Exam #1 10/14/14

Question 1

How does Florence Nightingale define “Nursing”?

Answer 1

as having charge of the personal health of somebody and put the patient in the best condition for nature to act upon him.

Question 2

What is the present definition of “Nursing”?

Answer 2

The protection, promotion, and optimization of health & abilities, prevention of illness & injury, alleviation of suffering through the diagnoses & treatment of human response, & advocacy in the care of individuals, families, communities, & populations.

Question 3

What is Primary Prevention/True Prevention?

Answer 3

True prevention - precedes disease or dysfunction with strategies aimed at reducing vulnerability of a person or population.
(protection from accidents - speed limits, seat belts)

Question 4

What is Secondary Prevention?

Answer 4

Secondary - focuses on people who are experiencing health problems & who are at risk for developing complication or worsening of their condition.
Emphasis is on prompt diagnosis & intervention
(screening strategies - BP testing, annual physical)

Question 5

What is Tertiary Prevention?

Answer 5

Tertiary - occurs when a defect or disability is permanent, irreversible, & stabilized.
Focus is on minimizing effects of the problem and preventing complication/deterioration.
(rehab for stroke, cardiac disease)

Question 6

What is the difference between Passive and Active strategies?

Answer 6

Active strategies are like fluoridation of water or age restrictions on alcohol purchases. These are population driven.
Passive are like choosing a low sodium diet, joining a weight reduction program. These are driven by individual choices.

Question 7

What does NCLEX stand for?

Answer 7

National Council Licensure Examination

Question 8

What are the Institute of Medicines five core competencies to maximize care efforts?

Answer 8

Delivering patient-centered care
Working as part of interdisciplinary team
Practicing evidence-based medicine
Focusing on quality improvement
Using information technology

Question 9

According to Rebecca Hendren, HealthLeaders list of most pressing issues for Nursing in 2012 are?

Answer 9

Advanced degrees are no longer optional
Patient engagement gets real
Patient safety
Cost cutting
Retention

Question 10

What is the Townsend Definition of Self-concept?

Answer 10

The composite beliefs and feelings that one holds about oneself at a given time, formed from perceptions of others’ reactions. The self-concept consists of the physical self, or body image: the personal self or identity: and the self-esteem.

Question 11

What are the Self-concept developmental stages?

Answer 11

Infancy - positive self worth resulting from nurturing
Toddler - eager to gain control & autonomy
Preschool - taking the initiative
School age - industrious with vast intake of knowledge
Adolescence - develop self identity & body image
Middle Age - accepts aging & body changes
Elder - feels positive about past life experiences

Question 12

What are factors the influence self concept?

Answer 12

Body image - how we see ourselves
Self-esteem - the value we place on ourselves
Role performance - our ability to function
Identity - What we project to others

Question 13

What does identity mean?

Answer 13

Sense of uniqueness, individuality

Composed of gender, sexuality, racial, and cultural parameters.

Question 14

What is resiliency?

Answer 14

The ability to harness inner strength to bounce back from adversity.

Question 15

Define Spirituality?

Answer 15

Spirituality is a basic human phenomenon that helps create meaning in the world. Its a way of being & experiencing that comes about through awareness of a transcendent dimension. It is characterized by certain values in regard to self, others, nature, life and whatever one considers to be the Ultimate.

Question 16

What is Religion?

Answer 16

Religion is a concept and a social system supporting group expression and devotional activity. A formal venue for expressing belief in an Ultimate creator.

Question 17

What is Tachypnea?

Answer 17

more than 24 bpm

Question 18

What is Bradypnea?

Answer 18

less than 10 bpm

Question 19

What is Hyperventilation?

Answer 19

Increased rate and depth

Question 20

What is Hypoventilation?

Answer 20

Decreased rate and depth

Question 21

What are Cheyne-Stokes

Answer 21

Alternating deep breaths with periods of apnea

Question 22

What are Agonal?

Answer 22

Last breaths of life

Question 23

Where are Bronchial sounds heard?

Answer 23

Over the trachea and larynx, loud, high pitched, harsh, hollow.

Question 24

Where are Bronchial-Vesicular sounds heard?

