Nursing Process
Alcohol, caffeine, or drugs are high risk factors that all fall under which broad classification of risk factors?
Psychosocial
Psychosocial risk factors include life style choices like the use or abuse of alcohol, caffeine and illicit drugs in addition to smoking and psychological status. Low income, age, and ethnicity are social demographic risk factors. Second hand smoke and air pollution are environmental risk factors; and biophysical risk factors include genetic considerations, nutritional status and disorders such as diabetes.
As you are working you suspect that another licensed practical nurse is verbally and physically abusing a patient. What is the first thing that you will do?
Report your suspicions to the charge nurse
Nurses and other healthcare providers are mandated by law to report all suspected abuse and neglect. You do NOT have to be certain about it; an expert will perform the investigation. You do not contact the police or the security department; the charge nurse will follow established procedures for notifications not the licensed practical nurse.
The treatment of swallowing disorders
Speech and language therapist
Ill health, malnutrition, and wasting as a result of chronic disease are all associated with
Cachexia
When caring for an infant during cardiac arrest, which pulse must be palpated to determine cardiac function?
Brachial
During which phase of the nursing process does data get collected and validated with the patient and/or family members by the nurse?
The assessment phase
Subjective, objective, primary and secondary data is collected and validated with the patient and/or family members by the nurse during the assessment phase of the nursing process. The implementation phase is the actual care of the patient; the evaluation phase includes the comparison of current data to expected outcomes to determine if the patient has achieved the pre-established goals and the planning phase consists of priority setting and care planning.
Who should document care?
All staff members should document all of the care that they have provided.
You have just learned that another nurse was fired for taking photographs of patients without their permission using a cell phone and posting them on Face book. This nurse was fired because the nurse has:
This nurse was fired because the nurse has violated a federal law, namely, the U.S. government’s Health Insurance Portability and Accountability Act (HIPAA). This law protects the patients’ rights to the privacy and confidentiality of all medical information, including written, oral electronic information, and personal identity information like photograph taking unless the client has expressly consented to it in writing. Negligence is failing to do something in the proper manner; this invasion of patient privacy is far more serious than a breach of an ethical principle. Lastly, photographs and Facebook posting should never be done so proper documentation is not required. It is still illegal documented or not.
Which of the following is a vector of infection?
An infectious fly is an example of a vector that can transmit infection. Other vectors, or nonhuman living beings that can transmit infections to humans, include mice, vermin and mosquitoes. Inanimate items that can spread infection by contact are referred to as fomites. Examples of fomites include a contaminated thermometer, balls and door knobs. An infected human being is a host according to the chain of infection and not a vector.
What is the World Health Organization’s (WHO) definition of health?
A holistic state of wellbeing
The World Health Organization (WHO) defines health as a holistic (wholistic) state of wellbeing. This state of wellbeing is far more than the absence of illness, diseases and comorbidities. Lastly, the use of health promotion activities does promote health but these activities do not define health according to the World Health Organization.
Which of the following is the best worded expected outcome?
“The patient will cough and deep breathe every two hours”
This outcome or goal is specific, measurable, achievable, realistic, within a specified timeframe, trackable and it should be agreed to by the patient. All expected outcomes are worded in terms of what the patient, not the nurse, will do and it should also be specific and measurable. “The patient will value health” is not measurable.
You have been asked to speak at a new nursing assistants' orientation class about infection control and handwashing techniques. What would you include in this teaching?
Demonstrate the correct 2 minute handwashing procedure using soap and running water.
The best way to teach the techniques of handwashing is to actually demonstrate the correct handwashing procedure. Proper handwashing must be done for a minimum of two minutes. Warm not cold water or hot water is used for handwashing.
Which of the following is best for a client who has difficulty swallowing and chokes frequently?
Tucking the chin in when swallowing.
The client should tuck the chin when swallowing rather than tilting the head back. Thin fluids and liquids, like water, are thickened prior to drinking to prevent chocking. Tilting the head back is dangerous.
You are caring for a patient with multiple-trauma. Of all of these injuries and conditions, it the most serious?
A deviated trachea
A deviated trachea is a serious life threatening condition. A deviated trachea is a symptom of tension pneumothorax which can be life threatening.
What intervention is the best to relieve constipation?
Increasing the consumption of fruits and vegetables
Which nursing diagnosis is the most commonly used among patients who are affected with fibromyalgia?
Decreased self care in the activities of daily living related to fatigue
The signs and symptoms of fibromyalgia include widespread aching, muscle stiffness, fatigue and sleep disorders. The degree of fatigue can be so severe that the patient is unable to even perform the activities of daily living. Fibromyalgia, a chronic disorder associated with periods of exacerbation and remission is not associated with a swallowing disorder, hypervigilance, mental functioning alterations or electrolyte imbalances.
What is the single most important thing that nurses do in order to prevent the spread of infection?
Handwashing
Help injured or ill people improve their movement and manage their pain. These therapists are often an important part of rehabilitation, treatment, and prevention of patients with chronic conditions, illnesses, or injuries.
Periwound maceration occurs when:
The skin around the wound softens and is damaged.
Periwound maceration, also classified as moisture associated skin damage, is the softening of the skin and damaging of connective fibers which leads to the wound drying out and hardening. Dressing selection can help prevent this complication, and negative pressure may reduce it by reducing edema.
Number the choices below to reflect the correct sequence for using a fire extinguisher:
A. Aim at the base of the fire
B. Squeeze the handle
C. Sweep back and forth
D. Pull the pin
D, A, B, C
What is SOAPIER?
Subjective, Objective, Assessment, Planning, Implementing, Evaluating, Reassessing
Your long term care patient has chronic pain and at this point in time the patient needs increasing dosages to adequately control this pain. What is this patient most likely to be affected with?
Drug tolerance
Patients with chronic pain are often affected with drug tolerance. Drug tolerance occurs when the patient needs increasing dosages of analgesic medications to adequately control their pain in order to produce the same effect that was produced when the drug was originally begun. Drug addiction, on the other hand, is a constant and compulsive need for a drug even when the use of the drug causes harm to the person. Addiction can occur with or without physical dependence. The need for increasing dosages is not the result of medication side effects or food/drug or drug/drug interactions.
are responsible for helping individuals, families, and groups of people to cope with problems they're facing to improve their patients' lives.
Social Worker
Which of these patients is affected with a healthcare acquired infection?
A 5 year old pediatric patient who develops the measles rash 3 days after admission
A 18 year old male patient who developed a intravenous line infection two days after insertion
A 18 year old male patient who developed a intravenous line infection two days after insertion
The 18 year old male patient who developed a intravenous line infection two days after insertion is affected with a healthcare related, or nosocomial, infection. These infections include all infections that occur while the patient is receiving healthcare services. The patient who was admitted with a urinary tract infection and the pediatric patient who develops the measles rash 3 days after admission acquired these infections prior to receiving healthcare services so they are not considered healthcare related, or nosocomial, infections. Lastly, the 72 year old male patient who is at risk for infection secondary to AIDS/HIV has not yet been infected; he is simply at risk for infection.
Your 54 year old male HIV positive patient has just expired. How should you care for this deceased patient?
Bathe the patient using the same standard precautions you used when he was alive.
You should bathe your patient as part of post mortem care using the same standard precautions that you did when the patient was alive. The patient is still infectious. Similarly, all patients are bathed after death using standard precautions. Double shrouding and an isolation area in the morgue with negative air pressure are not necessary.