Multidimensional Care 1 Exam 1 Latest Exam Guide 2023, Exams of Career Counseling

Download Multidimensional Care 1 Exam 1 Latest Exam Guide 2023 and more Exams Career Counseling in PDF only on Docsity! Multidimensional Care 1 Exam 1 Latest Exam Guide 2023 What does Maslow believe about the hierarchy of needs? - Correct answer a person could not meet the needs of love and belonging and self-esteem without meeting basic physiological needs . herbal supplements & their usage - Correct answer Ginko Biloba: Depression, memory Ginseng: depression Kava: Depression, anxiety Echinacea: common cold Chamomile: calming and soothing properties. Goldenseal: Stimulates immune system and bile secretion Melatonin: sleep Kava - Correct answer Herbal Antianxiety Agent and Depression Name the pain scales - Correct answer 1-10 FACES FLACC CRIES FLACC pain scale - Correct answer F:face L:legs A:activity C:cry C:consolability Things to know about pain assessment - Correct answer PQRST If treatment works It's subjective Ginko Biloba - Correct answer Depression and memory (dementia) Ginseng - Correct answer fatigue and depression Echinacea - Correct answer common cold Goldenseal - Correct answer Stimulates immune system and bile secretion Chamomile - Correct answer calming and soothing properties. Melatonin - Correct answer sleep When dealing with maslow hierarchy of needs, what is done first? - Correct answer ABCs!! Maslow Hierarchy of needs - Correct answer Self-Actulaization, Esteem, Safety & Security, Love & Belonging, & physiological SelfActualization - Correct answer Met when the person reaches maximum potential and acts in an unselfish manner. Examples of self actualization - Correct answer (e.g., extent to which goals are achieved, role performance, Personal growth, reaching one's highest potential) Catholic End-of-Life indviduals may be - Correct answer brought to hospitalized patients by a priest, deacon, or designated lay Eucharis- tic minister A Roman Catholic who is seriously ill might - Correct answer wish to receive the sacrament of anointing the sick. (last rites) Last Rites - Correct answer Anointing of the Sick (Catholic) Mormons follow a strict - Correct answer health code, known as the Word of Wisdom Word of Wisdom (Mormon Culture) - Correct answer advises healthful living and pro- hibits the use of tea, coffee, alcohol, and tobacco Mormons believe in - Correct answer life before and after death; thus, death repre- sents the passage into another life phrase (Mormon) Nurses may remove garments - Correct answer before surgery, but it must at all times be considered intensely private and be treated with respect Mormons wear garments at all times except for - Correct answer hygiene, elimination, or being intimate in marriage Nursing Interventions to achieve self actualization - Correct answer Provide art supplies Esteem - Correct answer Met when a person feels a sense of accomplishment and are recognized by others for that achievement. Esteem tier consists of? (Maslow Hierarchy of needs) - Correct answer 1. Feeling of accomplishment 2. Body image 3. Pride in achievements 4. Admiration from others What is perfusion? - Correct answer Adequate arterial blood flow to the peripheral tissue. What does peripheral and central perfusion relate to? - Correct answer Peripheral=peripheral tissue Central=major organs Definition of pulse? - Correct answer rhythmic expansion of an artery produced when a bolus of oxygenated blood is forced into it by contraction of the heart. Bradycardia pulse rate - Correct answer less than 60 bpm Tachycardia pulse rate - Correct answer beats higher than 100/min Influences for pulses? - Correct answer o Exercise o Age o Gender o Anxiety o Pain Documentation for pulse? - Correct answer o Rhythm - even tempo o Strength (0-4+, absent, weak or thready, normal, strong, bounding) o Regular rhythm: 30 seconds x 2- or 15-seconds x 4o Irregular rhythm (regular/irregular); full minute; apical. o •Amplitude is what is measured o •Rate, rhythm (regular or irregular), and quality (strong, weak or bounding) Quality of pulse - Correct answer strong, weak or bounding Strength of pulse - Correct answer 0 = absent 1+ = thready or weak 2+ = normal 3+ = strong 4+ = bounding Rhythm of pulse - Correct answer regular or irregular Peripheral pulses (Normal, bradycardia, tachycardia) - Correct answer - Normal= 60- 100 beats per minute o Bradycardia = beats below 60/min o Tachycardia= beats higher than 100/min rhythm of respiration - Correct answer even, regular Depth of respiration - Correct answer deep, moderate, shallow Inspiration - Correct answer drawing air into the lungs (diaphragm contracts > lungs expand); Breathing in expiration - Correct answer expulsion of air from the lungs (diaphragm relaxes > lungs recoil); breathing out systolic blood pressure - Correct answer ventricles contract, 90-120, maximum pressure on the arteries Pain assessment before and after treatment - Correct answer Scale of 0-10(0 being no pain 10 being the worst pain you have ever felt) Assessment of pain history - Correct answer · P: Provocation and Palliati o no What causes it? o What makes it better? o What makes it worse? · Q: Quality and Quantity o How does it feel, look, or sound? o How much of it is there? · R: Region and Radiationo Where is it? o Does it spread? · S: Severity and Scale o Does it interfere with activities? o How does it rate on a severity scale of 1-10? · T: Timing and Type of Onseto When did it begin? o How often does it occur? o Is it sudden or gradual? What is communication? - Correct answer Two-way process of sending & receiving messages Diastolic Blood Pressure (DBP) - Correct answer ventricles relax, 60-80, minimum pressure on the arteries Hyperthermia Preventions - Correct answer ii. Wear lightweight, loose-fitting clothing. iii. Avoid excessive sun exposure. iv. Stay indoors with fans or air conditioning