immobility
The registered nurse is teaching a nursing student about psychosocial effects on patients with immobility. Which statements made by the nursing student indicate a need for further learning? Select all that apply.
1
"Every patient responds to immobility in a same way."
2
"Patients with restricted mobility may have depression."
3
"Impaired mobility can cause social isolation and loneliness."
4
"Immobilization leads to emotional and behavioral responses."
5
"Withdrawn patients often want to participate in their own care."
1, 5
Every patient responds to immobility in a different way. Withdrawn patients often do not want to participate in their own care. Patients with restricted mobility may experience depression. Impaired mobility can cause social isolation and loneliness. Immobilization often leads to emotional and behavioral responses, sensory alterations, and changes in coping.
two patient deaths have occurred on a medical unit in the last month. The staff notices that everyone feels pressured and team members are getting into more arguments. as a nurse on the unit, what will best help you manage this stress?
a)Keep a journal
b) participate in a unit meeting to discuss feelings
c) ask the nurse manager to assign you to less difficult patients
d) review the policy and procedure manual on proper care of patients after death
B
by connecting and meeting with staff colleagues, you can talk about the experiences of caring for dying patients and learn that your feelings are likely shared by others.
Coordinated efforts of the musculoskeletal and nervous systems
body mechanics
cannot be delegated
nursing process, client education, tasks requiring nurse judgement or wound wrapping
whats my middle name
agnes
Which metabolic changes are observed in immobile patients?
1
Increased appetite
2
Increased peristalsis
3
Increased metabolic rate
4
Increased nitrogen levels
4
In an immobile patient, his or her body often excretes more nitrogen that in ingests, resulting in negative nitrogen balance. Immobility disrupts normal metabolic functioning, and causes gastrointestinal disturbances such as decreased appetite and slowing of peristalsis. The metabolic rate decreases in patients with immobility.
A nurse has seen many cancer patients struggle with pain management because they are afraid of becoming addicted to the meds. Pain control is a priority for cancer care. By helping patients focus on their values and beliefs about pain control, a nurse can best make clinical decisions. this is an example of:
a) Creativity
b)Fairness
c) clinical reasoning
d) applying ethical criteria
D
The use of ethical criteria for nursing judgement allows a nurse to focus on a patient's values and beliefs
connects muscle to bone
Tendons
who can RNS delegate tasks to
other RNs, LPNs, and AP
what did shannon regurgitate as a child that she now has an aversion to
peanut butter
Which physiological changes are observed in a patient when the head of a hospital bed is elevated to 60 degrees? Select all that apply.
1
Formation of pressure ulcers
2
Skin remains against the sheets (shearing)
3
Increased blood flow in the blood vessels
4
Blood vessels in the underlying tissues are strengthened
5
Bony skeleton moves forward towards the foot of the bed
1, 2, 5
When the head of the hospital bed is elevated, pressure ulcers often develop within the undermined tissue. When the bed is elevated to 60 degrees, gravity pulls a patient so that bony skeleton moves towards the foot of the bed while the skin remains against the sheet. The blood vessels in the underlying tissue are not strengthened; instead they are stretched and damaged, resulting in the impeded blood flow to the deeper tissues and blood vessels.
A nurse prepares to insert a Foley. The procedure manual calls for the patient to lie in the dorsal recumbent position. The patient complains of having back pain when lying on her back. Despite this, the nurse positions the patient in dorsal recumbent aas the manual recommends and begins to insert the foley. this is an example of:
a) Accuracy
b) Reflection
c) Risk taking
D) Basic Critical Thinking
D
Basic critical thinking is concrete and based on a set of rules or principles such as the guidelines in a hospital procedure manual. This is not Accuracy because that requires use of all the facts, including the patients discomfort. Critical Thinkers would be willing to take risks to try different ways to solve problems; following one basic approach is not risk taking. There was no reflection involved.
force exerted against the skin while the skin remains stationary and the bony structures move (causes pressure ulcers)
shear
five rights of delegation
Make sure you have the right...
-Task
-circumstance
-Person
-Direction/communication
-Supervision/evaluation
whats deirdre favorite candy
reeses
The nurse is teaching a nursing student about various deformities of the spine. Which statements are true about spine deformities? Select all that apply.
1
Scoliosis is the medial deviation and plantar flexion of the foot.
2
Kyphosis is the increased convexity in curvature of the thoracic spine.
3
Kyphosis is the internal rotation of forefoot or entire foot.
4
Lordosis is the exaggeration of the anterior convex curve of lumbar spine.
5
Scoliosis is the lateral S- or C-shaped spinal column with vertebral rotation.
2, 4, 5
Kyphosis is the increased convexity in the curvature of the thoracic spine, which may be caused by rickets, osteoporosis, or tuberculosis of the spine. Lordosis is the exaggeration of the anterior convex curve of the lumbar spine. This can be a congenital condition or a temporary condition as in the case of pregnancy. Scoliosis is the lateral S- or C-shaped spinal column with vertebral rotation. This can be a consequence of numerous congenital, connective tissue, and neuromuscular disorders. The medial deviation and plantar flexion of the foot is called clubfoot and is not a spinal deformity. The internal rotation of forefoot or entire foot is called pigeon toes, and it is not a spine deformity.
By using known criteria in conducting an assessment such as reviewing with a patient the typical characteristics of pain, a nurse is demonstrating which critical thinking attitude?
A) Curiosity
B) Adequacy
C) Discipline
D) Thinking independently
C
Discipline is being thorough in whatever you do. Using known criteria for assessment and evaluation, as in the case of pain, is an example of discipline.
type of equipment that goes on the lower extremities that promotes venous return to the heart
those weird stocking stuff
A nurse on a medical-surgical unit has received change-of-shift report and will care for four clients. Which of the following client's needs may the nurse assign to an assistive personnel (AP)?
A. Feeding a client who was admitted 24 hr ago with aspiration pneumonia
B. Reinforcing teaching with a client who is learning to walk using a quad cane
C. Reapplying a condom catheter for a client who has urinary incontinence
D. Applying a sterile dressing to a pressure ulcer
C
shayla and shannons moms name
joyce
What is the correct order of assessments of patient mobility performed by the nurse?
1.
Walking
2.
Lying position
3.
Transferring to chair
4.
Sitting position in bed
2, 4, 3, 1
Assessment of mobility focuses on range of motion, gait, exercise, and activity tolerance. Generally, the nurse performs the assessment of movement starting with the patient in a lying position, proceeding to assessing sitting positions in bed, then transferring to a chair, and finally walking.
A nurse just started workin gat a well-baby clinic. One of her recent experiences was to help a mother learn the steps of breastfeeding. During the first clinic visit the mother had difficulty positioning the baby during feeding. Agter the visit the nurse considers what affected the inability of the mother to breastfeed, including the mother's obesity and inexperience. The nurse's review of the situation is called:
A) Reflection
B) Perseverance
C) Intuition
D) Problem solving
A
The mother had difficulty breastfeeding first time. The nurse relied on reflection to consider her previous actions and review what was successful and the opportunities for improvement. The nurse has not yet problem solved but might do so after reflection in anticipation of the patient's next clinic visit.
drop of BP when patient changes from supine to standing. Systolic drops 20mmHg, diastolic drops 10 mmHG
orthostatic hypotension
A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? (Select all that apply.)
A. The roommate is up independently.
B. The client ambulates with his slippers on over his antiembolic stockings.
C. The client uses a front-wheeled walker when ambulating.
D. The client had pain medication 30 min ago.
E. The client is allergic to codeine.
F. The client ate 50% of his breakfast this morning.
B, C, D
is ramen a soup or a noodle
noodle