NURS 360-FINAL STUDY GUIDE EXAM, Exams of Nursing

Download NURS 360-FINAL STUDY GUIDE EXAM and more Exams Nursing in PDF only on Docsity! NURS 360-FINAL STUDY GUIDE EXAM Spiritual distress: Book: • Patients are at high risk for spiritual distress (belief or value system disruption) in certain health situations that threaten their meaning and sense of purpose in life. (Ex. Patients may have spiritual needs when learning of a life-changing diagnosis or experiencing a health crisis). • Patients may require spiritual care when making health care decisions. • Patients may need assistance during these at-risk times to lessen the degree of their spiritual distress. Nurses must be alert to such situations so that they can intervene appropriately. • Spiritual distress may be expressed as anger, depression, neediness, or crying. Spiritual Distress Diagnoses: • Some nursing diagnoses that may be written for patients exhibiting spiritual needs include: • Spiritual Distress related to chronic illness as evidenced by expressions of hopelessness and statements indicating concern over the recent inability to pray • Impaired Religiosity related to illness as evidenced by difficulty adhering to religious dietary customs and expressions of emotional distress over special diet restrictions • Readiness for Enhanced Religiosity as evidenced by rejecting harmful customs and seeking reconciliation with previously estranged family members Assessment of the patient not speaking English patient: Book: Diversity considerations box: Know some common phrases in the language of the patient to obtain accurate information, and work with qualified interpreters. Use of a professional interpreter is necessary if the nurse and the patient do not speak the same language fluently. Avoid translation of medical information via patient’s family members or friends to ensure privacy and accuracy of an essential, personal information. Cathy Parkes: • Do not use patient’s family or friends. • Use certified medical interpreter. • Explain purpose of meeting to interpreter prior to approaching the patient. • Direct questions at family (not interpreter) • Ask one question at a time. • Use laymen’s terms. • Do NOT supplement words with gestures or nonverbal reinforcement. 3 NURS 360-FINAL STUDY GUIDE EXAM Normal ABG values: pH: 7.35-7.45 PaCO2: 45-35 ® HCO -: 22-26 (M) Hyper and hypoventilation. What ABG interpretation would you expect?: Powerpoint: PaCO2: “Resps” • A high PaCO2 indicates hypo ventilation (Brain injury, medication/sedation) • A low PaCO2 indicates hyperventilation (Panic attack, anything body perceives as a threat) Vomiting and diarrhea. What ABG interpretation would you expect?: Causes of Metabolic Alkalosis: VOMITING (AlkaYAK) - Fluid loss from GI (Vomiting, NG tube aspiration) - Diuretic therapy - Cushing’s disease - Severe potassium depletion - Alkali administration - Non-parathyroid hypercalcaemia (tumors) Causes of Metabolic Acidosis: DIARRHEA (ASSSSSS) - Diabetic Ketoacidosis (DKA) - Starvation Ketoacidosis - Alcoholic Ketoacidosis - Poisonings- Salicylate, Ethylene Glycol - Lactic acidosis - Renal failure - Diarrhea Normal vital signs and oximetry: BP: <120/80 HR: 60-100 RR: 12-20 SpO2: 95-100 (Low 90s expected for COPD patients) Temp: 36-38 (Oral) NURS 360-FINAL STUDY GUIDE EXAM Discharge planning: Early, structured discharge planning ensures a smoother transition of patients from hospital to home. Discharge documentation should include medical information, patient goals, and interventions developed to accelerate recovery and provide needed care. Research has demonstrated that in adequate discharge planning may lead to an increase in patients returning to the hospital, more frequent emergency room encounters, And adverse events. A structured, collaborative approach that focuses specifically on the need of at-risk patients has proved beneficial. Various resources for improving the discharge planning process have been developed by nurses. Use of these planning and documentation tools has improve patient outcomes and satisfaction associated with hospital to home transit. Cathy Parkes: • Diet and activity restrictions. • Detailed instructions for procedures at home (wound dressing changes) • List of medications, when to take them, precautions regarding medications. • Signs/symptoms of complications, when to seek medical attention. • Follow-up appointment information. • Names, numbers of providers and community resources. Appropriately written discharge instructions: Book: • Discharge planning begins in the