Exam One Study Guide Questions And Answers 2023 LATEST UPDATED, Exams of Nursing

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Exam One Study Guide Questions And Answers 2023 LATEST UPDATED Critical Thinking: What are your responsibilities as a nurse? • Recognize health problems • Anticipate and plan for problems • Initiate actions to ensure appropriate and timely treatment, patient safety, and optimal health outcomes Critical thinking defined • Intentional higher-level reasoning • Influenced by knowledge, experience, skills, attitudes, and interpersonal skills • Used as a guide for rational judgment and action  Takes time and practice to develop Critical thinking attitudes • Independence – think for themselves • Fair-mindedness – assesses all viewpoints • Insight into egocentricity – biases • Intellectual humility – knows the limit of one’s own knowledge • Intellectual courage to challenge status quo requires immediate intervention to prevent life-threatening complications) Critical thinking techniques Critical Thinking – is the process of intentional higher-level thinking to define a pts problem, examine the evidence-based practice in caring for the pt, and make choices in the delivery of care Critical Reasoning – is the cognitive process that uses thinking strategies to gather and analyze pt information, evaluate the relevance of the information, and decide on possible nursing actions to improve the pts physiological and psychosocial outcomes Critical Analysis – is the application of a set of questions to a particular situation or idea to determine essential information and ideas and discard unimportant information and ideas Socratic Questioning – is a technique one can use to look beneath the surface, recognize and examine assumptions, search for inconsistencies, examine multiple points of view, and differentiate what one knows from what one merely believes Inductive Reasoning – generalizations are formed from a set of facts or observations Deductive Reasoning – is reasoning from general premise to the specific conclusion Nursing Process – is a systematic, rational method of planning and providing individualized nursing care. It begins with assessment of the pt and use of clinical reasoning to identify pt problems. Clinical Judgment – is a decision-making process to ascertain the right nursing action to be implemented at the appropriate time in the pt’s care Cognitive Processes – are the thinking processes based on the knowledge of aspects of client care, cognitive skills are learned through reading and applying health-related literature Metacognitive Processes – include reflective thinking and awareness of the skills learned by the nurse in caring for the pt, the nurse reflects on the pt’s status, and through the use of critical thinking skills determines the most effective plan of care Problem solving techniques and treatment of human responses to actual or potential health problems” • Nurses use knowledge from other disciplines • Nurses deal with change in stressful environments • Nurses make important decisions Nursing process • Is a systematic, rational method of planning and providing individualized nursing care • Its purposes are to identify a pt’s health status and actual or potential health care problems or needs, to establish plans to meet identified needs, and to deliver specific nursing interventions to meet those needs • The pt may be an individual, a family, a community, or a group The nursing process is… Systematic – the nursing process has an ordered sequence of activities and each activity depends on the accuracy of the activity that precedes it and influences the activity following it Dynamic – the nursing process has great interaction and overlapping among the activities and each activity is fluid and flows into the next activity Client Centered – the nursing process ensures that nurses are client-centered rather than taskcentered Goal-Directed – the nursing process is a means for nurses and clients to work together to identify specific goals and to match them with the appropriate nursing actions Universally applicable – the nursing process allows nurses to practice nursing with well or ill people, young or old, in any type of practice setting ADPIE A – assessment D – diagnosis P – planning I – implementation E – evaluation Assessment • Collect data • Organize data • Observation • Interview • Examine Types • Subjective (symptoms), what client states • Objective (signs), observe or measurable by nurse Sources • Primary – nurse obtains information from client • Secondary – information is from a secondary source Fill in the blank review: Secondary source is information that comes from another person like family or another nurse. One method to collect data is an interview. Data that can be measured is objective data. A method of collecting data that occurs first would be observation. A physical assessment is a primary source of data. Data collection methods Observing – gather data by using the senses Interviewing – planned communication to gain information • Focused interview – specific questions • Directive interview – nurse controls interview, used to gain information when time is limited • Nondirective interview – rapport building interview, nurse allows client to control the purpose, subject matter, and pacing Examining – physical assessment, head to toe o a combination of directive and nondirective approaches can be used during the information-gathering interview. Nurse may realize fears of pt. Nurse should acknowledge fears and provide support of fears, not dismiss them Step 2: Diagnosis • a clinical judgment about individual, family, or community responses to actual and potential heath problems or life processes • a statement that describes a specific human response to an actual or • Anorexia Nervosa • Pneumonia • Closed Head Injury Nursing – clinical judgment that identifies that client’s responses to a health state, problem, or condition • Constipation • Ineffective Airway Clearance • Deficient Fluid Volume • Imbalanced Nutrition NANDA – nursing uses NANDA-I nursing diagnoses (North American Nursing Diagnosis Association – International) The language of nursing diagnosis (Actual) – Acute Pain, related to surgical incision, as evidenced by pt pain rating 8/10 and pain behaviors (rubbing knee, grimacing) (Risk For) – Risk for Fall, related to diminished lower extremity strength (Health Promotion) – Readiness for Enhanced Nutrition, related to blood sugar control, as evidenced by pt asking questions regarding diet recommendations, low-sugar recipes and sugar substitutes (Syndrome Diagnosis) – Post-Trauma syndrome r/t physical abuse aeb alienation, anger, anxiety, and depression. Note this is a three-part nursing diagnosis The diagnostic process  Analyzing data - Compare data against standards (identify specific cues) - Cluster the cues (generate tentative hypotheses) - Identify gaps and inconsistencies  Identifying health problems, risks, and strengths - Determining problems and risks - Determining strengths • Formulating diagnostic statements Formulating diagnostic statements Basic two-part statements Basic three-part statements • (P) Problem: NANDA label • (E) Etiology: factors contributing to or probable causes of the response (related to) • Formulate goals (long term and short term) • Select nursing interventions Maslow’s Hierarchy P.S.L.E.S Pushy Salesmen Love Easy Sales Physiological Safety Love/belonging Esteem Self-actualization Planning cont. Types of Planning • Initial • Ongoing • Discharge Formulate Goals – SMART goals • Specific or directly related to the diagnosis (client centered)    Measurable Attainable Realistic or reasonable • Timed Select & Write Interventions (orders) • Independent – don’t need a health care provider’s order • Dependent – need a health care provider’s order • Collaborative – use of standing orders, protocols, interventions that require expertise of others (ex. PT, RT, etc.) Standard approaches to care planning • Standardized Care Plans – pre- developed guide that provides essential    • Drawing conclusions about problem status • Continuing, modifying, or terminating the nursing care plan Ch 30 part 1 Assessment • Includes health history and physical examination • Types of Physical examination - Complete (ex. Head-to-toe) - By body systems - By body area • Factor in client’s energy and time needed - Subjective Data – what the client says    - Objective Data – what is observed • Purposes of examination - Evaluate physiologic outcomes and progress - Make clinical judgments - Identify areas for health promotion and disease prevention - Obtain baseline data - Supplement, confirm, or refute data from the history - Help establish nursing diagnoses and plans of care Preparing the client • Explain when and where • Explain why examination is important    • Explain what will happen • Client disrobes - Puts on gown - Empties bladder (collect urine if needed for testing) Preparing the environment • Light, warm, and comfortable • Private • Culture, age, gender of both pt and nurse influence how comfortable pt will be • Family, friends should not be present unless upon pt request Draping • Area to be assessed, exposed, and other body areas covered    Supine Description: back-lying position with legs extended, with or without pillow under the head Areas Assessed: head, neck, axillae, anterior thorax, lungs, breasts, heart, vital signs, abdomen, extremities, peripheral pulses Cautions: tolerated poorly by pts with cardiovascular and respiratory problems Sitting Description: a seated position, back unsupported and legs hanging freely Areas Assessed: head, neck, posterior and anterior thorax, lungs, breasts, axillae, heart, vital signs, upper and lower extremities, reflexes    Cautions: older adults and weak pts may require support Lithotomy Description: back-lying position with feet supported in stirrups; the hips should be in line with the edge of the table Areas Assessed: female genitals, rectum, and female reproductive tract Cautions: may be uncomfortable and tiring for older adults and often embarrassing Sims’ Description: side-lying position with lowermost arm behind the body, uppermost leg flexed at hip and knee, upper arm flexed at shoulder and elbow Areas Assessed: rectum and vagina    Cautions: difficult for older adults and people with limited joint movement Prone Description: lies on abdomen with head turned to the side, with or without a small pillow Areas Assessed: posterior thorax and hip joint movement Cautions: often not tolerated by older adults and people with cardiovascular and respiratory problems Methods  Methods of examining - Inspection – is the sense of sight - Palpation – is the sense of touch    Auscultation • Listening to sounds produced within the body - Direct: use of unaided ear - Indirect: use of stethoscope • Pitch, intensity, duration, and quality • Before percussion and palpation - In efforts to not create false body sounds Ch 30 Part 2 General survey • General appearance • Level of comfort • Mental status    • Measurement of vital signs, height, and weight Integumentary • Integumentary system – includes the skin, hair, and nails  Some different findings of skin assessment include: - Pallor – an unhealthy pale appearance P1 - Cyanosis – a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood P2 - Erythema – superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilation of the blood capillaries P3    - Edema – puffiness caused by excess fluid trapped in the body’s tissues P4   Additional integumentary findings - Vesicle – a circumscribed, round or oval, thin translucent mass filled with serous fluid or blood (ex. herpes simplex, small burn blister) P1 - Bulla – a larger circumscribed, round or oval, thin translucent mass filled with serous fluid or blood, bullae are larger than 0.5cm (ex. large blister, second degree burn, herpes simplex) P1 - Pustule – vesicle or bulla filled with pus (ex. acne vulgaris and impetigo) P2  Head • Inspect and palpate simultaneously, then auscultate • Skull and face - Normocephalic – normal head size according to standard size tables - Exophthalmos – protrusion of eyeballs, may result from hyperthyroidism Eyes and vision - Visual acuity - Visual fields – peripheral vision  Common refractive errors of lens: - Myopia (nearsightedness) - Hyperopia (farsightedness) - Presbyopia (loss of elasticity and seeing close objects) - Astigmatism (uneven curvature) • External eye structures • Pupils - Color, shape, and symmetry of size - Direct and consensual reaction to light - PERRLA (Pupils Equally Round and React to Light and Accommodation) Ears and hearing • External ear – check skin • Cerumen - Earwax inside ear canal Nose and sinuses • Inspection and palpation  External nose • Patency of nasal cavities • Inspection of nasal cavities (nares) Mouth and oropharynx • Inspection and palpation • Lips, oral mucosa, tongue, and floor of mouth, teeth and gums, hard and soft palate, uvula, salivary glands, and tonsils • Normal mucus membranes are pink and moist Neck Gurgles (rhonchi) Description: continuous, low-pitched, coarse, gurgling, harsh, louder sounds with a moaning or snoring quality. Best heard on exhalation but can be heard on both inhalation and exhalation Cause: air passing through narrowed air passages as a result of secretions, swelling, or tumors Location: loud sounds can be heard over most lung areas but predominate over the trachea and bronchi Friction rub Description: superficial grating or creaking sounds heard during inhalation and exhalation. Not relieved by coughing Cause: rubbing together of inflamed pleural surfaces Location: heard most often in areas of greatest thoracic expansion (ex. lower anterior and lateral chest) Wheeze Description: continuous, high-pitched, squeaky musical sounds. Best heard on exhalation, not usually altered by coughing Cause: air passing through a constricted bronchus as a result of secretions, swelling, or tumors Location: heard over all lung fields Ch 30 Part 3 Cardiovascular and peripheral  Assess the heart through inspection, palpation, and auscultation  Normal heart sounds include: - S1 – occurs when the atrioventricular (AV) valves (Tricuspid and Mitral) close, sounds like “lub” - S2 – occurs when the aortic and pulmonic valves close, producing the second heart sound “dub”  Abnormal heart sounds, palpation’s, and observations include: - Murmur – abnormal sound of heart sound -Listen over carotid: o Bruit – listen with stethoscope for the bruit  Not normal over carotid  • Femoral pulses Bowel Sounds • Relatively high-pitched sounds heard with diaphragm of stethoscope • 4 quadrants – must listen in each quadrant and identify the types of sounds heard  Normal bowel sounds include: o Intestinal sounds that are relatively high-pitched o A sound every 5-20 seconds • Abnormal bowel sounds include: o Hyperactive sound – heard every 3 seconds o Hypoactive – one sound per minute, extremely soft sounds and  infrequent o Absent – no sounds at 3-5 minutes o Listen in every quadrant, might be different from one quadrant to another • 4 abdominal quadrants RLQ, RUQ, LUQ, LLQ • RLQ o Lower lobe of right kidney, cecum, appendix, section of ascending colon, right ovary, right fallopian tube, right ureter, right spermatic cord, part of uterus • RUQ o Liver, gallbladder, duodenum, head of pancreas, right adrenal gland, upper lobe of right kidney, hepatic flexure of colon, section of  ascending colon, section of transverse colon • LUQ o Left lobe of liver, stomach, spleen, upper lobe of left kidney, pancreas, left