitor the client for dizziness or lightheadedness when changing positions. Nausea and vomiting can also be an effect and the nurse should monitor/treat as needed.) - Correct Answers A nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. Which of the following effects should the nurse anticipate? (select all that apply) A. urinary incontinence B. diarrhea C. bradypnea D. orthostatic hypotension E. nausea C (Rationale: PCA allows the client to self-administer pain medication on an as-needed basis. If the client is not achieving adequate pain control, he should let the nurse know so that she can initiate a reevaluation of the client's pain management plan and possible dosage change.) - Correct Answers A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device? A. "I'll wait to use the device until its absolutely necessary." B. "I'll be careful about pushing the button too much so I don't get an overdose." C. "I should tell the nurse if the pain doesn't stop while I am using this device." D. "I will ask my adult child to push the dose button when I am sleeping." Alternative medical philosophies - Correct Answers complete medical systems outside of allopathic medicinal beliefs (traditional chinese medicine, Ayurveda, homeopathy) Biological and botanical therapies - Correct Answers Involve the use of natural products to affect health (diets, vitamins, minerals, herbal preparations, probiotics) Body-based and manipulative methods - Correct Answers Involve external touch to affect body systems (massage, touch, chiropractic therapy, acupressure) mind-body therapies - Correct Answers Connect the physiological function to the mind and emotions (acupuncture, breathwork, biofeedback, art therapy, meditation, guided imagery, yoga, psychotherapy, tai chi) energy therapies - Correct Answers forms of CAM treatment that use energy fields originating either within the body or from outside sources to promote health and healing (reiki, therapeutic touch, magnet therapy) Movement therapies - Correct Answers use exercise or activity to promote physical and emotional well-being (pilates, dance therapy) acupuncture and acupressure - Correct Answers needles or pressure along meridians to alter body function or produce analgesia licensing or certification. Which of the following should the nurse encourage the students to use? (select all that apply) A. guided imagery B. massage therapy C. meditation D. music therapy E. therapeutic touch B (Rationale: the first action the nurse should take using the nursing process is to assess or collect data from the client. Because people can have personal, cultural, or religious sensitivities or aversion to religious practices such as prayer, the nurse must first determine that the client is comfortable with a therapy that involves prayer.) - Correct Answers A nurse is planning to use healing intention with a client who is recovering from a lengthy illness. Which of the following is the priority action the nurse should take before attempting this particular mind-body intervention? A. tell the client the goal of the therapy is to promote healing B. ask whether the client is comfortable with using prayer C. encourage the client to participate actively for best results D. instruct the client to relax during the therapy Routes of administration - Correct Answers - oral/enteral - sublingual - buccal - transdermal - topical - instillation (drops, ointments, sprays) - inhalation - nasogastric and gastrostomy - suppositories - parenteral - intradermal - subcutaneous - intramuscular - intravenous Oral or enteral - Correct Answers - tablets, capsules, liquids, suspensions, elixirs, lozenges - most common route - least expensive - convenient Nursing Considerations: Oral/Enteral Med Administration - Correct Answers - contraindications for oral medication administration include vomiting, decreased GI motility, absence of a gag reflex, difficulty swallowing, and a decreased level of consciousness - have clients sit upright at 90 degrees to facilitate swallowing - administer irritating medications, such as analgesics with small amounts of food - do not mix with large amounts of food or beverages in case clients cannot consume the entire quantity - avoid administration with interacting foods or beverages such as grapefruit juice - in general, administer oral medications on an empty stomach (30 min to 1 hour before meals, 2 hours after meals) - follow the manufacturer's directions for crushing, cutting, and diluting medications. Break or cut scored tablets only. - Make sure clients swallow enteric-coated or time-release medications whole - Use a liquid form of the medication to facilitate swallowing whenever possible Sublingual and Buccal - Correct Answers Directly enters the bloodstream and bypasses the liver - sublingual: under the tongue - buccal: between the gum and cheek Nursing considerations: sublingual and buccal medication administration - Correct Answers - instruct clients to keep the medication in place until complete absorption occurs - clients should not eat or drink while the tablet is in place or until it has completely disolved Nursing considerations: Liquids, suspensions, elixirs medication administration - Correct Answers - follow directions for dilution and shaking - when administering the medication, pour it into a cup on flat surface. Make sure the base of the meniscus (lowest fluid line) is at the level of the dose Transdermal - Correct Answers medication in a skin patch for absorption through the skin, producing systemic effects Nursing considerations: transdermal medication administration - Correct Answers - apply the patches as prescribed to ensure proper dosing - wash the skin with soap and water, and dry it thoroughly before applying a new patch - place the patch on a hairless area and rotate sites to prevent skin irritation Topical Meds - Correct Answers - painless - limited adverse effects Nursing considerations: topical medication administration - Correct Answers - apply with a glove, tongue blade, or cotton-tipped applicator - do not apply with a bare hand Nursing consideration: administering meds into eyes - Correct Answers - use medical aseptic technique - have clients sit upright or lie supine, tilt their head slightly and look up at the ceiling - rest your dominant hand on the client's forehead, hold the dropper above the conjuctival sac about 1-2 cm, drop the medication into the center of the sac, avoid placing it directly on the cornea, and have them close the eye gently. If they blink during instillation, repeat the procedure. - apply gentle pressure with your fingers and a clean facial tissue on the nasolacrimal duct for 30-60 seconds to prevent systemic absorption - if instilling more than one medication in the same eye, wait at least 5 minutes between each - for eye ointment, apply a thin ribbon to the edges of the lower eyelid from the inner to the outer canthus Nursing considerations: administering medications into ears - Correct Answers - use medial aseptic technique - have clients sit upright or lie on their side - straighten the ear canal by pulling the auricle upward and outward for adults or down and back for children. Hold the dropper 1 cm above the ear canal, instill the medication, and then gently apply pressure with your finger to the tragus of the ear unless it is too painful - do not press a cotton ball deep into the ear canal. If necessary, gently place it into the outermost part of the ear canal - Have clients remain in the side- lying position if possible for 2-3 minutes after installation of ear drops Nursing considerations: Medication administration through NG/G-Tubes - Correct Answers - verify proper tube placement - use a syringe and allow the medication to flow in by gravity or push it in with the plunger of the syringe General guidelines for NG/G-Tubes - Correct Answers - use liquid forms of medications, if not available, consider crushing medications if appropriate guidelines allow - do not crush specially prepared oral medications (extended/time-release, fluid-filled, enteric-coated) - administer each medication separately - do not mix with enteral feedings - completely dissolve crushed tablets and capsule contents in 15-30mL of sterile water prior to administration - to prevent clogging, flush the tubing before and after each medication with 15-30mL water - flush with another 15-30mL sterile water after instilling all the medications Nursing considerations: rectal suppositories - Correct Answers - position the clients in the left lateral or Sim's position (shown) client how to administer ear drops. Which of the following statements should the nurse identify as an indication that the client understands the proper technique? A. "I will straighten my ear canal by pulling my ear down and back." B. "I will gently apply pressure with my finger to the front part of ear after putting in the drops." C. "I will insert the nozzle of the ear drop bottle snug into my ear before squeezing the drops in." D. "After the drops are in, I will place a cotton ball all the way into my ear canal." 1,000 - Correct Answers 1mg = __________ mcg 1,000 - Correct Answers 1g = _____________ mg 1,000 - Correct Answers 1kg = ___________ g 30 - Correct Answers 1 oz = _________ mL 1,000 - Correct Answers 1L = __________ mL 5 - Correct Answers 1 tsp = __________ mL 15 - Correct Answers 1 tbsp = _________ mL 3 - Correct Answers 1 tbsp = __________ tsp 2.2 - Correct Answers 1kg = ________ lb 60 - Correct Answers 1gr = ________mg 30 - Correct Answers 1 fl oz = ________ mL 15 - Correct Answers 3 tsp = _______ mL 32 - Correct Answers 1 L = ________ fl oz 32 - Correct Answers 1 qt = ________ fl oz 1 - Correct Answers 16 fl oz = __________ pt 2 - Correct Answers 1 pt = _______ cups 8 - Correct Answers 1 cup = ________ fl oz 240 - Correct Answers 8 fl oz = _________ mL 2.5 - Correct Answers 1 in = __________ cm 2 - Correct Answers 1 fl oz = ________ Tbsp 16 - Correct Answers I pt = ________ fl oz 2 - Correct Answers 1 qt = ______ pt 16 - Correct Answers 1 lb = _______ oz Farhenheit --> Celcius - Correct Answers subtract 32 and then divide by 1.8 Celcius --> Farhenheit - Correct Answers multiply by 1.8 and add 32 2 capsules Rationale: - 1 g = 1,000mg (1 x 1,000) - 0.2g = 200mg (0.2 x 1,000) - have/quantity = desired/x - 100mg/1 cap = 200mg/x cap - Correct Answers A nurse is preparing to administer phenytoin 0.2g PO every 8 hr. The amount available is phenytoin 100mg/capsule. How many capsules should the nurse administer per dose? (round the the nearest whole) 5 mL Rationale: - 1g = 1,000mg (1 x 1,000) - 0.25g = 250mg (0.25 x 1,000) - have/quantity = desired/x - 250mg/5mL = 250mg/x mL - Correct Answers A nurse is preparing to administer amoxicillin 0.25g PO every 8 hr. The amount available is amoxicillin oral suspension 250mg/5mL. How many mL should the nurse