when outside v. temperatures are elevated. vi. Limit consumption of alcohol and caffeine. vii. Apply sunscreen of at least 30 SPF. viii. If overheated, take a cool water shower or bath. Pulse - Correct answer Pulse allows the nurse to assess the how adequate the heart is pumping the blood to the body Normal Pulse Values - Correct answer 60 to 100 beats per minute Pulse points - Correct answer carotid radial femoral popliteal posterior tibial dorsalis pedis arteries Rate of pulse - Correct answer number of times the heart beats per minute; varies person to person rhythm of pulse - Correct answer regular or irregular quality of pulse - Correct answer strong, weak or bounding Normal BP values - Correct answer 120/80 cuff size the length needs to be - Correct answer 80% of the arm circumference width of the cuff should be - Correct answer 40% of the arm circumference What can occur if you have the wrong cuff size? - Correct answer false reading Hypotension related to dehydration - Correct answer from inadequate fluid intake, from diarrhea, elevated temp fits well with this unit. Hypotension Nursing interventions - Correct answer · Vital signs Initially increase HR and BP · Discuss other signs and symptoms associated with fluid loss · Identify high-risk populations · I & O, daily weights as examples Normal Resp Values - Correct answer 12-20 breaths per minute Resp Rate, Rhythm, and depth - Correct answer Normal, deep, or shallow Determine clients Respiratory effort - Correct answer (nasal flaring; use of accessory muscles, and body positioning) Pulse Ox - Correct answer measures the oxygen level in the blood Hypoxia is - Correct answer a low oxygen level in the blood, which leads to symptoms that may affect the client's basic care and comfort needs. vi. Cutaneous Stimulation vii. Warm and colf therapies How to do pain assessment - Correct answer PQRST - Pain rating scales 0-10 - reassess pain after interventions given to reduce pain (eg. Analgesia) have had time to work - Assessment of pain history Types of pain - Correct answer Acute Cutaneous Visceral Phantom Somatic Radiating Referred Neuropathic Chronic Fall safety - Correct answer Lighting Visualize patient Orient to enviornment 2 bed rails Fire safety - Correct answer Oxygen RACE PASS Smoke detectors Code Red Priority safety for different age groups - Correct answer Middle age drugs Adolescent suicide Elderly falls Infant Suffocation Sentinel Event - Correct answer an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof within hospital Examples of Sentinel Events - Correct answer Suicide Death during/after labor Wrong place surgery Surgical error Infant abduction in hospital Medication errors Safe patient transfer techniques - Correct answer Use mechanical lift Nonslip shoes/socks Don't twist back Don't pull on neck Priority hygiene practices - Correct answer Dry skin folds Moisturized skin promote venous retour Oral hygiene principles - Correct answer Encourage pt assist HOB (Head of bed) elevated Unconscious-suction NPO-Oral care q2hrs Perineal Care Principles - Correct answer Wipe front to back Clean rag and water Away urethral meatus Cutaneous pain - Correct answer Arises from burning your skin like on a hot iron or from touching a hot pan on the stove. Visceral pain - Correct answer Caused from deep internal disorders such as menstrual cramps, labor pains, or gastrointestinal infections. Deep Somatic pain - Correct answer Originates from the ligaments, tendons, nerves, blood vessels and bones. Examples would be fractures or sprains. Radiating pain - Correct answer Starts at an origin but extends to other locations. Example: pain from a sore throat might extend to ears and head. Referred pain - Correct answer Occurs in an area distant from the site of origin. Example: pain from a heart attack might be felt in the left arm or jaw. Phantom pain - Correct answer Pain that is perceived from an area that has been surgically or traumatically removed. Example: pain from an amputated limb. Neuropathic pain - Correct answer Results from an injury of one or more nerves where messages regarding pain are transmitted without a pain stimulus occurring. Acute pain - Correct answer Short duration, rapid onset, and associated with some kind of injury. Chronic pain - Correct answer Last 6 months or longer and interferes with activities of daily living. Therapeutic communication - Correct answer Client-centered communication directed to achieve the patients' goal. (Avoid asking "why") Five qualities of therapeutic relationship - Correct answer Empathy Respect Genuineness Concreteness Confrontation Empathy - Correct answer A desire to understand and be sensitive to the feelings and situation of another person. Put yourself in the client's place, mentally and emotionally. Respect - Correct answer Allow the client to make choices. Be flexible when meeting the needs of each client. Genuineness - Correct answer Respond honestly. If the answer is not known to you, do not guess. Tell the client you need assistance prior to answering the question. Concreteness - Correct answer Provide your answers in specific understandable terms. Confrontation - Correct answer Request the client express his or her thoughts clearly so you can understand the meaning of the communication. Therapeutic Responses & Techniques - Correct answer - Active Listening - Cultural competence - Don't interrupt - Veracity - Fidelity - Establishing Trust - Being Assertive - Restating, Clarifying, and Validating Messages - Interpreting Body Language and Sharing Observations - Exploring Issues - Using Silence - Summarizing the Conversation Why incident reports? - Correct answer Lessen future risks Medication errors Needle sticks Falls Non therapeutic responses & Techniques - Correct answer -Asking Too Many Questions - Asking Why - Fire-Hosing Information - Changing the Subject Inappropriately - Failing