Answer 24

Over the main-stem bronchi (below clavicals & scapulae), mod pitch and amplitude

Question 25

Where are Vesicular sounds heard?

Answer 25

Over the lung periphery, low, soft pitched, rustling sound

Question 26

Where are Fine Crackles heard?

Answer 26

Heard mainly inspiratory, discontinous Dry, high pitched popping or crackling Due to movement of air through fluid in the airways and alveoli.

Question 27

What causes Fine Crackles?

Answer 27

Collapsed terminal bronchioles and alveoli snap open, formally known as Rales

Question 28

Where are Coarse Crackles heard?

Answer 28

Heard mainly inspiratory, discontinous | Moist, low-pitched gurgling, bubbling

Question 29

What causes Coarse Crackles?

Answer 29

Air moving through large bronchi and trachea that are intermittently occluded with secretions. Formally known as Rhonchi

Question 30

Where is Senorous Wheeze heard?

Answer 30

Heard mainly expiratory, continous, low pitched, snoring

Question 31

What causes Senorous Wheezing?

Answer 31

Due to narrowing of large airways from secretions, spasms, tumors or swelling Wheezes that clear with coughing indicate secretions.

Question 32

Where is Sibilant Wheeze heard?

Answer 32

Heard mainly expiratory, continous, high pitched, musical

Question 33

What causes Sibilant Wheezing?

Answer 33

Due to narrowing of large & small airways from secretions, spasms, tumor or swelling. When wheezes inspiratory & expiratory indicative of asthma.

Question 34

Where is Pleural friction rub heard?

Answer 34

Heard late expiratory and early inspiratory, continuous, loud grating or creaking sound

Question 35

What causes Pleural friction rub?

Answer 35

Due to inflamed pleura rubbing against each other.

Question 36

Where is Stridor heard?

Answer 36

Heard inspiratory, continuous, crowing, harsh honking wheeze.

Question 37

What causes Stridor?

Answer 37

Due to partially obstructed upper airway.

Question 38

What are the health history questions you might ask your patient during a respiratory assessment?

Answer 38

``` Cough Sputum Shortness of breath Smoking history Chest pain with breathing Past history of respiratory infections Environmental exposures Self-care behaviors ```

Question 39

What are normal respiratory rates for a newborn?

Answer 39

30-70 bpm

Question 40

What are normal respiratory rates for a 1 year old?

Answer 40

20-40 bpm

Question 41

What are normal respiratory rates for a 3 year old?

Answer 41

20-30 bpm

Question 42

What are normal respiratory rates for a 6 year old?

Answer 42

16-22 bpm

Question 43

What are normal respiratory rates for a 10 year old?

Answer 43

16-20 bpm

Question 44

What are normal respiratory rates for 17 & older?

Answer 44

12-20 bpm

Question 45

What are some considerations to take when assessing respiratory?

Answer 45

Child: nasal flaring, accessory muscle use Older Adult: less compliant chest Pregnancy: less space Critical Care: assess from the lung bases up, able to determine extent of fluid or problem

Question 46

What is the Medication Administration Process?

Answer 46

1. The medication is ordered by the physcian 2. Pharmacy verifies medication order 3. Nurse receives meds from pharmacy/or withdrawls meds from pyxis 4. Nurse verifies meds against order 5. Nurse verifies pt ID against MAR 6. Nurse uses 2 ID's 7. Nurse administers meds 8. Nurse documents admin in MAR

Question 47

What are the 6 rights for Safe Medication Administration?

Answer 47

``` Right medication Right dose Right patient Right route Right time Right documentation ```

Question 48

What is considered Therapeutic effect?

Answer 48

Intended effect of medication

Question 49

What is considered a Side effect/adverse reaction?

Answer 49

Unpredictable or unexplainable response to medication

Question 50

What is considered an Adverse effects?

Answer 50

Undesired, unintended, unpredictable response

Question 51

What is considered a Toxic effect?

Answer 51

Potential to cause injury or death

Question 52

What is considered a Idiosyncratic reaction?

Answer 52

Over or under reaction to the medication

Question 53

What is considered an Allergic reaction?

Answer 53

Immunological sensitivity to the medication