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fundamentals exam 3 > fundamental exam > Flashcards

fundamental exam Flashcards

1
Q

What are ways that a nurse can assess a patient’s oxygenation// breathing?

A

Pulse ox
Listening to lungs
Respiration Rate

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2
Q

What assessmet finding would lead to an intervention of applying oxygen to a patient?

A

Pulse ox falls below 89%
Aterial oxygen pressure falls below 60mmHg

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3
Q

What is Atelectasis?

A

Collapse of partial or full lung

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4
Q

What are some nursing interventions that can help prevent atelectasis?

A

Deep Breathing
Proper use of incentive spirometer
Chest physiotherapy

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5
Q

What is normal respiratory rate?

A

Between 12-20

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6
Q

What is dyspnea?

A

Shortness of breath

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7
Q

What happens to the respiratory rate if the body has an increased demand for oxygen?

A

Breathing rate increases
Heart beats faster

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8
Q

If someone is dyspenic & has an elevated respiratory rate, what simple interventions could you offer?

A

Deep breathing
Changing positions

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9
Q

How would you manage care for patients with poor oxygenation?

A

Coughing techniques
Deep breathing
Supple of oxygen through nasal cannula or face mask

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10
Q

What does a nursing diagnosis of impaired gas exchange mean?

To make this nursing diagnosis, what may we assess?

A

a disruption of oxygen and carbon dioxide exchange in the lung tissues

Assess: pulse ox, cardiac function, bloodwork, arterial blood gasses

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11
Q

What is right-sided heart failure?
What are the symptoms of it?

A

Right ventricle is too weak to pump enough blood to the lungs

Symptoms: shortness of breath, swelling in your ankles, dizziness, fatigue, swelling

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12
Q

What is left-sided heart failure?
What are the symptoms of it?

A

Left ventricle of the heart no longer pumps enough blood around the body

Symptoms: coughing, shortness of breath, swelling in your ankles, & weight gain

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13
Q

When do we use a nasal cannula vs face mask to deliever oxygen to a patient?

A

Nasal cannula: experiencing minimal respiratory distress

Face mask: for patients who need LARGE amounts of oxygen at once; needs constant level of oxygen

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14
Q

What are some interventions to help thin secretions?

A

Deep breathing
Chest physiotherapy
Supplemental humidication
Changing positions
drinking fluids

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15
Q

What is intracellular space?

A

Everything inside of the cell membrane

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16
Q

What is extracellular space?

A

everything outside of a cell

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17
Q

What are signs & symptoms of specific electrolyte imbalances?

A

Cold clammy skin
Hypotension
Dizziness
Sudden weight loss
Tachycardia

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18
Q

What are the normal rangs of lab values for electrolytes?

A

Potassium: 3.5-5.0
Sodium: 135-145
Calcium: 8.6-10.3
Magnesium: 1.7-2.2

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19
Q

What is clinical dehydration? And nursing interventions for it

A

Absence of sufficient amount of water in your body

Nursing interventions: encourage fluid intake & IV fluids

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20
Q

What are nursing interventions for fluid retention?

A

Record intake & output
Administer diuretics
Enforce fluid restrictions

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21
Q

What is respiratory acidosis?

A

Lungs cannot remove all of the carbon dioxide produced by your body

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22
Q

What is respiratory alkalosis?

A

low carbon dioxide levels disrupt your bloods acid-base balance

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23
Q

What is metabolic acidosis?

A

Buildup of acid in the body due to kidney disease or kidney failure

24
Q

What is metabolic alkalosis?

A

the body pH is greater than 7.45 secondary to some metabolic process

25
Q

How do we assess electrolytes & acid-base imbalances?

A

Labwork, ABG & serum electrolytes to determine acid-base imbalances

26
Q

How do we assess sleep; what would you ask a patient?

A

Sleep study
Has anyone told you snore?
What is your sleep schedule?
Sleep pattern?
Do you snore?

27
Q

What are some risk factors & signs for obstructive sleep apnea? How is it treated?

A

Loud snoring
Daytime sleepiness

Type 2 Diabetes
High blood pressure
Obese
Males
Congestive heart failure

Treated - CPAP machine

28
Q

What are some nursing interventions used to promote sleep in care setting?