to Probe - Offering Advice Personal space is - Correct answer boundary lines that determine how close another person can come Intimate Distance is - Correct answer the area immediately surround- ing people that they define as their "private space." Personal Distance - Correct answer 18 inches to 4 feet. Social Distance - Correct answer 4 to 12 feet. It is used in more formal interaction or when communicating with a group of individuals at the same time. Public Distance - Correct answer > 12 feet. This distance requires loud and clear enunciation for communication. An interpreter is specially trained to - Correct answer provide the meaning behind the words Serve as a cultural broker by conveying the client's responses to questions and by providing general information about the client's culture. Recognize empathy by - Correct answer a. Adapt to different styles, tone, vocabulary and behavior b. Place yourself in the patients situation c. Understand the needs (be sensitive) Is silence a communication barrier? - Correct answer No, Remaining attentive and waiting for the client to compose the next statement in the conversation enhances therapeutic communication. What does the acronym stand for (SBAR)? - Correct answer Situation, Background, Assessment, Recommendation-Readback What types of situations are appropriate for use of SBAR? - Correct answer i. Interdisciplinary communication ii. Critical situations iii. Rapid response needed iv. Nurse- physician communication v. Team communication and collaboration Socialization - Correct answer learning how to become a member of a society or a group. Acculturation - Correct answer An individual assumes the characteristics of a culture they just immigrated too. Assimilation - Correct answer A new member learn and take essential values, beliefs and behaviors of the dominant culture gradually. Stereotype - Correct answer Considering everyone are the same under their racial or ethnic group. i. Assuming everyone from that culture practices health or treats illnesses the same way. Example pf stereotype - Correct answer All Asians are naturally intelligent. All Africans are naturally athletes or runners. Archetype - Correct answer Something recurrent that makes beliefs that everyone has under the same racial or ethical group Ex. of Arcgetype - Correct answer All Irish population will have reddish tone hair color. All Mexican will have brown eyes. All Europeans will have light color skin. Social effect in meeting basic care & comfort needs - Correct answer o Close social organization (Man is dominant and female is housemaker) o Social organization related to birth, death, illness, grieving & mourning (Delaying treatment with home remedies)o Kinship and social ties (VIP care compared to homeless) Health effects in meeting basic care & comfort needs - Correct answer o Scientific (hospitals, clinics, medications)o Magico-Religious: alternative or indigenous (supernatural forces of healing, rituals) o Holistic: need for harmony and balance of the body with nature (yoga, meditation) Folk medicine effects in meeting basic care & comfort needs - Correct answer o Beliefs and practices an individual performs when ill than conventional medicine (eating soup, resting, folk healer, teas, circumcision) o Passed down by generations to generations Environmental effect in care - Correct answer i. person's beliefs that they could change the outcomes of an illness without seeking help. Biological effect in care - Correct answer i. Genetic and physical aspects that determine situations ii. Ex. African American Females have a higher risk for breast cancer, Pacific Islanders and Native Hawaiians have a higher rate of uncontrolled diabetes and hypertension Health belief system - Correct answer Individual perception of health 3 Major Health Beliefs - Correct answer 1. Scientific 2. Magico-Religious 3. Holistic Holistic belief - Correct answer need for harmony and balance of the body with nature (yoga, meditation, etc.) Magico - Correct answer Religious belief - "alternative or indigenous" (supernatural forces of healing, rituals) Scientific belief - Correct answer Hospitals, clinics, medications, etc. Folk Medicine - Correct answer ii. Beliefs and practices an individual performs when ill than conventional medicine. iii. Passed down by generations to generations Examples of folk medicine - Correct answer a. Eating soup and resting when getting a cold b. Placing ointments c. Having a folk healer (North America, a professional healthcare provider is considered a folk healer) d. Circumcision after male birth e. Washing the death before burial f. Drinking teas Complementary and alternative therapy (CAM) - Correct answer inclusion of different approaches to achieve health Examples of Complementary and alternative therapy (CAM) - Correct answer 1. Pet Therapy 2. Massages 3. Biofeedback 4. Exercise & Fitness 5. Nutritional Supplements 6. Health-Focused TV 7. Music Therapy 8. Acupuncture 9. Acupressure 10. Disease Management 11. Aromatherapy Cultures that refuse blood? - Correct answer Jehovah witness Jehovah witness refuse - Correct answer Transplants & blood transfusions Do NOT self donate blood Prioritization and Maslow's Hiearchy - Correct answer ABCs 1ST!! Phsyiological Safety & Security (In that order) Know delegation to other staff, like Nurse Assistants - Correct answer No assessments, double check if they find a critical finding Skin integrity (how to prevent pressure ulcers) - Correct answer a. Turn every 2 hours b. keep area dry Skin integrity (How to prevent shearing and friction) - Correct answer a. Use a lift- don't use drawsheet Restraints should - Correct answer i. Never interfere with treatment ii. Restrict movement as little as is necessary iii. Fit properly and be as discreet as possible iv. Be easy to remove or change v. Be avoided as much as possible vi. Not be used without