preoperative phase. • A successful discharge plan is achieved by identifying potential problems preoperative. • After the physician has indicated patient can leave the discharge process is completed as soon as possible. Incentive spirometry: Powerpoint: • Prevention of atelectasis and pneumonia. • Semi Fowler/ High Fowler’s position: For use of incentive spirometer. • Have the patient hold the breath for 5 seconds after goal volume is reached when using an incentive spirometer. • Cough deeply after each use. This will facilitate the removal of secretions from his lungs. Book: • The incentive spirometer is used by the patient to practice inhalation. • The patient attempts to reach a set inhalation volume, the volume may be set by the primary care provider or respiratory therapy or calculated from standard charts. • The technique encourages deep breathing • Maintains lung expansion and help prevention of atelectasis and pneumonia. • If patient has surgery the technique is taught before surgery. NURS 360-FINAL STUDY GUIDE EXAM The patient should be an upright position, semi Fowler or Fowler if possible. The patient’s goal is to have a steady rise of a marker in the device to achieve a specific inhalation volume, which is marked on the device. Instruct the patient to inhale slowly with the mouth on the mouthpiece. Inhale as much as possible and hold that breath for 3 to 5 seconds. Slowly exhale. Repeat each inhalation and exhalation 5 to 12 times. And with two controlled coughs. Perform this exercise every 1 to 2 hours per orders. Document the patient education concerning correct procedure and performance times. Note the patient’s concerns and discomfort, and document noncompliance issues. Include a respiratory assessment before and after the procedure. Document the patient’s use of the incentive spirometer and tolerance of the procedure. Pulmonary therapy, including incentive spirometer breathing was found to decrease recovery time and improve lung functioning of obese patients if begun immediately after surgery in recovery in the PACU. Lung function was significantly improved for 24 hours post operatively. Rights of Delegation: 1. Right task: Repetitive, non-invasive, doesn’t require much supervision. 2. Right circumstances: Do not assign a patient who is unstable. 3. Right person: Make sure delegate is competent and operating within their scope of practice, check facility’s job description. 4. Right direction/communication: Communicate timeline, expected results, and follow-up communication expectations. 5. Right supervision/evaluation: Intervene if needed, provide feedback. Rights of medication: 1. Right patient 2. Right medication 3. Right time 4. Right dose 5. Right route 6. Right documentation 7. Right patient education 8. Right to refuse 9. Right assessment (before/ after administration) 10. Right evaluation Medication administration (what actions if a medicine is held): Notify the PCP promptly the reason for holding medication. If the patient refuses medication: do not administer. The patient has the right to refuse medication. If the patient continues to refuse although the medication is correct, document this in accordance with facility policies and procedures and notify the PCP. If the medication is expired: do not administer expired medication. Notify the pharmacy of any expired medication. Follow facility policies and procedures for disposal of expired medication. Obtain new medication to administer to the patient and restart the procedure. Has the medication been dropped on the floor or other unclean Surface?: discard the medication appropriately, and document in accordance with facility policies and procedures. Repeat the preparation with a new pill. NURS 360-FINAL STUDY GUIDE EXAM Nursing process. Know what each step means and examples of application: STEPS OF THE NURSING PROCESS: Correct writing of a nursing diagnosis: How to write nursing diagnosis: NURS 360-FINAL STUDY GUIDE EXAM Dementia/ Intellectual disabilities: • Require special attention by caregivers. • Consulting with the family members of these patients often provides helpful hints and insights into what is most effective in gaining their cooperation with necessary nursing interventions. • Avoiding confrontation is important. It is better to accept a demented patient’s thought process than to argue or try to correct an erroneous line of thinking. Patients diagnosed with intellectual disabilities or dementia require special attention by caregivers. Consulting with the family members of these patients often