What is the Numeric Rating Scale (NRS) for pain, and how is it scored?
What is a pain scale where patients rate their pain from 0 to 10, with 0 being no pain and 10 being the worst possible pain.
What is the importance of turning and repositioning a patient every 2 hours?
What is it helps prevent pressure ulcers and promotes circulation.
What is the normal range for an adult’s body temperature?
What is 97.8°F to 99.1°F (36.5°C to 37.3°C).
What is the first stage of a pressure ulcer, characterized by redness of intact skin?
What is Stage 1: Non-blanchable redness over a bony prominence, with intact skin.
Name a priority nursing action when completing medication administration of an antidysrhythmic to Mr. Jones. Recent vital signs: BP 165/94 HR 58 RR 16 O2 98% T 98.7
What is withhold the medication and notify the physician due to heart rate being under 60 bpm.
What is the difference between acute and chronic pain?
What is acute pain is short-term and usually related to injury or surgery, while chronic pain lasts longer than 3 months and persists beyond normal healing time.
Define the term "contracture" in relation to immobility.
What is a contracture is the permanent shortening of a muscle or joint due to immobility, leading to loss of function and stiffness.
What condition results from the body overheating and can lead to heatstroke?
What is Hyperthermia.
In which stage of a pressure ulcer does partial-thickness skin loss occur, sometimes presenting as a blister or shallow open ulcer?
What is Stage 2: Partial-thickness skin loss with exposed dermis, often appearing as a blister or shallow open wound.
List at least four risk factors for cardiac disease.
What is high cholesterol, high blood pressure, fatigue, nausea, chest discomfort, and/or sleep disturbances.
Name two non-pharmacological interventions for pain management.
What is heat/cold therapy, relaxation techniques, massage, acupuncture, or distraction techniques.
What is the purpose of using assistive devices such as a gait belt?
What is to support patient mobility and prevent falls during transfers or ambulation.
Name two signs of hypothermia.
What is shivering, confusion, slurred speech, slow breathing, and drowsiness.
What is the distinguishing feature of a Stage 3 pressure ulcer?
What is Stage 3: Full-thickness skin loss with visible fat, but without exposure of bone, tendon, or muscle.
Name the clinical manifestations of a patient with right-sided heart failure.
What is SWELLING? Swelling of legs, hands, liver, and abdomen (ascites), weight gain, edema (pitting), large neck veins (jugular vein distention), lethargic (weak and very tired), irregular heart rate (atrial fibrillation), nausea (from swelling of abdomen and liver), and girth of abdomen increased (from swelling).
What is neuropathic pain, and how does it differ from nociceptive pain?
What is neuropathic pain arises from damage to the nervous system, while nociceptive pain results from tissue damage or inflammation.
What is the effect of prolonged bed rest on the musculoskeletal system?
What is it leads to muscle atrophy, bone demineralization (osteoporosis), and joint stiffness.
What is the role of the hypothalamus in thermoregulation?
What is the hypothalamus acts as the body's thermostat, regulating temperature by signaling heat production or loss.
At which stage of a pressure ulcer is there full-thickness tissue loss with exposed bone, tendon, or muscle?
What is Stage 4: Full-thickness tissue loss with exposed bone, tendon, or muscle, often with slough or eschar.
Name the clinical manifestations of a patient with left-sided heart failure.
What is DROWNING? Difficulty breathing, rales (crackles), orthopnea (cannot tolerate lying down), weakness (heart cannot compensate for increased activity), nocturnal paroxysmal dyspnea (awakening during sleep with extreme dyspnea), increased heart rate (due to fluid overload in the lungs), nagging cough (frothy or blood-tinged sputum), and gaining weight from the body retaining fluid.
What is referred pain, and provide an example?
What is pain perceived in an area distant from the source. Example: Pain from a heart attack is often felt in the left arm or jaw.
What is the difference between active and passive range of motion (ROM) exercises?
What is active ROM is when the patient moves their own joints, while passive ROM involves the caregiver moving the patient’s joints.
What is malignant hyperthermia, and when is it most likely to occur?
What is life-threatening reaction to certain anesthetics, causing a rapid rise in body temperature and severe muscle contractions.
What is an unstageable pressure ulcer, and why can't it be staged initially?
What is an unstageable pressure ulcer is one where the extent of tissue damage cannot be determined due to the presence of slough or eschar covering the wound, obscuring the depth.
List and describe the three main layers of the heart.
What is the epicardium, myocardium, and pericardium. The epicardium is the outermost layer of the heart made of a thin layer of connective tissue and fat that cushions the heart. The myocardium is the middle and thickest layer of the heart wall made up of cardiac muscle fibers. The pericardium surrounds the heart and anchors the heart in the thoracic cavity.