adrenal gland, splenic flexure of colon, section of transverse colon, section of descending colon • LLQ o Lower lobe of left kidney, sigmoid colon, section of descending colon, left ovary, left fallopian tube, left ureter, left spermatic cord, part of uterus  9 abdominal regions Right hypochondriac, epigastric, left hypochondriac, left lumbar, umbilical, right   Aphasia – loss of power to express language o Orientation  Person, place, time, and self  Disorientation  Confusion o Memory  Immediate, recent, and long-term memory o Attention span and calculation  Ability to focus on mental task o Level of consciousness (LOC)  Glasgow Coma Scale o Cranial Nerves  12 each o Reflexes  Automatic response of body to stimulus   Tested with percussion hammer o Motor function  Proprioceptors • Sensory nerve terminals that occur chiefly in muscles, tendons, joints, and internal ear Cranial Nerves: On Old Olympus Towering Top A Finn And German Viewed A Hop On – Olfactory Old – Optic Olympus – Oculomotor Towering – Trochlear Top – Trigeminal A – Abducens  Finn – Facial And – Auditory German – Glossopharyngeal Viewed – Vagus A – Accessory Hop – Hypoglossal Cranial Nerves I-VI Nerve Number Nerve Name Function Action Cranial Nerve I Olfactory Sensorial Smell Female genitals and inguinal area • Inspect pubic hair • Inspect skin of pubic area • Inspect the clitoris, urethral orifice, and vaginal orifice • Palpate the inguinal lymph nodes Male genitals and inguinal area • External genitals o Inspect pubic hair o Inspect penis o Inspect urethral meatus o Inspect scrotum • Prostate gland • Hernia’s o Inspect inguinal or femoral areas for bulges Assessing the anus • Inspect the anus and surrounding tissue for: o Color o Integrity o Skin lesions • Ask the pt to bear down o Inspecting for rectal fissures, rectal prolapse, polyps, or internal hemorrhoids AWIPE A – announce W – wash hands I – ID (name, DOB, MR#) P – privacy E – explain DHCOW D – down H – handrails x2 C – call light in pt hand O – open curtains W – wash hands Ch 29 Vital Signs Vital signs • Four traditional vital signs o Body temperature o Pulse o Respirations o Blood pressure • Additional vital signs – pain, O2 saturation  When do we measure vital signs? o Agency policies for frequency o Nursing judgment o Provider order o Whenever the pt’s health status requires • Who can measure vital signs? o RN o LPN o Providers • Types of fever o Intermittent – body temp alternates at regular intervals between periods of fever and periods of normal or subnormal temps o Remittent – a wide range of temp fluctuations (more than 3.6˚F) occurs over a 24hour period, all of which are above normal o Relapsing – short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temp o Constant – body temp fluctuates minimally but always remains above normal o Fever spikes – a temp that rises to fever level rapidly following a normal temp and then returns to normal within a few hours Clinical manifestations of fever • Increasing pulse, respiratory rate, and depth • Shivering • Pallid, cold skin • c/o feeling cold • Cyanotic nail beds • “Gooseflesh” appearance of the skin • Cessation of sweating Hypothermia • Decreased body temperature, pulse, and respirations • Severe shivering (initially) • Feelings of cold and chills • Pale, cool, waxy skin • Frostbite (discolored, blistered nose, fingers, and toes) • Hypotension • Decreased urinary output (oliguria) • Lack of muscle coordination • Disorientation • Drowsiness progressing to coma Nursing Interventions • Provide warm environment • Provide dry clothing • Apply warm blankets • Keep limbs close to body • Cover pt’s scalp to preserve heat • Supply warm fluids PO or IV • Apply warming pads o Disadvantage – can be uncomfortable and involves risk of injuring the membrane if the probe is inserted too far o Disadvantage – repeated measurements may vary, right and left measurements may differ o Disadvantage – presence of cerumen can affect the reading • Temporal artery o Advantages – safe and noninvasive; very fast o Disadvantage – requires electronic equipment that may be expensive or unavailable o Disadvantage – variation in technique needed if the pt has perspiration on the forehead Heart rate (pulse) • Palpation – assessing the wave of blood created by the contraction of the left ventricle of the heart • Compliance – compliance of the arteries is their ability to contract and expand • Cardiac output – stroke volume multiplied by heart rate • Peripheral pulses – not apical, located away from the heart (ex. foot or wrist) • Apical pulse – central pulse that is located at the apex of the heart (also referred to as the point of maximal impulse PMI) Peripheral pulse sites • Temporal • Carotid • Brachial • Radial • Femoral • Popliteal • Posterior tibial  Dorsal pedis Average pulse Factors affecting the pulse Age Pulse (bpm) & Ranges Newborn 130 (80-180_ 1 year 120 (80-140) 5-8 years 100 (75-120) 10 years 70 (50-90) Teen 75 (50-90) Adult 80 (60-100) Older adult 70 (60-100_ impair oxygenation can alter the resting pulse rate Assessing the pulse • Assess the pulse volume o Absent, +1, +2, +3, +4 (bounding)  Doppler US and stethoscope o Middle three fingertips  Using the thumb