provides helpful hints and insights into what is most effective in gaining their cooperation with necessary nursing interventions. Avoiding confrontation is important. It is better to except a demented patient thought process than to argue or try to correct and erroneous line of thinking. Cathy Parkes: Aphasia: • Speak clearly and slowly, using short sentences. • Make sure only one person speaks at a time. • Give patient plenty of time to respond. • Tell patients if you don’t understand them. Normal lab values and what the test indicates (CBC, BMP, Coags): Complete blood count (CBC) • The CBC and differential provide information regarding oxygen and carbon dioxide transport capabilities and the current status of the immune response. Basic metabolic panel • The basic metabolic panel is a series of blood tests that are used to assess the renal , glucose, and electrolyte balance in the body. Sodium (135–145 mEq/L) Potassium (3.5–5 mEq/L): Along with sodium, produces resting membrane potential is and action potentials of nerve and muscle cells. Principal action of the ICF and responsible for intracellular osmolarity, essential component of the Na-K pump and involved in protein synthesis. Serum levels regulated by the kidneys through reabsorption and excretion. Calcium (8.5–10.5): Calcium is required for nerve conduction, muscle contraction, blood vessel expansion and contraction, and the secretion of hormones and enzymes. Magnesium (1.3–2.1): Magnesium works in conjunction with calcium to promote structural support. The remaining amount is involved in a large number of chemical reactions, such as energy production and bone formation. Magnesium combined with calcium regulates blood NURS 360-FINAL STUDY GUIDE EXAM pressure and maintains a regular heartbeat and nerve and muscle function. This nutrient is associated with the production of dopamine, norepinephrine, noradrenalin, and epinephrine; adrenaline. Increasing research focuses on the use of magnesium to treat conditions such as asthma, diabetes, cardiovascular disease, and attention deficit disorder in children. Magnesium deficiency may result from a dietary intake with little or no nutritional value, including additives, refined sugars, and foods high in calories and low in protein, vitamins, and minerals. An excessive amount of zinc intake may lower magnesium levels. Deficiencies of minerals such as calcium phosphorus and magnesium also affect bone mass density, which increases the risk of fractures. Chloride (95–105): Most abundant anion in the ECS. Key role in maintaining serum osmolality. Required for formation of stomach hydrochloric acid. Buffering role in acid-base balance. Homeostasis maintained in similar way as sodium; where sodium goes, chloride also goes. Phosphorus (1.7–2.6): Like calcium, plays a major role in the development of bone. It aids in the contraction of muscles, kidney function, nerve conduction, and a maintenance of regular heartbeat. It also plays an important role in the body is use of the major nutrients such as carbs, fats, and proteins, all of which are crucial in the maintenance and repair of cells and tissues. Intake of phosphorus is considered adequate if intake of milk and meat products is sufficient. Creatinine (M: 0.6-1.3 / F: 0.5-1.1): DECREASED LEVELS : ATROPHY OF MUSCLE, PREGNANCY. INCREASED LEVELS : congestive heart failure, dehydration, diabetes mellitus, Glomerulonephritis, renal failure, rheumatoid arthritis, shock, uremia. Bun (10-20): DECREASED LEVELS: ALCOHOL ABUSE, DIET INADEQUATE IN PROTEIN, HEPATITIS, LIVER FAILURE, MALNUTRITION. INCREASED LEVELS: ACUTE GLOMERULONEPHRITIS, CONGESTIVE HEART FAILURE, DIABETES MELLITUS, HIGH-PROTEIN DIET, NEPHROTIC SYNDROME, RENAL DX, SEVERE DEHYDRATION, SEVERE INFECTION, SHOCK. Urine specific gravity (1.005 to 1.030): DECREASED LEVELS: Anti-diuretic hormone deficiency, chronic pyelonephritis, diuretics, high fluid intake. INCREASED LEVELS: Acute glomerulonephritis, congestive heart failure, dehydration, diabetes mellitus, low fluid intake, liver failure, vomiting and diarrhea. Glucose (70-110): Increased values indicate diabetes mellitus, infection, or stress. NURS 360-FINAL STUDY GUIDE EXAM Lab Signs of hemorrhage: Red blood cells (M: 4.7-6.1/ F: 4. 