Mobility
This gait pattern moves: right crutch → left foot → left crutch → right foot.
What is the 4-point gait?
This sleep stage includes hypnic jerks and is the lightest sleep.
What is NREM Stage 1?
This pain scale is commonly used for children and uses illustrated faces to show pain level.
What is the Wong-Baker FACES Scale?
This is the most serious complication of TPN
What is infection/sepsis?
“Good stress” that motivates you is called what?
What is eustress?
Name two risks for skin breakdown.
What are immobility, incontinence, poor nutrition, or decreased sensation?
Name two interventions for promoting sleep.
What is cluster care, decrease noise, warm milk, relaxation techniques, avoid caffeine?
During infection, this lab value increases above its normal range of 5,000–10,000.
What is WBC count?
This lab drops early and is the earliest sign of malnutrition.
What is prealbumin?
This defense mechanism involves acting like an earlier developmental stage.
What is regression?
After hip surgery, the patient should never bend more than this angle.
What is 90 degrees?
During REM sleep, this vital sign pattern happens.
What are increased and irregular HR, BP, and RR?
Give one example of a nonpharmacologic pain intervention.
What is heat, cold, guided imagery, meditation, massage, repositioning, or distraction?
When checking NG tube residual, feeding should be held if the amount is greater than this.
500ml
During the alarm stage of GAS, these hormones spike.
What are epinephrine and cortisol?
List two complications of immobility affecting different body systems.
What are pneumonia, constipation, clots, muscle atrophy, pressure injuries, orthostatic hypotension, depression?
The greatest long-term concern with chronic insomnia is this type of body damage.
What is weakened immunity or cardiovascular/metabolic disease?
This type of precaution requires N95 masks and a negative pressure room.
What are Airborne precautions?
A clear liquid diet includes this fruit juice that is not orange juice.
What is apple, grape, or cranberry juice?
List three physiologic changes from the fight-or-flight response.
What are ↑HR, ↑RR, ↑BP, ↑glucose, dilated pupils, muscle tension?
Case Study:
A 76-year-old patient is recovering from abdominal surgery. She has been on bedrest for 3 days. When you help her stand for the first time, she becomes dizzy, says her legs feel weak, and begins to sway. You also notice her heels are red, and she reports constipation.
Question:Based on the nurse’s assessment, list THREE complications of immobility this patient is likely experiencing, and identify ONE intervention for each.
Orthostatic hypotension
Intervention: Allow her to sit and dangle legs before standing; stand slowly; monitor BP.
Muscle weakness / atrophy
Intervention: Encourage ROM exercises, assist with ambulation using a gait belt, use walker/cane if needed.
Pressure injury risk (heel redness)
Intervention: Reposition every 2 hours, use heel protectors, keep skin clean/dry.
Constipation (GI stasis)
Intervention: Increase fluids if allowed, fiber, ambulation, stool softeners as ordered.
A 45-year-old patient reports,
“I can’t stay asleep at night. I wake up multiple times, and during the day I feel irritable, tired, and can’t focus.”
You walk in at 10 PM and notice:
The TV is on loudly
The room lights are still on
The patient is drinking a soda
Their phone is in their hand
They napped for 2 hours earlier that afternoon
Question:
Based on the assessment, identify THREE factors negatively affecting this patient’s sleep and list ONE intervention for each.
Caffeine before bed (soda)
Intervention: Avoid caffeine, alcohol, and heavy meals before bedtime.
Screen use before sleep (phone/TV)
Intervention: No screens 30–60 minutes before bed; create a quiet environment.
Bright lights and noisy environment
Intervention: Dim lights, turn off TV, reduce noise.
Long daytime naps (2 hours) (bonus)
Intervention: Limit naps to 20–30 minutes.
No bedtime routine (bonus)
Intervention: Encourage relaxing routines—reading, warm bath, deep breathing.
A patient with suspected meningitis is coughing, febrile, and confused. Provider has NOT confirmed the organism yet.
Question:
What isolation precautions should start immediately?
Droplet precautions (meningitis until proven otherwise).
A 68-year-old patient is admitted for unintentional weight loss and poor nutritional intake. He has a history of dysphagia (difficulty swallowing) and frequently coughs during meals. Labs show low albumin and hemoglobin levels. He is currently on a pureed diet and requires assistance with feeding.
Question:
Identify two nutritional risks this patient faces and provide one intervention for each.
Malnutrition (low albumin, low hemoglobin):
Intervention: Provide high-calorie, high-protein supplements if ordered, and monitor nutritional labs regularly.
Aspiration due to dysphagia:
Intervention: Sit the patient upright (90°) during meals, use thickened liquids as ordered, and provide feeding assistance to reduce the risk of aspiration.
A 30-year-old nursing student is feeling overwhelmed during finals week. She reports difficulty concentrating, frequent headaches, and trouble sleeping. She states she feels anxious and keeps worrying about failing her exams. She's been skipping meals and relying on energy drinks to stay awake.
Question:
Identify two stress-related symptoms she is experiencing and provide one healthy coping intervention for each.
Anxiety and difficulty concentrating:
Intervention: Use relaxation techniques (deep breathing, guided imagery), and break study sessions into manageable chunks.
Physical symptoms like headaches and poor sleep:
Intervention: Encourage good sleep hygiene (consistent bedtime routine, limit caffeine/energy drinks), and take short breaks for healthy meals.