administer per dose? (round to nearest tenth) 0.8 mL Rationale: - no conversion needed - have/quantity = desired/x - 10,000 units/1mL = 8,000 units/x mL - Correct Answers A nurse is preparing to administer heparin 8,000 units subQ every 12hr. Available is heparin injection 10,000 units/mL. How many mL should the nurse administer per dose? (round to the nearest tenth) 2 mL Rationale: - 2.2lb/1kg = client's weight in lb/x kg - 2.2lb/1kg = 22lb/x kg - x=10 kg - mg x 10kg/1 day = x - 8mg x 10mg/1 day = 80mg - have/quantity = desired/x - 100mg/5mL = 40mg/x mL - Correct Answers A nurse is preparing to administer cefixime 8mg/kg/day PO to divide equally every 12 hour to a toddler who weighs 22lb. Available is cefixime suspension 100mg/5mL. How many mL should the nurse administer per dose? (round to nearest tenth) Buddhism: birth rituals and health care decisions - Correct Answers - can refuse care on holy days - can refuse analgesics or strong sedatives Buddhism: dietary rituals - Correct Answers - some are vegetarians - can avoid alcohol and tobacco - clients might fast on holy days Buddhism: death rituals - Correct Answers - clients can request a priest to deliever last rites - chanting is common - brain death is not considered as a requirement for death Christianity: birth rituals and health care decisions - Correct Answers - some baptize infants at birth Christianity: dietary rituals - Correct Answers - some avoid alcohol, tobacco, and caffeine - might fast during lent - some wish to receive the Holy Communion Christianity: death rituals - Correct Answers some give last rites Hinduism: birth rituals and health care decisions - Correct Answers - those practicing do not prolong life - personal hygiene and cleanliness are valued Hinduism: dietary rituals - Correct Answers - some are vegetarians Hinduism: death rituals - Correct Answers - clients might want to lie on the floor while dying - a thread is placed around the neck/wrist - the family pours water into the mouth - the family baths the body - group is more important than individual (collectivists) - herbal medicine, tea, acupuncture ** - may not embrace or show expression in public, avoid eye contact - pregancy -- HOT condition (avoid bathing because it causes cold condition) Angina pectoris - Correct Answers pain/angina caused by ischemia - caused by the decrease in oxygenation of heart muscle - ischemia is from decreased blood flow/oxygen to heart usually form an increase in demand - should be reversible **pain relieved by nitroglycerin **If patient is experiencing dyspnea... - Correct Answers ...ask fewer questions Role of the Nurse in Teaching and Learning** - Correct Answers Teach information that patient and family need to make informed decisions regarding their care Determine what patients need to know Identify when patients are ready to learn 5 Rights of Teaching - Correct Answers - time - context - goal - content - method Rights of teaching: Time - Correct Answers - readiness, motivation - if you know patient is not ready, then it is not the right time to teach - don't have the luxury we used to have to allow patient to get ready - increased need for knowledge when we are turning patient over as quickly as we do Rights of teaching: context - Correct Answers - is it the right environment? Ex. when we go into room to teach, is the room lit so the patient can see, is the TV turned down, are they comfortable/have to go to the bathroom? Rights of teaching: goal - Correct Answers - SMART goal: specific, measurable, attainable, realistic, timely - meeting desired behavioral changes - learner involvement *** Rights of teaching: content - Correct Answers - appropriate to learner's level and circustances - learn to adjust as a nurse Rights of teaching: method - Correct Answers - strategy fits the learner - demonstrate, talk, etc. Assessing readiness to learn - Correct Answers - evidence of willingness to learn (is patient asking questions?) - physically and emotionally ready; can be affected by stage of grieving - the client must desire to know - be mentally and physically alert (not ready after receiving pain meds) - indicated when the client asks questions and participates in learning Evaluation of learning - Correct Answers -written exams -oral tests** -return demonstrations** -questionaires Deltoid IM Injection - Correct Answers Syringe size: 1-3mL Needle gauge: 23-25 Needle length: 5/8-1in Angle of insertion: 90 degrees Site capacity: 0.5-1mL - locate acromion process - place 2-3 finger breadths below - draw imaginary line at the axilla - insert in middle of triangle SubQ Injection - Correct Answers Gauge: 25-27 Length: 3/8-5/8in Angle of insertion: 45 degrees Dose: .5 - 1.5mL - pinch 1-2in of skin - insert at 45 degree angle - hold for 10 seconds, then release - avoid 1-2 in from umbilical Ventrogluteal IM Injection - Correct Answers Syringe size: 3-6mL Needle gauge: 20-23 Needle length: 1.5-2in Angle of injection: 75-90 degrees Site capacity: up to 3mL - place palm on greater trochanter, thumb toward groin - make "V" by placing index finger over anterior superior iliac spine and middle finger over iliac crest toward buttock - insert in center of "V" Vastus Lateralis IM Injection - Correct Answers Syringe: 1-3mL Gauge: 20-23 Length: 1in Angle: 90 degrees Capacity: 2-3mL - place 1 hand breadth above knee - place 1 hand breadth below greater trochanter - insert needle into middle 1/3 of muscle