doctor's order use least restrictive first Have pt close to nurses station What is the universal choking sign? - Correct answer a. Grasping the neck between the thumb and index finger b. clutching the neck with both hands What are the interventions of choking? - Correct answer a. Inspect toys for small, removable parts. b. Do not attach pacifiers, rattles, or other infant toys to ribbons or strings. c. Do not use sweatshirts or jackets with neck tie strings. d. Position mobiles well above the crib, out of the infant's reach. e. Keep window blind cords out of the child's reach. f. Store plastic bags away from young children in a secure place. g. Ensure that the crib is designed to meet federal regulations: Crib slats must be less than 23⁄8 inches (6 cm) apart, and the mattress must fit snugly. h. When feeding children meat, cheese, or other firm foods, cut the food into very tiny pieces. Do not give a young child hard candy, chewing gum, nuts, popcorn, grapes, or marshmallows. Supervise children's balloon play, and dispose of burst balloons promptly. What type of environment is best when interviewing? - Correct answer quiet environment What aids might you need when interviewing? - Correct answer a. Glasses, hearing aids Self determination - Correct answer Feeling free to decide how to do your work Autonomy - Correct answer independence Would you promote self determination/autonomy? - Correct answer a. Yes- independence How to reduce the risk of UTI - Correct answer a. 8-10 oz glasses of water a day b. Urinate when you feel like it c. Wipe from front to back d. Wear cotton underwear e. Urinate after sex f. avoid bubble baths g. report any symptoms promptly X. What can proper footwear prevent? a. Falls b. Foot problems like bunions or ingrown toenails Oral care should be done every ___ hours? - Correct answer 2 What to know about peripheral vascular disease and Diabetes? (nail care) - Correct answer a. Do not cut nails or put lotion on What is the Joint Commission? - Correct answer Non-profit organization that established the National Patient Safety Goals to ensure safety and quality care is provided to all patients. ii. Medication reconciliation, communication, National Patient Safety goals iii. Required for Medicare and Medicaid reimbursement What are Centers for Medicare & Medicaid Services (CMS)? And what do they ensure? - Correct answer part of the Department of Health and Human Services (HHS) that provides multiple services to the U.S. communities. Ex. Medicare, Medicaid, Affordable Care Act, Statistical Information for healthcare delivery. Ensure proper quality of care is provided and not overcharged. What do the Agency for Healthcare Research and Quality (AHRQ) do? - Correct answer produces evidence to make healthcare safer, higher-quality, accessible, equitable and affordable. Who do the Agency for Healthcare Research and Quality (AHRQ) work with? - Correct answer With the HHS as a partner for evidence. What is the American Nurses Association (ANA)? - Correct answer premier organization representing the nursing workforce in the U.S. and territories. what is the American Nurses Association (ANA) goal? - Correct answer Their goal is to foster high-standards of the nursing practices, promoting a safe and ethical work environment, bolstering nursing health and wellness, and advocate for healthcare issues that affect the nurses and public. What are some education points to teach parents with school age children on how to prevent injuries at home? - Correct answer .... Never Events - Senital Events - Correct answer Serious injuries or death to a patient that should have never happened in a hospital. (Ex. Air embolism, wrong transfusion, falls, and trauma or injuries) a. These mistakes may have been prevented with proper surveillance by the health care professionals involved in the event. Examples of never events - Correct answer - air embolism - wrong transfusion - Labor Death - Wrong site surgery - falls - trauma or injuries -DVT or PE after knee surgery - CAUTIs - CLABSIs - HAPIs, etc. Preventing falls at home - Correct answer o Exercise regularly o Take your time o Lighten loads/brighten paths Storms (Community Safety) - Correct answer · Deaths caused by lighting strikes is the lead cause of fatalities due to weather conditions. · The second leading cause is flooding · Education about outdoor activities during a storm is important to reduce the incidents. Motor vehicle accidents (Community Safety) - Correct answer · Failure to use seat belts and proper child car seats are the main factor of deadly accidents · Use of cellphones while driving increases the risk of accidents · Motor vehicle accidents are the leading cause of accidental deaths in the U.S. Radiation injury (Occupational safety) - Correct answer - Avoid excess radiation - Use protective equipment - TIME: limit time of exposure - DISTANCE: only perform care of patient near the patient when its essential - SHIELDING: wear protective shielding Needle stick (Occupational safety) - Correct answer -26% of nurses even with osha regulation - Increased risk when (stress, +12hr shifts, low skill level, lack of protective devices) Back injury (Occupational safety) - Correct answer - 52% nurse report back pain - Causes include transferring, repositioning, changing bed linens, & weighing patients Most common cause of fires - Correct answer cooking fires, smoking, heating equipment, and home oxygen administration equipment (75% of home fires involves oxygen, smoking materials are the ignition source) If a fire occurs call a - Correct answer "Code Red" or "Code yellow" depending on the institution process. Stay safe and evacuate if needed. Use RACE or PASS Fires in healthcare settings (Healthcare environment hazards) - Correct answer o Smoking is prohibited in healthcare facilities (think about home fires 75% are related to oxygen). Oxygen is highly