Exam 3

Question 1

R.A.C.E.

Answer 1

Rescue those in danger, Activate alarm system, Confine by closing doors, Extinguish or evacuate as needed.

Question 2

Nursing Diagnoses related to behavior change

Answer 2

Ineffective health maintenance, Health seek behaviors, noncompliance, Knowledge deficit, Decisional conflict, Ineffective management of therapeutic regimen

Question 3

Physiological responses to pain

Answer 3

GI distress, tachycardia, chest pain, dizziness, tachypnea, dry mouth, tremors, diaphoresis, change in B.P.

Question 4

Benner’s Theory

Answer 4

Bottom: Novice (nursing student)
2nd: Advanced beginner (1st yr RN)
3rd: Competent (2-3 yr. RN)
4th: Proficient (Charge Nurse)
Top: Expert (preceptor)

Question 5

List critical thinking indicators

Answer 5

Self aware, genuine, effective communicator, curious, alert, analytical, logical and insightful, confident and resilient, autonomous, careful and prudent, realistic, proactive, courageous

Question 6

T.H.I.N.K.

Answer 6

Total recall, Habits, Inquiry, New ideas, Knowing

Question 7

Nursing Diagnoses for immobility

Answer 7

Activity intolerance, risk for inactivity, impaired mobility, risk for pressure ulcers, self-care deficit, risk for impaired skin integrity

Question 8

Disuse Syndrome

Answer 8

deterioration of body systems as a result of prescribed or unavoidable inactivity.

Question 9

stress incontinence

Answer 9

described as “little dribbling” due to decrease in bladder muscle tone, stimulus (laughing)

Question 10

urge incontinence

Answer 10

feels the urge to go but is not able to get to the bathroom in time due to immobility or decreased bladder muscle control

Question 11

functional incontinence

Answer 11

sudden, unpredictable voiding; often related to dementia or impaired cognition

Question 12

reflex (overflow) incontinence

Answer 12

not aware that bladder is full; common with neurological impairment or spinal cord injury

Question 13

total incontinence

Answer 13

unknown, constant voiding; as soon as urine is produced, it is voided.

Question 14

Bactrim use and side effects

Answer 14

Bacteriostatic - Used to treat UTIs; side effects: N, V, D, cough, SOB, Steven-Johnson’s

Question 15

Pyridium use and side effects

Answer 15

Analgesic - Used to relieve pain related to UTI; side effects: orange urine, headache, GI distress, jaundice

Question 16

This is defined as distended abdomen, anal leakage, with no BM for 3 or more days

Answer 16

fecal impaction

Question 17

7 Elements of Critical Thinking

Answer 17

clinical judgment, clinical reasoning, deliberate informed thought, controlled and purposeful, uses strategies, analyzes data, makes changes

Question 18

List 5 barriers of critical thinking

Answer 18

overuse of the habit mode, anxiety, working under deadlines, overcommittment to principles, lack of confidence

Question 19

List personal characteristics that affected one’s stress response.

Answer 19

hardiness, sense of coherence, resilience, attitude

Question 20

List the 3 Stages of GAS (general adaptation syndrome)

Answer 20

Alarm Reaction - fight/fight
Resistance - mobilize reserves, body coping
Exhaustion - energy expended, illness or fatality occur

Question 21

Nursing Diagnosis for coping, defined as a positive or negative coping mechanism.

Answer 21

ineffective denial

Question 22

Nursing Diagnosis defined as coping by masking issues with negative habits or behaviors.

Answer 22

ineffective coping

Question 23

Labs of importance when assessing for altered physical mobility

Answer 23

calcium, phosphorus, alkaline phosphatase, creatinine, lactate dehydrogenease

Question 24

List Primary preventions for immobility

Answer 24

nutrition, regular activity, ideal body weight, rest

Question 25

List Secondary preventions for immobility

Answer 25

fall risk assessment, skin integrity assessment (Braden Scale), screening for mobiliy

Question 26

Vision disturbance brought on suddenly with excruciating pain, N&V, red eye and vision change.

