Fundamentals Flashcards

Question

What are the 4 areas of routine self-care?

Answer 1

Bathing Feeding Toileting Dressing

Answer 2

Performance of routine self-care

Answer 3

Keeps skin intact & healthy Prevents infection Removes oils, perspiration, and bacteria Increases circulation Promotes relaxation & comfort Promotes sense of well being

Answer 4

True. Rationale: most important to promote independence.

Answer 5

Environment Motivation Mental health Cognitive abilities Energy Pain Acute illness Surgery Neuromuscular function Sensory deficits

Answer 6

Energy Rationale: chronic respiratory issues would lead to lack of energy. Motivation & Cognitive factors would have to be further assessed.

Answer 7

Poor hygiene/grooming Not able to demonstrate self care Says they don’t want to or shows reluctance

Answer 8

Bathing/hygiene self-care deficit Feeding self-care deficit Dressing/grooming self care deficit Toileting self care deficit

Answer 9

Active participation in hygiene measures Increased level of independence eating Active participation in dressing Managing toileting as independently as possible

Answer 10

Scheduling care assistance Bathing and skin care- methods of bathing Perineal care Sits bath Back massage Foot care Hair care- shampooing Shaving Feeding Toileting- beside commodes, urinals, bedpans, condom cath

Answer 11

True. Rationale: usually lasts 20 mins; take care not to burn pt

Answer 12

Bathing: no slip mats, hand rails, shower chairs Grooming/dressing: sit down, wear easy to put on clothes, nonslip shoes Food prep: easy make, good food choices, encourage rest before and after Toileting: hand washing, commodes, urinals, hand grips

Answer 13

Fundamental to daily living, & ADL performance Important for stress release, protection, an self concept Vital to musculoskeletal system

Answer 14

Bones Muscle Joints

Answer 15

Framework for muscles, tendon, ligaments to attach

Answer 16

Striated, long muscle fibers connect at or across joints

Answer 17

Areas where bone meets bone; ligaments/tendons connect and support joints.

Answer 18

Alignment/posture Balance Coordinated movement

Answer 19

Uses alignment, posture, and balance to coordinate efforts to perform activities

Answer 20

A. Limbic system Rationale: it is involved w/ the processes of motivation, emotion, learning, and memory.

Answer 21

D. Athetosis Rationale: ataxia is impaired muscle coordination. A tremor is rhythmic repetition movement. Chorea is spontaneous, brief, and involuntary muscle twitch

Answer 22

Exercise, work type, leisure activities Satisfaction w/ activity level Rating scale of independence level

Answer 23

Assess for weakness/fatigue/distress after exercise or activity Assess fall risk Assess for present/chronic health probs

Answer 24

X-ray Arthrograms Myelograms Bone mineral density testing Arthroscopy (exam of joint w/ fiber optic instrument) Hematocrit (HCT) Hemoglobin (HgB)

Answer 25

Shear Rationale: happens when immobile, because friction anchors to sheets/other surfaces; deeper structures move with pt

Answer 26

Hemostasis (coagulation) Inflammatory (assist & prevent) Proliferation (rebuild) Maturation (healed)

Answer 27

True. Rationale: minimal tissue loss (clean surgical incision/shallow wounds) heal by primary intention

Answer 28

Constantly moist

Answer 29

False Rationale: cold= constriction, heat= dilation; decreases circulation to compromised area

Answer 30

Ab. Affective Rationale: affective learning= learning aimed at changing: Beliefs Attitudes Values

Answer 31

Health & wellness promotion: Allows increase in health control for pt Associated with lifestyle choices increasing wellness

Answer 32

D. Health literacy level Rationale: Devon failed to take # of servings into consideration; got correct # of contained calories, showing some literacy

Answer 33

C. Return demonstration Rationale: nurse observes pt performing new skill; teachback= pt attempts to teach info back to nurse; simulation= uses models for demonstrating

Answer 34

False: Rationale: health promotion behavior= general behavior or make health better; not specific

Answer 35

False. Rationale: fat soluble is stored; water soluble is excreted

Answer 36

A. Imbalanced nutrition: less than body requirements Rationale: intake is more likely from poor dentition & pain from sores

Answer 37

D. Carbs Rationale: not discrete category created for carbs

Answer 38

A. Rationale: other choices doesn’t reduce lung movement as much

Answer 39

B. Rationale: fremitus= vibration of air movement through chest wall, best felt by placing palm on back and having pt say 99

Answer 40

False. Rationale: measures Arterial O2

Answer 41

False. Rationale: O2= drug

Answer 42

False Rationale: Self-concept is the mental image a person has of oneself. Self-perception is how a person explains behavior based on self-observation.

Answer 43

False Rationale: Intrapersonal role conflict exists when role expectations conflict with the person’s values. Interpersonal role conflict exists when the person’s expectations differ from those of a significant other.

Answer 44

A. Assessment Rationale: Asking questions during a patient history is a part of the assessment phase of the nursing process. Outcome identification is done with the help of the patient after assessment and formulation of nursing diagnoses. Health promotion is a method of care plan implementation. Evaluation is done to measure the attainment of goals.

Answer 45

True Rationale: Persons themselves define who is in their family; physical location alone does not define family membership.

Answer 46

Emotional problems Rationale: Retired persons are more prone to the emotional problem of depression. Role strain usually is manifested when additional roles are given to people in addition to those already existing. Abuse often is a result of unhealthy life style such as substance abuse. Isolation is a manifestation of the family’s difficulty in communicating with a family member.