used in every healthcare facility. o Our role is to ensure the patients and family follow these policies. o If a fire occurs call a "Code Red" or "Code yellow" depending on the institution process. Stay safe and evacuate if needed. Use RACE or PASS Restraints (Healthcare environment hazards) - Correct answer · Method use to restrict movement or access. · Use in the hospitals when the situation or all other approaches have been tried without success. · Avoid their use as much as possible by promoting commitment to reduce restraints and seclusion, educate caregivers about options, maintain 1 to 1 view of patients who are restrained or secluded, have adequate staff and involve all the staff members in the decision making. · Sometimes restraints are needed to maintain safety because it outweighs other methods. · Using rails to restrict the patient's independence is considered a restraint and can cause more harm. DO NOT use this method of restraint.· Perform constant assessment · Do not use without a Doctor's order Biological Hazards (Healthcare environment hazards) - Correct answer · Hand hygiene is the #1 mechanism of defense against contaminants. · As nurses our role is to maintain our patient safe and reduce the risk of cross- contamination. · Complete hand-hygiene when entering, exiting and change of gloves to help keep the patients safe. Violence (Healthcare environment hazards) - Correct answer · Raising in the professional healthcare system· Higher risk in the ED · Recognizing the signs are important, They include: · Anxiety, angry, acute illness that they don't understand can trigger aggression, it can escalate to physical aggression. · Gang violence is common in the ED or acute setting· Stay alert! most common causes of accidental death for all age groups (Infants, Children, adolescents, adults, older adults) - Correct answer ● Poisoning and exposure to noxious substances ● Motor vehicles ● Firearms ● Falls ● Drowning ● Fires, flames, and smoke Safety measures for fall - Correct answer a. Do one thing at a time. b. Change positions slowly to avoid dizziness. c. Be sure pathways are well lit. d. Have your eyes checked at least once a year. e. Wear shoes with non-skid soles. f. Avoid clutter Who is at risk for falls? - Correct answer h. Everyone but older adults are more at risk How do we prevent falls at home? - Correct answer a. Exercise regularly b. Take your time c. Lighten loads- brighten paths d. use caution on stairs e. minimize bathroom hazards f. Childproof the home g. Don't trip yourself up How do we prevent falls at home for Older adults - Correct answer ii. Use beds that are low to the floor iii. Keep a cordless phone near by iv. ask doctor to review medicines v. get treatment for postural hypotension and cardiovascular disorders How do we prevent falls in healthcare facilities? - Correct answer a. Lock the bed b. Safety locks on wheelchairs c. Apply nonskid slippers d. Keep water, urinal, bedpan, and tissues within easy reach of the patient. e. Place the call light within reach. Have the patient demonstrate the ability to call for the nurse. f. Provide a night light. g. Keep floors dry and free of clutter. h. For patients at risk for falls, place a warning sticker on the chart or door. i. Place patient in a room next to the nurse's station j. Stay with patient in bathroom k. Keep bed at lowest level l. Place overbed table across wheelchair m. Offer regular opportunities to toilet n. Provide back rubs and distractions What are our assessment priorities if falls are unwitnessed? (ex. Patient hits head) - Correct answer a. Neuro assessment Know interventions if you have a patient falling and you are with them - Correct answer a. accompany client during ambulation utilizing a transfer safety belt if he/she is weak or dizzy b. encourage client to request assistance whenever needed c. provide ambulatory aids (e.g. walker, cane) if client is weak or unsteady on feet d. Do not rush client e. instruct and assist client to rise and change positions slowly f. perform actions to increase strength and activity tolerance g. Best interventions with a client who has dementia - Correct answer a. Orient client b. Observe closely c. Avoid cultivation of false ideas d. Discourage suspiciousness e. Use simple explanations f. Positive feedback when thinking and behavior is appropriate What is OSHA's primary purpose? - Correct answer i. Defines types of personal protective equipment and situations in which you are required to wear it E. Community Safety Motor Vehicle accidents - Correct answer a. Leading cause of accidental death b. Not wearing seat belt Pathogenic causes - Correct answer (foodborne, Water-borne, or vector-borne illnesses) Pollution - Correct answer a. Contact local agencies to inquire about proper disposal of paint, tires, etc. b. Use local public transportation to reduce air pollution. Storms - Correct answer a. Seek shelter inside a building when there is a storm. b. Avoid riding/driving open vehicles such as bicycles or motorcycles. c. Do not seek shelter under a tree. Poisoning - Correct answer i. Have the poison control 800 number posted so it is easily accessible. ii. Keep all chemicals and medications in a locked cabinet. iii. Dispose of unused medication by mixing it with cat litter or take it to a community disposal center. Carbon Monoxide - Correct answer i. Have a functioning CO2 monitor in the home. ii. Ensure all gas and wood burning devices are vented to the outside. iii. Be sure vehicles do not allow exhaust fumes to enter the passenger area. iv. Never use a kerosene heater, gas stove, or gas oven to heat the home. • Patient who does not believe in the healthcare institutions will delay treatment and will use home remedies instead. Kinship and Social Ties • VIP care for famous celebrities compared to a poor individual or homeless. Using rails to restrict the patient's independence