Age Related
List one normal sign of aging related to the integumentary system.
Thinning of the skin.
Give an example of subjective data.
Anything the patient tells you (history, allergies, feelings, pain).
What does ISBARR stand for?
Introduction-Situation-Background-Assessment-Recommendation-Readback.
The nutrient your body needs to promote regular bowel movements.
Fiber.
What parts of the nursing process can the nurse delegate?
None.
Lasts for typically >6 months.
Chronic pain.
Most important nursing action to prevent pressure injury.
Turn every 2 hours.
Group of members who share a common cultural heritage.
Ethnicity.
What are the health concerns of older adulthood?
Cancer and chronic diseases.
Give an example of objective data.
Anything you the nurse assess (vital signs, BMI, physical assessment findings, information obtained from chart review).
You have committed a medication error, what do you do?
Complete an incidence/occurrence report.
Bowel elimination pattern commonly associated with taking antibiotics.
Diarrhea.
Agency that defines the scope of practice for nurses.
State board of nursing (BON).
True or False: Vital signs are the best indicator of pain.
False - patient self report is.
Type of injury has a wound base that is unable to be visualized.
Unstageable pressure injury.
Religion that anoints the sick or provides last rights when a patient is dying.
Catholics.
Domestic violence is common in what age group of adults?
Young adults.
Which type of assessment is performed to determine discharge needs and functional status?
Special needs assessment.
What you tell your neighbor who asked you to look in their chart while they are in the ED where you work?
No, this is a violation of privacy and confidentiality (HIPAA).
Bowel diversion that bypasses the large intestine.
Ileostomy.
What type of healthcare delivery system is limited in provider options?
Healthcare maintenance organization (HMO).
How is neuropathic pain typically described?
Sharp, radiating, or shooting pain that follows nerve pathways.
Osteoporosis is caused by what mineral deficiency?
Calcium (and Vitamin D)
True or False: It is safe to say that all people of a culture share the same beliefs and practices.
False.
What is the second leading cause of death in older adults and when should it be screened for?
Cancer; annually.
What should evaluation occur?
During implementation after interventions are performed.
What should the nurse say to her coworker if both side rails are up for a patient with normal mental capacity?
This is considered a restraint.
Leading cause of UTIs in hospitalized patients.
Indwelling foley catheters.
What does an ethical nurse do?
Practice based on professional standards and participate in ethical decision making.
How is pain tolerance different from the pain threshold?
Pain tolerance - max amount of pain a person can tolerate. Pain threshold - point at which pain is being felt.
Patients with what disease process should limit protein intake?
Liver disease.
Define assimilation.
A person from a different culture adopts the practices of the new dominant culture.
What law is important to follow when working with an older adult who is a victim of physical abuse, neglect or financial exploitation?
Mandatory Reporting Law.
Give an example of a direct nursing care intervention.
Emotional support, teaching, physical care (administering medications, turning/positioning the patient).
What should you do when the patient and the medical record have conflicting information on allergies?
Clarify the allergy with the patient and determine reaction.
What is a key teaching point for urinary stress incontinence?
Kegel exercises.
What is the difference between battery and libel?
Battery is physical assault and libel is written or published form of slander.
What change in vital signs might you see when assessing someone with activity intolerance?
Elevated HR and BP.
Nutrient essential for muscle contraction, acid/base balance, and blood pressure control.
Potassium.
Type of data defined as numbers and used to generalize results about a group of people.
Quantitative data.
Give an example of abnormal signs of aging.
Memory loss, infection, incontinence.
What are the 3 components of an actual nursing diagnosis?
Diagnosis + etiology + defining characteristics.
An act done on behalf of the client.
Indirect nursing intervention.
What type of incontinence would be seen if there is an obstruction between the bladder and the urethra?
Overflow incontinence.
An error of omission or commission.
Negligence or malpractice.
When moving obese patients, the nurse should do what to prevent back injury?
Get assistance, use a mechanical lift, make sure wheels are locked on the bed.
Healing by what intention makes a wound more prone to infection?
Secondary.
What does PICOT stand for?
Problem/Population
Intervention
Comparison
Outcome
Time
Name a screening done at the annual exam during middle adulthood?
lipid panel screening (total cholesterol, triglycerides, HDL, LDL, ratios), blood glucose screening, breast/pelvic exams for women, DRE and prostate exams for men, annual eye exam, colorectal cancer screening, osteoporosis screening
What are the goals for NANDA diagnoses for an actual problem?
To resolve the health issue.
List one action the nurse can take when documenting electronically to protect client information.
Log off the computer when finished.
Do not share username and password.
Do not leave patient information on the screen if you walk away.
Name one way a sterile urine specimen can be obtained.
If they have a foley - through the side port.
If able to void, cleanse the genitalia, start urine stream then obtain specimen midway through.
What are the six ethical principles?
Veracity, fidelity, autonomy, beneficence, maleficence, justice.
How does the center of gravity relate to the base of support?
The line of gravity passes through the middle of the center of gravity to the base of support (which must be close to the base of support).
External factor that contributes to the formation of pressure ulcers.
Friction and shearing forces.
Function or component of family development theory.
Reinforcing ethical and moral values.
Promoting joint decision making between parents and children.
Maintaining support for young adults.