is contraindicated because the nurse’s thumb has a pulse that could be mistaken for the pt’s pulse • Rate and rhythm o Tachycardia o Bradycardia o Arrythmia Respirations • Inhalation – or inspiration refers to the intake of air into the lungs • Exhalation – or expiration refers to breathing out or the movement of gases from the lungs to the atmosphere • Ventilation – is also used to refer to the movement of air in and out of the lungs • Costal breathing – or thoracic breathing, involves the external intercostal muscles and other accessory muscles, such as the sternocleidomastoid muscles • Diaphragmatic breathing – or abdominal breathing, involves the contraction and relaxation of the diaphragm, and it is observed by the movement of the abdomen, which occurs as a result of the diaphragms contraction and downward movement Factors affecting respirations • Increase respiratory rate (RR) o Exercise o Stress o Increased environmental temperature o Elevation/altitude • Decrease respiratory rate (RR) o Decreased environmental temperature o Medications o Increased intracranial pressure (ICP) Assessing respirations • Pt should be relaxed Age Respirations & Ranges Newborn 35 (30-60_ 1 year 30 (20-40) years5-8 20 (15-25) 10 years 19 (15-25) Teen 18 (15-20_ Adult 16 (12-20) Older adult 16 (15-20_ • Pulse pressure – the difference between systolic and diastolic pressures o 120-80= 40mmHg • Measured in millimeters of mercury (mmHg)  Normal blood pressure is 120/80 mmHg Assessing blood pressure • Sphygmomanometer o Use the right cuff size • Electronic devices • Hypertension – a blood pressure that is persistently above normal • Hypotension – a blood pressure that is below normal, that is, a systolic reading consistently between 85 and 110mmHg in an adult whose normal pressure is higher than this • Orthostatic hypotension – is a blood pressure that decreases when the client sits or stands Factors affecting blood pressure • Age – the pressure rises with age, reaching a peak at the onset of puberty, and then tends to decline somewhat • Exercise – physical activity increases the cardiac output and hence the blood pressure • Stress – stimulation of the sympathetic nervous system increases cardiac output and vasoconstriction of the arterioles, thus increasing blood pressure reading • Race – African Americans older than 35 years tend to have higher blood pressures than European Americans of the same age • Sex – after puberty, females usually have lower blood pressures than males of the same age; this difference is thought to be due to hormonal variations • Medications – many medications, including caffeine, may increase or decrease the blood pressure • Obesity – both childhood and adult obesity predispose to hypertension • Documenting and reporting helps facilitate conversation between health professionals • Can be formal or informal • Can be oral, written, or computerized • Documenting typically occurs in a pt chart o A pt chart is a legal record of a care rendered to a pt • Recording, documenting, charting o Terms are synonymous Ethical and legal considerations • The pt chart is a legally protected record of pt care • Restricted access • “need to know” • The organization owns the record • Pts maintain the right to the same records • HIPAA not HIPPA o Health Insurance Portability and Accountability Act  Est in 1996; amended in 2003  Maintains regulations over Protected Health Information (PHI)  PHI – is identifiable health information that is transmitted or maintained in any form or medium, including verbal discussions, electronic communications with or about pts, and written communications o Duty to protect • Computerized records o Cerner o Epic o Meditech • Follow facility policies and procedures to protect PHI  How do we protect computerized PHI? o Ensuring confidentiality of computer health records Purpose of pt records • Communication • Planning of pt care • Auditing health agencies • Research • Education • Reimbursement • Legal documentation • Health care analysis Documentation systems exceptions to norms are recorded o Flow sheets o Standards of nursing care o Bedside access to chart forms Documenting nursing activities • Admission nursing assessment • Nursing care plans • Kardex’s • Flow sheets • Progress notes • Nursing discharge/referral summaries General guidelines for recording • Date and time • Timing • Legibility • Permanence • Accepted terminology • Signature • Accuracy • Completeness Reporting • Change-of-shift-reports • Telephone reports o ISBAR  I – introduction  S – situation  B – background  A – assessment  R – recommend • Telephone orders • Care plan conference • Nursing rounds Ch 31 Infection Control Preventing infection by asepsis • Medical asepsis – includes all practices intended to confine a specific microorganism to a specific area o Clean – absence of almost all microorganisms o Dirty – likely to have microorganisms, some of which may be capable of causing infection • Surgical asepsis – refers to those practices that keep an area or object free of all microorganisms o Also referred to as sterile technique o Sterile procedure Types of infection • Colonization – is the process by which strains of microorganisms become