is considered - Correct answer a restraint and can cause more harm. DO NOT use this method of restraint. Elderly are at high risk for - Correct answer injury;primarily from falls Elderly are primarily at high risk for? - Correct answer falls How often do you assess the patient when they're in restraints? - Correct answer Every 30 minutes Falls are the most? - Correct answer Reported incidents When do falls frequently occur? - Correct answer during night time, weekends and holidays The morse scale is used to assess? - Correct answer patient's likelihood of falling Remove patient restraints every? - Correct answer 2 hours What are common code names for fire? - Correct answer "Mr. Red," "Dr. Red," and "code red" are common NCLEX STYLE PRACTICE:Connor's elderly patient becomes disoriented as the day wears on and starts to wander in the hall and go into other patient's rooms. Connor persuades him to get back to bed four separate times. The nurse understands that to avoid using patient restraints, they should: • Select All That Apply • ❑ Orient patient to the environment • ❑ Get a sitter • ❑ Do not encourage family to stay • ❑ Use consistent scheduling of patient activities • ❑ Place the patient away from the nurses' station, so they are not disturbed • ❑ Ask for medication from the primary care provider - Correct answer ❑ Orient patient to the environment- Yes • ❑ Get a sitter-Yes • ❑ Do not encourage family to stay—No, it is safer if they stay • ❑ Use consistent scheduling of patient activities—YES • ❑ Place the patient away from the nurses' station, so they are not disturbed—No, place the patient by the nurses' station • ❑ Ask for medication from the primary care provider—No, often increasing medications makes patients more confused NCLEX STYLE PRACTICE:The nurse understands that if a restraint is needed, it should be: A. released once a day B. Tied to itself, so the patient cannot get out C. Be the least restrictive as possible D. Unpadded, so it does not become loose - Correct answer A. released once a day— No, they should be released every 2 hours B. Tied to itself, so the patient cannot get out—No, they should be slipped knotted to the bed C. Be the least restrictive as possible—YES D. Unpadded, so it does not become loose—No, padding should be used RACE is an acronym used to - Correct answer prioritize order of procedures for a fire Meaning of RACE acronym - Correct answer R : Rescue: • Remove clients from the general area A: Alert/Alarm: • Sound alarm C :Confine: • Contain fire (close doors and windows, make sure fire doors close) E : Extinguish fire PASS - Correct answer • Pull the pin; • Aim the nozzle; • Squeeze the handle • Sweep at the base of the fire. NCLEX STYLE PRACTICE: A patient who is cognitively impaired is admitted to the hospital for pneumonia. The patient has a history of wandering at night. What should the nurse do to ensure the safety of this patient? *Encourage a family member to remain with the patient every night. *Obtain a sedative to be administered to the patient at bedtime. *Apply a vest restraint when the patient plans to go to sleep. *Activate the bed alarm on the patient's bed. - Correct answer Encourage a family member to remain with the patient every night. - NO unrealistic to have family EVERY single night Obtain a sedative to be administered to the patient at bedtime. NO- it's a chemical restraint Apply a vest restraint when the patient plans to go to sleep. - NO, too restrictive; less restrictive method must be tried first Activate the bed alarm on the patient's bed. YES- Will alert the nurse NCLEX STYLE PRACTICE:Which is an important step when transferring a patient using a mechanical lift? • Position the chair as close as possible to the bed. • Remove the sling after the patient is moved to the chair. • Position the sling at the middle of the patient's back to the ankles. • Attach the longer belts to the lower grommets on each side of the sling. - Correct answer Position the chair as close as possible to the bed. • It is not necessary to position the chair as close as possible to the patient's bed. Mechanical lifts are designed to move a patient completely across a room safely. Remove the sling after the patient is moved to the chair. • The sling remains under the patient after the transfer. It would be difficult or even impossible to remove and then reposition the sling if the patient were obese or immobile Position the sling at the middle of the patient's back to the ankles. • The sling should start at the shoulders and end at the knees. This completely supports the patient for the transfer. If it is too high, the patient could slide out from the bottom of the sling. If it is too low, the patient could slide out from the top of the sling. Attach the longer belts to the lower grommets on each side of the sling. • When the longer belts/chains are attached to the bottom of the sling and the shorter belts/chains are attached to the top of the sling, the patient will be raised to a sitting position when the lift raises the sling and the patient up and off the bed NCLEX STYLE PRACTICE:A patient who is legally blind says to the nurse, "I once was able to see a little bit, but now I can't see anything." What should the nurse encourage the patient to do while hospitalized? • Wear dark tinted eyeglasses. • Keep a light on in the room at all times. • Close the window blinds during the day. • Call for assistance when getting out of bed - Correct answer • 1. Dark-tinted eyeglasses will not benefit a patient who "can't see anything." • 2. Keeping a light on in the room may help a patient with partial vision, but it will be insignificant for a patient who "can't see anything." • 3. Closing window blinds will be beneficial for a patient with partial vision who is affected by glare; this intervention will not benefit a patient who "can't see anything." • 4. A patient who