Chapter 28
Chapter 29
Chapter 31
Chapter 32
Bonus
100

What factors can influence pain?

Emotions, previous pain experience, sociocultural factors, communication and cognitive impairments, life stage.

100

How often should you turn patients to protect their skin and complications of immobility?

Every 2 hours

100

What is defined as mild to no activity and the person feels refreshed.

Rest

100

During a wound assessment you note formation of granulation tissue, that easily bleeds when performing wound care. What phase of wound healing would this be considered?

Proliferative phase


100

A patient who has a skin injury should be encourage to maintain/increase intake of?  

Proteins

200

What are some examples of non-pharm pain relief measures?

Acupuncture, TENS units, massage, Temp. therapy, cognitive-behavioral interventions, immobilization.

200

What are some proper body mechanics to avoid injury?

Minimize bending and twisting of back, keep objects close to your body, squat to lift heavy objects, use wide base of support (feet spread apart), get help.

200

Dreaming and mental/emotional restoration occurs during this sleep.

REM sleep.

200

When performing a skin assessment you note full thickness skin loss extending down to fascia, what level pressure injury would this be considered?

Stage III

200

What is the difference between acute and chronic pain?

-Acute- pain that is short in duration, rapid onset, and may last up to 6 months.

-Chronic- persistent pain that lasts 3-6 months or longer, often interferes with ADL's.

300

What are some non-verbal indicators of pain?

- Increased HR, Increase systolic BP, and Increase respiration

-Facial grimacing

-Guarding 

-Eating and sleeping poorly 

-Irritability

300

What does a well rounded fitness program include?

Flexibility, resistance training, and aerobic conditioning.

300

Characterized by excessive daytime sleepiness, or falling asleep at times and in situations they need to be awake and alert.

Hypersomnia

300

A patient after surgery falls and has a total separation at the incision site with viscera protruding out, what is the term used for this complication?

Evisceration

300

This wound involves full thickness skin loss, and the base of wound is obscured by slough and eschar. What kind of pressure injury is this?

Unstageable pressure injury

400

What are side effects of Opioid pain relief and treatment?

-Constipation- Add more fiber to diet, exercise, fluid intake, stool softener.

- Nausea and Vomiting- reduce dose, antiemetic, relaxation techniques.

-Respiratory Depression- assess, reduce dose, Naloxone.

-Drowsiness- assess, educate, discontinue other nonessential CNS depressant med.

400

What is important to remember when creating a fitness program with patient?

Activity and exercise abilities are individualized, goals must consider the patient’s current condition, expected condition changes, lifestyles, and values.

400

What are some Interventions to promote sleep.


- schedule nursing care
- create a restful environment
- promote comfort
- support routines
- bedtime snacks (bread, milk, cheese)
- promote relaxation

400

You receive report that an older adult patient who is mobility impaired has been in a supine position all day. You would assess which areas for pressure injuries?

Back of head (Occipital bone), Scapulae, Elbow (Olecranon process), Sacrum, Heels (Calcaneus)

400

What is one of the most important steps when emptying a JP Drain

Re-compressing drain and closing it to reestablish suction and prevent contamination.

500

What are the different origins of pain and their meanings?

-Cutaneous (Superficial)- arise in skin or subQ tissue. (Burn or abrasion)

-Visceral- stimulation of deep internal pain receptor. Not well localized (tight, pressure, crampy pain).

-Deep somatic- originates from ligaments, tendons, nerves, bones. (fracture, sprain, arthritis)

-Radiating- starts at origin but extends to other locations. (Heartburn or sore throat).

-Referred- occurs in area distant from original site. (heart attack).

-Phantom- pain perceived from area that has been surgically removed. (amputation)

-Psychogenic- pain arsing from the mind though there is no physical cause.

500

A patient who is a quadriplegia would need what time of exercises?

Passive range of motion (PROM)

500

Name three examples of when people can have a disturbed circadian rhythm.

- People who work evening/night shifts 

- changing time zones

- Hospitalization

500

Your patient has a chronic wound around the inner ankle with reddend/brown surround skin, irregular margins, shallow, and pain with leg dependence. What type of wound would this be considered?

Venous stasis ulcer

500

What precautions should be performed for patient and nurse during Airborne precautions?

Isolation room with negative pressure, keep room door closed, Don N-95, have patient wear mask if transporting.