2-5.4): DECREASED LEVELS: Anemia, bone marrow suppression, chronic infection, hemorrhage, renal disease vitamin B6B 12 or full lick acid deficiency. INCREASED LEVELS: Iindicate major burns, cardiovascular disease, chronic lung disease, congenital heart defect, polycythemia vera. Hematocrit (M: 42-52/ F: 37-48): DECREASED LEVELS: Anemia bone marrow suppression chronic infection hemorrhage renal disease vitamin B6B 12 or folic acid deficiency. INCREASED LEVELS: Major burns cardiovascular disease chronic lung disease congenital heart defect polycythemia vera. White blood cells (5000-10,000): DECREASED LEVELS: Chronic leukemia or aplastic anemia. INCREASED LEVELS: Acute leukemia, infections, surgery, or trauma. Labs related to renal damage vs mild dehydration: BUN, Creatinine, GFR Assessment of pain: Parameter → Facial expression, shallow respirations, immobility PQRST: P: roximity Q: uality R: adatiation S: everity T: ime Assessment: ▪ The letters in the acronym SOCRATES mean: S = site (Where is the pain located?) O = onset (When did the pain start? Was it gradual or sudden?) C = character (What is the quality of the pain? Is it stabbing, burning, or aching in nature?) R = radiation (Does the pain radiate anywhere?) A = associations (What signs and symptoms are associated with the pain?) T = time course (Is there any pattern to when the pain occurs?) E = exacerbating/relieving factors (Does anything make the pain worse or lessen it?) S = severity (On a scale of 0 to 10, what is the intensity of the pain?) NURS 360-FINAL STUDY GUIDE EXAM O2 Delivery Devices: N.I: Watch for thrush SYSTEM DELIVERED O2 CONCENTRATION (FRACTION OF INSPIRED OXYGEN-FIO2) FLOW RATE NURSING CARE Nasal cannula 24-44% 1-6L/min Assess nares for 1 24% encrustations and 2 28% irritations. Assess top of 3 32% ears for signs of irritation 4 36% 5 40% 6 44% Simple face 40-60% 5-8L/min Inspect facial skin for mask* 5 40% dampness or chafing and 6 45% dryness, treat as needed 7 50% 8 55% Partial 70-90% 6-15L/min Inspect facial skin for rebreather 6 70% dampness or chafing and mask 15 90% dryness, treat as needed Nonrebreather mask 60-100% 10- 15L/min 10 60% 15 100% Inspect facial skin for dampness or chafing and dryness, treat as needed Venturi’s mask** Vary by manufacturer from 24- 60%, Color-coded adaptors (i.e., jets) have corresponding settings 4-12L/min Inspect facial skin for dampness or chafing and dryness, treat as needed Trach mask and collar 40-60% 5-8L/min For patients with tracheotomies. Oxygen is humidified Care of COPD patient: • Chronic obstructive pulmonary disease (COPD) is a general term used for a group of disorders characterized by impaired airflow in the lungs. (It is not one disease. Umbrella term) • Emphysema is one of the disorders and is characterized by disease of the airways due to inflamed and damaged alveolar walls in the lungs. (What makes COPD) NURS 360-FINAL STUDY GUIDE EXAM • Chronic bronchitis is another form of COPD and is characterized by inflammation of the larger airways, increased production of mucus, and chronic cough. (What makes COPD) • Precautions and complications are important to monitor when administering oxygen. • A patient with chronic hypercapnia may have respiratory depression when supplemental oxygen levels are too high. THIS IS IMPORTANT • Pts who have hypercapnia (high CO2) – sometime smokers/COPD retain a lot of CO2 (ABGs, CO2 levels will be off the roof) They are in constant hypercapnia. What triggers the brain to make you breath? is the high levels of CO2. And then you breath. • For patients with COPD, because they leave with high levels of CO2 constantly, after a while their brain don’t respond to the high levels of CO2. It is not CO2 that drive the respiratory drive is a deep in OXYGEN for a COPD patient. When their oxygen levels drop their brain tell their body to take a breath. • What happens when this patient with COPD is in the hospital and then you give supplemental oxygen over a long period of time? They are not going to breath they can go to respiratory depression They are going to stop breathing. Look at the oxygen. it is too high for a person with COPD, it is been to high for a long time, we have to lower the oxygen levels. Over 2L could be a lot for them. • COPD patient doesn’t live in high levels of oxygen, so they try to get their oxygen saturation high 80 low 90 maybe 92. When patient hits 92 you have to take off. If we don’t do it they can stop breathing sometimes they use the venturi mask. The difference with the normal person is that we look for oxygen saturation between 95- 100. • Used to living with a higher CO2 level than us; CO2 won’t be the determinant, OXYGEN will be the DETERMINANT • High levels of o2 for long periods of time – tells the brain not to breathe • Another concern for oxygen administration is that when FIO2 levels exceed 50%, atelectasis