A

Provide comfort setting
Encourage using the bathroom before sleeping
Make sure the environment is dark & quiet

29
Q

Examples of bad communication

A

Being insensitive
Not letting the patient express how they are feeling
Shrugging them off
Not being sympathetic

30
Q

Examples of good communication

A

Active listening
Showing respect
Presence
Honesty
Showing sympathy
Acknowledge the patients feeling

31
Q

Types of grief

A

Normal
Anticipatory
Disenfrachised
Complicated

32
Q

What makes complicated grief a concern for clients?

A

Someone can become depressed & more anxious
Physical & mental health could become worse

33
Q

Types of Loss

A

Actual loss: loosing someone, loosing a part of body

Perceived loss: loss of independence; less obvious to people

34
Q

What is palliative care?

A

Focuses on the prevention,relief, and reduction of symptoms

Goal is to help achieve the best possible quality of life

Patient can opt to get treatment of care

35
Q

What is hospice care?

A

6 months or less to live

Focuses on the care of terminally ill patients

Goal is to manage pain, provide comfort, ensure quality of life

Prioritize care according to patient wishes

36
Q

What is advanced directive?

A

A written statement of a persons wishes regarding medical treatment when they become incapable
( example: DNR)

37
Q

What are the 5 stages of grief & the behaviors shown?

A

Denial: you go numb, do not believe anything in your life

Anger: mad at everything

Bargaining: false hope

Depression: feel isolated, sad

Acceptance: emotions stable; you re-enter reality; come to accepting

38
Q

What are some physical signs of impeding death?

A

Irregular/shallow breathing
Lowered blood pressure
Loss of sensation in arms & legs
Rapid pulse
urinating less/ difficutly to urinate

39
Q

How would you approach/ communicate with unconscious patient who is dying?

A

Open-ended questions
Therapeutic communication
Talk to them

40
Q

What is General Adaptation Syndrome?

A

the process your body goes through when you are exposed to any kind of stress

41
Q

What are the stages of general adaptation syndrome?

A

Alarm stage: fight or flight
- Dilated pupils, increased heart rate, rapid breathing

Resistance stage; your body tries to repair itself after a shock of stress
- Headache, bowel issues, poor concentration, sadness

Exhaustion stage: dealing with stressors without relief to the point where your body cannot cope with stress
- burnout, fatigue, decreased stress tolerance

42
Q

What are some general reactions to stress?

A

Coping & defense mechanism

43
Q

What is a caregiver burden?

A

Stress associated with the demands of caring for someone with physical or mental impairments

44
Q

What are some nursing interventions for clients with stress/ anxiety?

A

Let them talk out how they are feeling
Acknowledge how they are feeling
Provide active listening

45
Q

Examples of healthy coping strategies

A

Exercising
Support systems
Journal writing
Drawing
Relaxation techniques

46
Q

Examples of non-healthy coping strategies

A

Isolating
Drinking
Self harm
Drug use

47
Q

What is anxiety (nursing diagnosis)

A

vague, uneasy feeling of discomfort or dread accompanied by an autonomic response; a feeling of apprehension caused by anticipation of danger

48
Q

What is sensory deprivation?

A

Inadequate quality or quanity of stimulation
example: being isolated, not having enough of something

49
Q

What is sensory overload?

A

Reception of multiple sensory stimuli
example: too much lights, too much music

50
Q

How cognitive response for a patient with sensory deprivation?

A

Depression & loneliness & be more confused

51
Q

How cognitive response for a patient with sensory overload?

A

Anxiety & feeling overwhelmed

52
Q

What interventions can a nurse offer for each?

A

Dim the lights & reduce noises
Talk to patients so they do not feel isolated

53
Q

What are some examples of sensory deficits & how can we improve communication with patients who have these deficits?

A

Examples of sensory deficits: deaf, blind, hearing impairement, vision impariment

Turn your face towards the patient, Speak clearly, do not shout or over exagggerate words or lip movements

54
Q

What is the difference between dementia & delirium?

A

Dementia: more permanent; gradually progressives over time

Delirium: temporary; medication can cause someone to be delirium

55
Q

types of loss

A

actual loss ( loosing someone, loosing your breast due to breast cancer, loosing ur limb)

perceived loss ( loss of independence)

situational loss ( loss of job)

56
Q

Sensory deficits:
Deficit in the normal function of sensory reception & perception
(example: someone that cannot hear or see)

Sensory deprivation
Inadequate quality or quantity of stimulation
(example: someone who is on bedrest, being isolated, not having enough of something)

Sensory overload
Reception of multiple sensory stimuli
(example: too much happening at once)
(anxiety is a concern when it comes to sensory overload)

A

fundamentals exam 3 (1 decks)

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