is in a strange environment and who has a visual impairment is at an increased risk for falls. The patient should seek assistance with transfers and ambulating until the patient feels comfortable engaging in these activities and the nurse determines that the patient is safe to perform this activity unassisted. • TEST-TAKING TIP: Identify the option with a specific determiner. Option 2 contains the specific determiner all. Identify the unique option. Option 4 is unique because it is the only option that involves another person and it is the only option that does not engage in adjusting the light in the room. Identify options that are equally plausible. Option 1 and 3 are equally plausible. Both reduce light that meets the eye. Option 1 is no better than option 3. Eliminate both from further consideration. NCLEX STYLE PRACTICE:A nurse is caring for an older adult who is cognitively impaired and has a history of pulling out tubes and falling. List the following safety Dominant culture - Correct answer the group that has the most authority or power to control values and rewards or punish behaviors ○ Usually but not always the largest group Ethnocentrism - Correct answer the tendency to think that your own group (cultural, professional, ethnic, or social) is superior to others and to view behaviors and beliefs that differ greatly from your own as somehow wrong, strange, or unenlightened ○ This exists in all groups, not just the dominant group* Intimate distance - Correct answer <18 inches Personal distance - Correct answer 18 inches to 4 feet Social distance - Correct answer 4 to 12 feet Public distance - Correct answer >12 feet Health disparities among race and ethnicity - Correct answer ○ Health status ○ Quality of care ○ Access to care Race - Correct answer strictly related to biology ○ Skin color, blood type, bone structure Bicultural - Correct answer describes who identifies with two cultures and integrates some of the values and lifestyles of each into his life ○ Will use one more than the other during certain situations ○ May feel divided or may enjoy the best of both worlds Rest - the body being in a decreased state of activity. Sleep - a state of rest accompanied by an alteration of consciousness and inactivity. Why sleep is necessary for the body's normal function? - Correct answer is an important regulator of energy metabolism may improve learning and adaptation affects almost every tissue in our bodies reduce stress and anxiety Nourishes health Growth hormone is released during sleep Important for mental health Sleep patterns - Correct answer circadian rhythm is a biorhythm based on the day- night pattern in a 24-hour cycle pattern that occurs everyday that the body is used to Identify nursing interventions beyond relieving discomfort/pain, which promote rest and sleep - Correct answer • Create a restful environment (clean, dry linens, dark, quiet room) • Promote relaxation techniques (back rub, guided imagery) • Avoid caffeine, smoking, and alcohol at bedtime • Eat a small carbohydrate snack before bed. • And others Nutrients are used for - Correct answer optimal cellular metabolism and health promotion How do changes in mastication and swallowing influence nutritional intake? - Correct answer • When the client is unable to chew, the food is ground or placed in a blender to eliminate the step of chewing, therefore the appearance of the food on the plate is not attractive. If the client has a swallowing issue, thickener is added to liquids to thicken them to a heavier consistency (such as thickening water to the consistency of pudding) to make it safe for swallowing without choking. The thickener also changes the flavor of the fluid. Oral - Correct answer Taking all nutritional intake by mouth Oral Nursing Care - Correct answer patient position sterile enviornment restrict liquid intake frequent small meals warm food Enteral - Correct answer Taking all nutritional intake through an MG tube, G-Tube, Peg Tube Jejunostomy tube Enteral Nursing Care - Correct answer confirm tube pplacement proper patient postion proper labeling monitor patient status Parenteral - Correct answer Taking nutrition through a centrally inserted IV line such as a PICC or central venous access device Parenteral Nursing Care - Correct answer Measure intake and output accurately Monitor weight dail Monitor calorie counts encourage additional fluid intake orally types of patients who may have fluid restrictions - Correct answer clients who have a problem with fluid volume excess such as chronic renal failure, heart failure, and SIADH medication that affects hydration status - Correct answer • Diuretics • laxatives • enemas • over-the-counter medications • herbal remedies. Stress incontinence - Correct answer Involuntary loss of urine associated with sneezing or laughing. Urge incontinence - Correct answer Involuntary loss of large amounts of urine accompanied by a strong urge to urinate. Overflow incontinence - Correct answer Loss of urine along with a distended bladder. Functional incontinence - Correct answer Loss of urinary control related to immobility or external obstacles, or problems in thinking or communicating that prevent the client from reaching the bathroom. Unconscious incontinence - Correct answer Loss of urine when the person does not realize the bladder is full and has no urge to urinate Nursing care for a client with incontinence - Correct answer diet high in fiber eating fruits, vegetables, and whole grains drinking 8 to12 glasses of water each day unless medically contraindicated. Remind them to promptly toilet or void when the urge occurs Bladder training - Correct answer o Program to help with elimination Intake - Correct answer consumed throughout the date. • Measured in mLs • Everything that is liquid • Solid food intake will be determined as percentage % • Example: Patient ate 55% of dinner Output - Correct answer elimination • Emesis (vomit)=Oral, Bleeding, Urine, Feces = Diarrhea • Solid feces are counted per how many • Example: Patient had 1 solid BMs at 1300 • Liquid stools will be measured using mLs. -Weak peripheral pulses -Dehydration -Reduced kidney function -Decrease urine output (less than 30mL/hr) Interventions promoting normal bowel elimination patterns - Correct answer • Encouraging pt to have diet high in fiber • Create meal plan • Keep track of stools everyday and how it appears • Make sure they use the toilet when they need to Diarrhea Nursing interventions - Correct answer • Protect the perineal and buttock area with zinc oxide or other barrier cream to prevent skin irritation and excoriation, especially for patients who are incontinent. • Wash and dry skin where stool and urine have made contact, especially for patients who are incontinent. • Encourage fluid intake and ensure that the patient consumes foods high in potassium such as oranges and potatoes. • Document food and fluid intake and urinary/stool output. • • Check the patient's weight each day for weight loss. • • Collaborate with the primary health care provider for prescribing an antifungal cream if needed. - provide fluid-balanced -administered medications as needed, - keep accurate track of I&O. -If severe diarrhea, keep patient NPO but provide IV fluids Constipation Nursing interventions - Correct answer • health teaching and collaboration with the interprofessional health care team. • teaching about measures to prevent worsening of constipation • stool softeners, • bulk-forming agents • mild laxatives as needed to restore normal elimination patterns. • enemas to stimulate peristalsis and empty the rectum. -Encourage a high-fiber diet - use medications as needed -increase activity -increase fluid intake. Sex/Reproduction is - Correct answer seen as a basic physiological need 1. The nurse recognizes that in order to effectively meet the goal of shared meaning in communication, verbal and nonverbal language should be A. absent B. Congruent C. Equally direct D. Noncongruent - Correct answer B. Congruent 2.While bathing a patient, the nurse recognizes that the personal space distance zone that he or she is in when physically touching the patient is A. Public B. Intimate C. Casual personal D. Social consultative - Correct answer B. Intimate 3. While obtaining a patient health history, the nurse recognizes that the personal space distance zone that he/she is in when standing within 3 feet of the patient is A. Public B. Intimate C. Casual personal D. Social consultative - Correct answer C. Casual personal 4. When interacting with a physician, the nurse recognizes that the personal spacedistance zone that he/she is in when standing within 5 feet of the physician is A. Public B. Intimate C. Casual personal D. Social consultative - Correct answer D. Social consultative 5. When teaching a class of nursing students, the nursing instructor stands 15ft from he audience. The personal space distance zone that the nursing instructor is in is A. Public B. Intimate C. Casual personal D. Social consultative - Correct answer A. Public 6. When interacting with patients, the nurse demonstrates a willingness to communicate when A. Standing over seated patients B. Slumping while talking to patients C. Folding arms while talking to patients D. Leaning slightly forward toward patients - Correct answer D. Leaning slightly forward toward patients 7. A patient who appears to be in pain does not ask the nurse for pain medication because he feels it would upset the nurse. The style of communication that the patient is demonstrating is A. Passive B. Assertive C. Aggressive D. Demeaning - Correct answer A. Passive 8. A patient throws his urinal at the nurse and tells the nurse that he thinks she is a terrible nurse. The nurse informs the patient that his behavior is inappropriate. The style of communication that the nurse is demonstrating is A. Passive B. Assertive C. Aggressive D. Demeaning - Correct answer B. Assertive 9. When the nurse educates a patient about his medications, the patient tells the nurse that she should go back to nursing school because she doesn't know very much about medications. The style of communication that the patient is demonstrating is A. Passive B. Avoidant C. Assertive D. Aggressive - Correct answer D. Aggressive 10. A nursing instructor teaches a class of student nurses that the most effective communication style for nurses to practice is: A. Passive B. Avoidant C. Assertive D. Aggressive - Correct answer C. Assertive 11. A nurse is caring for a patient who has end stage renal disease and will require dialysis three times per week. The patient states, "I'm upset that I didn't visit all the places I'd like to see. Now that I'm on dialysis I won't be able to." The most therapeutic response by the nurse is: A. "You are upset that it's too late to visit places that you would like to see?" B. "There are many people who feel exactly the same as you do." C. "Don't worry. You can still visit all of the places hat you would like to see." D. "I think you should visit the places you would like to see before it's too late." - Correct answer A. "You are upset that it's too late to visit places that you would like to see?" 12. The nurse is caring for a patient who has just been diagnosed with a brain tumor. The patient asks the nurse if he should choose to have surgery. The Nurse's most therapeutic response is: A. "Tell me what you know about surgery." B. "I would never decide against having surgery." C. "If I were you, I would definitely have the surgery." D. "Don't worry. You will be fine if you don't have surgery." - Correct answer A. "Tell me what you know about surgery." 13. The nurse is caring for a patient who develops dyspnea that does not improve with oxygen therapy and nebulizer treatment. The nurse immediately calls the