Comfort and Sensory
Mobility
Health and Wellness
Scope and Practice
Potpourri
100
The most reliable method of pain assessment for a conscious, verbal client.
What is the numeric pain scale?
100
Assessment
Subjective: states "I seem to be having trouble moving around my house, walking, standing up from a chair and moving around in bed."
What is the MOST appropriate nursing diagnosis:
Impaired physical mobility or activity intolerance
What is IMPAIRED PHYSICAL MOBILITY?
Activity Intolerance relates to the inability to carry out fundamental skills to care for oneself such as eating, bathing, toileting and mobility.
100
You are invited to teach a group of high school students about sexually transmitted diseases. You decide to hand out pamphlets and condoms. What level of prevention are you doing?
What is primary prevention?
Primary prevention includes preventing illness or conditions before exposure.
100
The patient will report to the nurse their pain level using the numeric scale of 0-10 every 4 hours. What is the next step in the nursing process?
What is nursing intervention?
The nurse will administer Acetaminophen 650mg po every 4 hours as needed for pain level above 3.
100
Your patient with peripheral vascular disease wants to get a pedicure. What is your recommendation?
PVD and DM are at increased risk for injury when performing foot and nail care because of decreased blood flow and decreased sensation due to nerve damage.
Have a qualified professional or podiatrist provide foot care.
200
Name 2 behaviors that your NONVERBAL patient exhibits if he/she is in pain.
What are: grimacing, restlessness, tachycardia, drowsiness, tachypnea, groaning, moaning and hypertension.
200
Mr. X has recently recovered from a stroke affecting his left side. PT has ordered him to ambulate with a cane. What side should Mr. X hold his cane on?
What is THE RIGHT SIDE.
Move the cane forward 6-10 inches. HOLD CANE ON THE OPPOSITE SIDE OF THE INJURY.
200
You have been invited to participate at a Banner Health Fair which includes blood tests for high cholesterol and blood glucose checks.
What level of prevention is this?
What is SECONDARY PREVENTION?
Secondary prevention- screening to identify diseases in the earliest stages, before the onset of signs and symptoms...mammograms, blood test screenings, and PSA are examples.
200
Asking allergies prior to giving medications is and example of
Beneficence or non-maleficence
Non maleficence is the obligation not to harm the patient.
200
Name an indication for a foley catheter
What are: hematuria, strict I and O, urological procedure, pressure ulcer of sacrum or perianal area, bladder obstruction, immobility, and end of life care.
300
TYPES OF PAIN True or False....
Diabetic neuropathy arises from damage to the bones, joints and connective tissue?
What is FALSE?
Diabetic neuropathy is a type of neuropathic pain that arises from damaged pain nerves and includes phantom limb pain.
300
Mrs. Y has suffered a subdural hematoma and is unconscious and on a ventilator. Drs order: Oral care every 2 hours. What 2 positions can you place your patient in while doing oral care to prevent aspiration?
What is
Semi-Fowlers or lateral supine.
300
Your patient has been experiencing chronic grief and depression ever since her husband died 9 months ago. She has agreed to attend a Grief counseling meeting at the local church. What type of prevetion is this?
What is ...Tertiary Prevention?
Tertiary prevention is an intervention for a client with an existing disease/injury to prevent further damage from this existing condition.
300
Your patient is starting chemotherapy and asks about the side effects. The nurse is aware that the side effects can be distressing to the patient and decides it would be best to tell the truth to the patient .
Is this an example of veracity or fidelity?
What is veracity?
Veracity truth telling/being honest with patients.
Fidelity-to remain true to professional promises, such as tthe promise to provide high quality, competent, safe and efficient patient care.
300
Which vitamin helps iron absorption?
What is a side effect of iron that can be prevented from eating raw fruits and vegetables?
What is Vitamin C (citrus fruits)
What is constipation.
400
WHAT IS WRONG WITH THIS SCENARIO...
You are educating your patient that is HOH on cleaning his brand new hearing aides. You lean in to his good ear and yell "Make sure you soak them in lukewarm water to clean your hearing aides twice per day!"
When speaking to a client with hearing loss...speak slowly and clearly, write down what the client doesn't understand, minimize background noise, stand in front of the client, and lower your voice.
Cleaning hearing aides...use a soft cloth to remove cerumen and never immerse in water. Battery changes vary from once per week up to twice per month.
400
You have received a new admission and are doing an initial assessment including skin. You notice a 2 cm full thickness circular wound extending into the subcutaneous layer of her right greater trochanter. You notice yellow, foul smelling drainage from the wound.
How would you Stage this wound? How would you describe the drainage? What does the drainage indicate?
What is ...Stage 3. Purulent drainage indicates infection.
Stage 1 redness, Stage 2 exposed dermis and partial thickness skin loss. Stage 4 deepest, extending into muscle, ligament, cartilage and even bone.
400
Name a modifiable risk factors for the disease diabetes.
What are: Sedentary lifestyle, obesity and stress can be changed.
Non-modifiable: genetics
400
Goal met: patients respiratory rate decreased to 12 breaths per minute after a guided imagery session
is an example of what part of the nursing process.
What is evaluation?
400
Fluid volume deficit or excess...
What is fluid volume excess.....Jugular vein distension
500
Reassessing the client after pain control is what part of the nursing process:
Assess-Nursing Diagnosis-Planning-Intervention-Evaluation
What is EVALUATION-
Goal met-Patient's pain level decreased to an acceptable range of 3/10.
500
Name two actions the nurse can do to prevent pressure ulcers from forming.
What are; diet rich in protein and Vitamin C, passive ROM exercises, adequate hydration, therapeutic mattress, pillows under ankles to float heels, and turn q 2 hrs.
No high fowlers for extended periods of time.
500
Applying SPF daily is an example of what type of prevention?
What is PRIMARY prevention?
500
Your patient states he doesn't feel right, falls down to the ground and starts making jerking movements with his upper and lower extremities.
What do you do?
What is a seizure.
Position the patient laterally, do not restrain, stay with patient, nothing in the mouth.
500
What position
What is lithotomy position with stir-ups.
What is Sims position for enema administration and rectal exams.