or oxygen toxicity may occur. • High levels of oxygen pose a fire hazard. • Nebulizers and humidifiers may have bacterial contamination, leading to infections. • Devices used to deliver oxygen are placed into the categories of low-flow systems, reservoir systems, and high-flow systems. • A commonly used low-flow system is the nasal cannula. • Mask delivery systems gather and store oxygen between patient breaths. • The partial rebreathing mask and non-rebreathing mask each have a 1-L reservoir bag that is flexible and has an oxygen inlet. The reservoir allows for higher inspired oxygen levels. Postoperative complications: • Wound infection is a common postoperative complication and usually occurs 48-72 hours postoperatively. • A delay in wound healing can cause infection, blood clots, tissue hypoxia, trauma, advanced age, abnormal lab values, obesity, undernourishment, immunosuppression, and systemic diseases such as diabetes. NURS 360-FINAL STUDY GUIDE EXAM Immediate actions for hypoglycemia: ADPIE 1. Assess the patient. 2. Check blood glucose. 3. Give insulin if needed. Signs and symptoms of fluid volume excess, labs associated with fluid excess: Cathy Parkes: • Symptoms: Tachycardia, tachypnea, hypertension, bounding pulse, weight gain, dyspnea, crackles, edema, jugular vein distension, pulmonary congestion. • Labs: All decreased – Hct, serum osmolarity, urine specific gravity, electrolytes, BUN, creatine. Signs of dehydration: Cathy Parkes: • Symptoms: Tachycardia, tachypnea, HYPOtension, weak pulse, fatigue, weakness, thirst, dry mucus membranes, GI upset, oliguria, decreased skin turgor, decreased capillary refill, diaphoresis, flattened neck veins. • Labs: All increased – Hct, serum osmolarity, urine specific gravity, hypernatremia Benefits of ambulation: • Early ambulation helps to prevent many complications postoperative: Constipation, deep vein thrombosis, atelectasis, pneumonia, and urinary stasis. • Promotes blood flow of oxygen throughout the body while maintaining normal breathing functions. • Stimulates circulation which can help stop the development of stroke-causing blood clots. • Aids in quicker wound healing. Health models: Powerpoint: • Several health models have been developed to guide practice using the nursing process: o Basic Human Needs Model ▪ Maslow’s hierarchy of needs (Guides health process/ health needs) • Health Belief Model NURS 360-FINAL STUDY GUIDE EXAM • Place infants on back to sleep. Do not place anything in the crib with the baby. Make sure crib slats are <= 2 3/8 inches apart. • Keep plastics bags, houseplants, cleaning agents out of reach. Lock up medications. • Use rear facing car seat until 2 years old. Use car seats with 5-point harness, place in back seat. • Turn pot handles away from front of stove. • Close bathroom doors and keep toilet lids down. School age children: • Use car booster seat while child is under 40lbs or under 4’9’’. Keep child in backseat until 12 years old. • Use protective gear (helmets, pads) for bicycling, sports. • Reduce water heating setting to < 120 degrees F. • Keep guns locked up, bullets stored in separate location. • Enclose pools with locked fence, supervise children in pools/water. Adolescents: • Educate teens on risks associated with smoking, drugs, alcohol, unprotected sex. • Warn against distracted or impaired driving. Reinforce need to wear seat belts. • Monitor teens for mental health issues (depression, anxiety) Middle-aged adult: • Heart disease • Cancer • Stroke Older adults: • Remove trip hazards from home: scatter rugs, loose carpet. • Place electrical cords against wall (behind furniture) • Install grab bars in bathroom/shower, use nonskid mat in shower. • Ensure adequate lighting in home. Use colored tape on step edges. Malpractice criteria: Cathy Parkes: • Medication error that harms patient. • Dating your patient. Hypernatremia/Hyponatremia. Know what actions/assessments are required for both (136- 145 mEq/L): ⟶ Maintains fluid balance in the body, nerve and muscle function. Hypernatremia: NURS 360-FINAL STUDY GUIDE EXAM • Causes: GI losses, diuretics, skin losses, SIADH, edema, hyperglycemia • Symptoms: Tachycardia, HYPOtension, confusion, fatigue, n/v, headache Hyponatremia: • Causes: Water deprivation, excess sodium intake, kidney failure, Cushing’s syndrome • Symptoms: Tachycardia, muscle twitching/ weakness, GI upset, edema Hyperkalemia/Hypokalemia. Causes (3.5-5.0 mEq/L): ⟶ Maintains ICF (Intracellular fluid balance), nerve function, regulates muscle and heart contractions. Hyperkalemia: • Causes: GI losses, diuretics, skin losses, metabolic alkalosis • Symptoms: Dysrhythmias, muscle weakness and cramps, constipation/ileus, HYPOtension Hypokalemia: • Causes: Uncontrolled diabetes (DKA), metabolic acidosis, salt substitutes, kidney failure • Symptoms: Dysrhythmias, muscle weakness, numbness/tingling, diarrhea, confusion Normal Mg++ level. Know what actions/assessments are required for high or low (1.3-2.1 mEq/L): ⟶ Nerve and muscle function, bone formation. Critical for many biochemical reactions in body. Hypermagnesemia: • Causes: Kidney disease, laxatives containing Mg. • Symptoms: HYPOtension, muscle weakness, lethargy, respiratory and cardiac arrest. Hypomagnesemia: • Causes: GI losses, diuretics, malnutrition, alcohol abuse • Symptoms: Dysrhythmias, tachycardia, hypertension, tremors, seizures, increased DTRs. Hypertonic, hypotonic, Isotonic: Hypertonic: D5 NaCl. D5 in Lactated ringers. D5 0.45% NaCl. Hypotonic: D5W (in the body) 0.25% NaCl. 0.45% NaCl (half normal saline) 2.5% Dextrose. Isotonic: 0.9% NaCl (Normal Saline) Lactated Ringers. D5W (In the bag) NURS 360-FINAL STUDY GUIDE EXAM Appropriate IV solutions for Dehydration: 0.9% NaCl (NS), Lactated Ringer’s (LR), D5W (In the bag) IV solution types: NURS 360-FINAL STUDY GUIDE EXAM Potassium rich foods (Interferes with effectiveness of Warfarin): • Warfarin works by interfering with the synthesis of vitamin K- dependent clotting factors. It takes days to get the coagulation levels to the therapeutic levels. Fish, excluding shellfish; whole grains, nuts, broccoli, cabbage, carrots, celery, cucumbers, potatoes with skins, spinach, tomatoes, apricots, bananas, cantaloupe, nectarines, oranges, tangerines. Immediate actions for blood products transfusion reactions: Stop the transfusion! S/S of IV infiltration: • Swelling around site, edema, coolness, dampness, slowed rate of infusion • Intervention: Discontinue IV, elevation, warm/cold compress NG indications and contraindications: Cathy Parkes: • Place patient in high Fowler’s position. • Agree on signal patient can use if he/she is feeling distress during procedure. • Lay a towel across the patient's chest. • Use water-based lubricant. • Have patient sip water while inserting. • Withdrawal slightly if patient gags/chokes. • Check placement by checking pH of gastric contents, confirm placement with x-ray. • Verify tube placement w/ x-ray before feeding the first time. • Verify presence of bowel sounds before feeding, check gastric contents pH (should be between 0-4). • Discard bags/tubing every 24 hours. • Measure gastric residual every 4-6 hours, return residuals to stomach. Hold feeding for residual amount over hospital policy (~ 500ml). • Flush feeding tubes with 30 ml water every 4 hours. • Formula should be at room temperature. • Contraindication: Trauma to nasal area, infection Best recommendations for health screenings for health promotion: • Eye examination every 2 years. • Pap smear every 3 years beginning at 21. • Mammogram annually for women 45 and up. • Colonoscopy every 10 years. NURS 360-FINAL STUDY GUIDE EXAM Foods for patients with renal failure: Renal: Diets restrict potassium, sodium, protein and phosphorus intake. Fresh fruits (Except bananas) and vegetables are excellent choices. (Meat, processed food and peanut butter, cheese, nuts, caramels, ice cream and colas are typically allowed in limited quantities or contraindicated). – Patients with kidney issues cannot process proteins. Renal: Low protein/ low potassium/ low sodium kidney problem. Have good protein control, limit potassium, phosphorus, and fluids Low potassium foods: Apples, cranberries, grapes, pineapples and strawberries Cauliflower, onions, peppers, radishes, summer squash, lettuce Pita, tortillas and white breads Beef and chicken, white rice Holistic nursing definition: It is important to care for the whole person and to see them as just that; a whole person, not just a patient or diagnosis. Holistic nursing care involves healing the mind, body, and soul of our patients. Holistic care is a philosophy; it's a method to ensure care for all parts of a patient. Interaction with school-aged children: Powerpoint: • Wearing a properly fitting helmet is important for bicycle safety. • Delight in developing new skills. • Enjoy competition and working with others to accomplish goals. • Become capable of making judgments based on reasoning, rather than on just what they see. • Develop the ability to classify objects. School-age Child: Industry versus inferiority (Erickson) psychosocial