Ch 33 & 34
This is how a person thinks/views self.
Self-concept
Assess: identity, body image, coping behaviors, consider environmental factors, talk to significant others/assess support from significant others, make note of non-verbal cues
Self-esteem is how one feels about self.
Establishing presence in nursing is a process of "being with" a patient vs. "doing for" a patient. The goal is to offer closeness physically, psychologically, and spiritually and prevents emotional and environmental isolation. Name 1 way you can establish presence with a patient.
Sit beside the patient; listen attentively; talk with the patient; accept/support a crying patient/ offer time for the patient; physical touch (massage/hold hand); support patients when making decisions
A person who experiences or witnesses a traumatic event and responds with intense fear or helplessness - possibly with recurrent nightmares, fear of going to sleep, repeated vivid memories, or inability to feel emotion might have this medical diagnosis.
posttraumatic stress disorder (PTSD)
This is the type of bath that can be used if someone cannot perform any of the bath themselves.
Complete bed bath
A partial bed bath would be used if the patient can perform some of the cares but in unable to reach all body parts.
If a person is post stroke with a decreased gag reflex and weakness, name one action that you can take to help feed the patient.
Flex head with chin down; Sit patient upright (Fowler's); Thickened liquids (if ordered); ensure swallow study complete; Place food on strong side
This is a role performance stressor noted with unclear role expectations.
Role Ambiguity
Other role performance stressors to know: role conflict, role strain, role overload
A person who believes that there is no known ultimate reality professes to be this.
Agnostic
Name 1 example of an ego-defense mechanism.
• Compensation: Making up for a deficiency in one aspect of self-image by strongly emphasizing a feature considered an asset (e.g., a person who is a poor communicator relies on organizational skills)
• Conversion: Unconsciously repressing an anxiety-producing emotional conflict and transforming it into nonorganic symptoms (e.g., difficulty in sleeping, loss of appetite)
• Denial: Avoiding emotional conflicts by refusing to consciously acknowledge anything that causes intolerable emotional pain (e.g., a person refuses to discuss or acknowledge a personal loss)
• Displacement: Transferring emotions, ideas, or wishes from a stressful situation to a less anxiety-producing substitute (e.g., a person transfers anger over an interpersonal conflict to a malfunctioning computer)
• Dissociation: Experiencing a subjective sense of numbing and a reduced awareness of one’s surroundings
• Identification: Patterning behavior after that of another person and assuming that person’s qualities, characteristics, and actions
• Regression: Coping with a stressor through actions and behaviors associated with an earlier developmental period
1) Eyes; 2) Face; 3) Arm & Chest; 4) Hands & Nails; 5) Abdomen and legs; 6) Perineum; 7) Back & Buttocks
True
Cleanest (eyes) to dirtiest (buttocks)
As the nurse, you are planning nutrition for an adolescent who plays sports. Name 1 modification that will be included.
Increase carbohydrates from 55% to 60% of total intake; Encourage water intake; Increase protein; Possibly increase iron, but no major alterations to vitamins/minerals
During the nursing process, this is an important consideration to prioritize the nursing diagnosis particularly related to sexual functioning.
Patient/Family preference and their greatest concern should be the priority.
Need a therapeutic relationship established to have those conversations and to build trust and caring.
Name 1 item you will include in a spiritual assessment.
Any topic from Box 35.1: Spirituality & spiritual health; faith/belief/fellowship; life and self-responsibility; life satisfaction; connectedness; vocation
To evaluate a patient's spiritual care, these items will guide the evaluation process:
Review patient's view of purpose in life; ask whether the patient's expectations were met; review the patient's self-perception regarding spiritual health; discuss with family and friends the patient's connectedness
Name 2 healthy stress management techniques.
Support systems - family, friends, colleagues; Time management techniques - blocking time/routines; Guided imagery/meditation/visualization - visualization of peaceful settings; Assertiveness training - practicing skills to communicate their needs/desires; Journal writing; Mindfulness-based stress reduction; Exercise; Healthy eating; Prayer
After retracting the foreskin for perineal care of an uncircumcised male patient, you would make sure to do what next.
Return the foreskin to its natural position.
An individual has a BMI of 21. Name the term that is associated with this number.
Normal weight = 18.5-<25
Overweight 25-<30
Obese >/= 30
The PLISSIT model is used as an approach nurses can use to assess sexuality in patients. Name 1 of the levels of intervention from this acronym.
• Permission to discuss sexuality issues
• Limited Information related to sexual health problems being experienced
• Specific Suggestions—only when the nurse is clear about the problem
• Intensive Therapy—referral to professional with advanced training if necessary
Name 2 types of grief.
Normal grief
Anticipatory grief
Disenfranchised grief (Ambiguous loss is a type of disenfranchised grief)
Complicated grief
- Chronic grief
- Exaggerated grief
- Delayed grief
- Masked grief
p. 785
General Adaptation Syndrome has three stages. Name the three stages.
In order:
Alarm
Resistance
Exhaustion
The patient you are assessing has cracked lips. Name the word you would use to document this assessment finding.
Cheilitis (cracked lips)
Halitosis (foul-smelling breath)
Glossitis (inflamed tongue)
Dental caries (cavities)
Once an feeding tube is placed, tube verification is required. Name the best way to verify tube placement.
X-Ray
*Always have X-ray confirmation to verify tube placement before feeding to prevent pulmonary aspiration.
For an individual who is sexually active, name the contraceptive method you would encourage to help protect against pregnancy and sexually transmitted infections (STIs).
Condom
A patient who has 3 months left to live is desiring care that focuses on care, comfort, and quality of life with an expectation for pain and symptom management and inclusion of the family in the care. Name the care that this individual would best benefit from.
Hospice care (patients usually have less than 6 months to live)
Palliative care focuses on prevention, relief, reduction, or soothing of symptoms of disease/disorders throughout the illness - still focused on quality of life.
Name a sociocultural factor that serves as a potential stressor in any age-group but especially stressful for young people.
Prolonged poverty and physical disability
- children vulnerable to loss of parents/caregivers through divorce, imprisonment, death or parents who have mental illness/substance-abuse disorders
Name 2 types of patients that you would prioritize as most at need of regular perineal care.
Anyone at risk for infection; Pt with rectal/genital surgical dressings; urinary/fecal incontinence; indwelling foley catheter; bariatric patient; uncircumcised male; bed bound patient; patient who just had a baby (childbirth); someone having menstrual cycle
True or false: This is the correct order for the administration of an enteral feeding.
1)Check for gastric residual volume
2) Verify tube placement
3)Elevate the HOB to at least 30 degrees
4) Flush the tubing with 30 mL of water
5) Initiate the feeding
False
Correct order:
1) Elevate head of bed to at least 30 degrees
2) Verify tube placement
3) Check for gastric residual volume
4) Flush tubing with 30 mL of water.
5) Initiate the feeding