Answer 26

Primary Angle Closure Glaucoma

Question 27

Vision disturbance that develops over time, presents as tunnel vision.

Answer 27

Primary open-angle Glaucoma

Question 28

Normal Creatinine range

Answer 28

Female: 0.5-1.1 mg/dL Male: 0.6-1.2 mg/dL

Question 29

BUN normal values

Answer 29

10-20 mg/dL

Question 30

Test to deter if there is backflow of the urine into bladder

Answer 30

Urodynamics

Question 31

Typically the last sensory system to disappear in the end of life.

Answer 31

hearing

Question 32

Pattern of breathing characterized by alternating periods of apnea and deep, rapid breathing.

Answer 32

Cheyne-Stokes respirations

Question 33

Vision disturbance presenting as decrease in vision, abnormal color perception, glare, poor night vision

Answer 33

Cataracts

Question 34

Anticholinergic agent used postoperatively to dilate the pupil

Answer 34

Cycloplegia

Question 35

Alpha adrenergic agonist that produces pupilary dilation and reduces inflammation in the eye; typically used postoperatively

Answer 35

Mydriatic

Question 36

It is important to teach patient using cycloplegics and mydriatics to do what?

Answer 36

Wear dark glasses to minimize photophobia and monitor for signs of systemic toxicity (tachycardia, CNS effects)

Question 37

Visual disturbance typically presenting asymptomatic; due to increased or decreased IOP and decrease peripheral vision

Answer 37

Glaucoma

Question 38

List of foods that may block an ileostomy

Answer 38

celery, coconut, coleslaw, mushrooms, corn, nuts, popcorn, raisins, seeds, stringy meats

Question 39

Sufficient oral intake range for adults

Answer 39

1200-1500 mL

Question 40

Normal values for RBCs in Urinalysis

Answer 40

Females: no more than 5 Males: no more than 3

Question 41

Normal lab value for pH of urine

Answer 41

4.5-7.8

Question 42

Immune-mediated disease; body's T cells attack and destory pancreatic beta cells. Manifests as polydipsia, polyuria, polyphagia.

Answer 42

Type I Diabetes

Question 43

What does SPICES stand for when assessing older adults?

Answer 43

Sleep disorders, Problems with eating/feeding, Incontinence, Confusion, Evidence of falls, Skin breakdown

Question 44

An emotional, physical, cognitive or behavioral response to bereavement, separation or loss

Answer 44

Grief

Question 45

Known as complicated grief; overly intense or lasting longer than normal

Answer 45

Pathological grief

Question 46

Occurs when relationship with deceased was ambivalent. Initally not showing pain but feels sadness and guilt about the relationship later.

Answer 46

Conflicted grief

Question 47

No grief present, may occur later when loss is realized.

Answer 47

Absent grief

Question 48

Engaging in detrimental activities during a phase of prolonged grief.

Answer 48

Maladaptive/Dysfunctional grief

Question 49

Using adaptive behaviors to deal with grief

Answer 49

Adaptive grief

Question 50

Involves the intellectual and emotional responses and behaviors by which individuals, families, and communities attempt to work through the proess of modification based on perception of potential loss.

Answer 50

Anticipatory grief

Question 51

Encompasses grief and mourning and demotes emotions and behaviors of a person, group or community suffering a loss

Answer 51

Bereavement

Question 52

Defined as an irreversible loss of all brain function; coma, unresponsiveness, absence of brainstem reflexes and apnea.

Answer 52

Brain death

Question 53

Condition preventing the body from converting certain fats to energy. Mainfests in early childhood as vomiting, lethargy, hypoglycemia.

Answer 53

MCAD deficiency

Question 54

Sign of stress effecting decision making and memory.

Answer 54

Cognitive sign

Question 55

Sign of stress causing increase or decrease in appetite or other coping mechanisms (ETOH, drugs, sex)

Answer 55

Behavioral sign

Question 56

Sign of stress resulting in decreased immune system and an increased risk for cardiovascular disease

Answer 56

Physical sign