Concrete operations (Piaget ) Cognitive School-age children: •Delight in developing new skills. •Enjoy competition and working with others to accomplish goals. •Become capable of making judgments based on reasoning, rather than on just what they see. •Develop the ability to classify objects. NURS 360-FINAL STUDY GUIDE EXAM Preschool child behaviors: Powerpoint: ⟶ Some warning signs of abuse include the following: • Physical evidence of abuse or neglect, including previous injuries • A vague explanation of how an injury occurred, or failure to offer any explanation at all • An explanation that is inconsistent with the pattern, age, or severity of the injuries • Markedly different stories from different witnesses about how an injury occurred Aggression is behavior that hurts a person or property. Preschoolers often exhibit aggressive behavior. Ways to avoid or minimize aggressive behavior include: • Limit exposure to media to 1 to 2 hours per day. • Discourage television viewing for children under age 2. • Remove televisions, Internet connections, and video games from children’s bedrooms. • Monitor television programs that children are watching. • View television programs with children to monitor content. • Encourage alternative activities to television, such as athletics, hobbies, and creative play. Ethnicity and cultural assessment: Cultural refers to learned, shared and transmitted knowledge of values and beliefs, and ways of life of a particular group that generally are transmitted from one generation to another. Influence the individual person’s thinking, decisions and actions in patterned or certain ways. Ethnicity person’s identification with or membership in a particular racial, national, or cultural group and observation of the group’s customs, beliefs, and language. The Giger and Davidhizar transcultural assessment model (2012) is a framework for collecting data related to six cultural domains: 1. communication 2. space 3. social orientation 4. time 5. environmental control 6. biologic variation NURS 360-FINAL STUDY GUIDE EXAM Appropriate charting for domestic violence: • Documentation Concerns: Accuracy and legibility are essential. Use the phrase “patient states” or “patient reports.” Detail new and old physical injuries. Photograph injuries (with patient consent). Coping/Ineffective coping: • Successful coping usually involves both problem- and emotion- focused efforts. • Problem-focused coping techniques are aimed at altering or removing the stressor. • In circumstances in which the problem may not have a solution, emotion- focused coping strategies work to ease the emotional distress associated with a stressful condition. Nervous system response to stress → • Physical signs from sympathetic nervous system stimulation. • Transmits stimuli to brain. • Fear can modify the perception of a stressor. • Hypothalamus has functions to adapt to stress. • Nervous system direct stimulation or release of hormones: Increased HR, cardiac output, blood flow to muscles, dilation of bronchi, increased RR, pupillary dilation. • Immune system response to stress: Pain, vasodilation, swelling, mobilization of WBCs, lymphocytes. • Endocrine system response to stress: Adrenal medulla releases hormones, sympathoadrenal response, hypothalamic-pituitary-adrenal complex, psychological and physiological stressors can trigger HPA, hyperglycemia. • Psychological responses to stress: Age, nutritional status, and genetic inheritance influence response, great variation among individual responses, stress appraisal influences individual response, frequency and intensity of stress exposure account for some differences in responses, personality factors can buffer the impact of stress, resilience, flexibility, resourcefulness, How well an individual copes can modify responses to stress. NURS 360-FINAL STUDY GUIDE EXAM Kubler-Ross stages: Kübler-Ross: Five Stages of Grief Bowlby: Model of Grief Denial Shock and Numbness Anger Searching and Yearning Bargaining Disorganization and Repair Depression Reorganization Acceptance Postmortem care: Powerpoint: • Treat with respect • Follow facility policy • Clean environment • Close eyes (avoid using saline for IV pushes) • Do not remove dentures • Place absorbent pads under patients • Cover with clean sheet or blanket (as if sleeping) • Place pillow under head Administrative Duties After Passing for the RN: • Follow facility policy • Coroner notification • Organ donation network notification • Contact mortuary services for pick up Heart failure nursing diagnosis: Goals for ineffective coping: How to conceive goals for patients: NURS 360-FINAL STUDY GUIDE EXAM Exam Review: 1. Know how to correct hypo/hyper. 2. If someone has a call light and tells you they have pain. What do you do first? ASSESS. 3. Nurse is preparing to teach a 5/7/10 year old.. KNOW ERICKSON. How would you approach them? 4. Real definition of malpractice. What needs to happen? 5. What can cause potassium to go high or low? 6. Review health promotion levels? Which if the best model for a particular scenario? 7. Definition of clear liquid diet. 8. Therapeutic communication. Tell a patient about a care plan you have and patient states they don’t want it. What do you say? 9. Biggest concern with a patient that had a bowel surgery? Dehiscence. 10. 5 rights of delegation 11. Generic nursing diagnosis? Ineffective coping NANDA (No r/t or aeb) 12. Know which lab values you will need to call your provider right away. 13. Patient’s mg level is . Highest priority goal for patient care? 14. What is the disease process that causes? ABG 15. Patient will chronic renal failure, what is the priority nursing diagnosis? 16.What labs do we monitor for renal patient? BUN, Creatine 17. Bed sore – Best intervention for someone who had a particular bed sore? 18.Nasogastric tubes - why, contraindications? Facial trauma, deviated septum 19. What can you delegate to a CNA? 20. Correct written diagnosis for a patient. NURS 360-FINAL STUDY GUIDE EXAM 41. Best way to answer patient that is confused/angry? 42. Basic idea of foods and drinks that can alter people’s lab values. Which food would the nurse encourage the patient choose from the menu? 43. Home care nurse – COPD/oxygen: They have low oxygen. 44. Patient needs to be discharged and is not very well educated. Talk to the patient to their level of education. Laymen’s term. 45. Spiritual distress: Patient is not doing well, ask if patient wants to speak with someone. 46. Best way of evaluation. Remember goals. Goals should be specific and measurable. How do you evaluate a goal? 47.What to do if patient has allergy to blood transfusion? Stop it. 48. Specific gravity, know what it is and normal values. Abnormal are usually caused by what? Patient is not drinking enough water if urine is very yellow, if urine is diluted, patient is drinking enough, 49.Dialysis – don’t give patient too much protein. 50. Side effects of opioids. 51. Know stages of development – Piaget’s. What is the best way to develop a particular skill, where they usually master that skill? What activity does the nurse suggest to parents to approve that. Select all that apply. 52. You have a patient who speaks Bulgarian, you think patient is in pain. Assess pain with a translator and give patient a pain scale. 53. Know risk for infection and choose answer that’s infection! 54. Health promotion and age groups. Women should be getting papsmear at age 21. 55. Know intake and output. Everything that is intake and everything that is output. Select all that apply. 56. Situation where patient has many disease processes and is confused. Best nursing diagnosis for this patient. Has to do with confusion or not being able to remember. 57. Goals do we want for patient with fluid volume excess? 58.Nursing integrated and computers – Informatics. NURS 360-FINAL STUDY GUIDE EXAM 59. Heart failure, nursing diagnosis? 60. Which statement is patient in need of further education? 61. How best ask patient about herbs or supplements? Don’t ask medications. 62. How to delegate care? Who are you going to give what to? 63. Pneumonia and nursing diagnosis. What to prioritize? 64. What do you do to a patient when he is in pain? ADPIE. 65. Taking care of patient who has infection or anemic. What would you look for to see patient has recovered? 66. Postmortem care. 67. Patient on restrictive diet. Religious holiday patient needs to attend. 68. What do you do when you hold medications? Criteria to hold meds? When patient refuses, assess patient and vitals aren’t right. 69. How do we eliminate potassium? 70. What should you do before you give potassium/ calcium? Check labs. 71. Ambulating patient. Safety implement you should do first. 72. Appropriate goal for this patient based on ND given. 73.Patient got ileostomy/facial reconstruction. Patient complains of 9/10 pain. Priority action that should be addressed first? Pain. 74.How would you best prepare and take care of a patient who will die the next day? Answer has to do with your own beliefs. 75. Alternatives – What kind of approach are you using? Holistic?