The Nursing Process
What are the phases of the nursing process?
Assessment, diagnosis, planning, implementation, evaluation.
Name at least 3 factors that influence body temperature
Developmental level, environment, exercise, gender, emotions/stress, circadian rhythm.
How do you prepare yourself before performing a physical exam?
Familiarize yourself on patient, have self knowledge, always know 1st approach should be used as an initial assessment.
When it comes to duration of pain... what are the 3 categories?
Acute: Rapid onset w/short duration.
Chronic: Lasts 3-6mths and interferes with ADLs.
Intractable- Both chronic and highly resistant to relief.
What does PERRLA mean?
Pupils, equal, round, reactive to light, and accommodation.
How to write a goal/outcome statement
subject, action verb, performance criteria, target time.
*BONUS POINTS of 100 points if you can give an example*
What scenarios would require you to take an apical pulse? Give at least two.
radial pulse is weak/irregular, rate is less than 60 beats per min or greater than 100 beats per min, pt is taking cardiac meds, pt is an infant or child up to 3.
SELECT ALL THAT APPLY!
A nurse concludes that a pt has inadequate nutrtition. Which patient adaptations support this conclusion?
A: Presence of surface papillae on the tongue
B: Redish-pink mucous membranes.
C: Sickly appearance (Cachectic)
D: Spoon shaped nails
E: Shin eyes
C: Cachexia is general ill health and malnutrition marked by weakness and excessive leanness.
D: Fingernails that curve inward lie spoons can be caused by iron deficiency, vitamin B12 deficiency, or anemia.
Give 3 examples of cognitive behavioral interventions.
Distraction, relaxation, guided imagery, diaphragmatic breathing, hypnosis, therapeutic touch, humor, writing, animal assisted.
What is phantom pain?
Perceived to originate from an area that has been surgically removed.
What is the difference between a dependent intervention and an independent intervention?
Dependent: requires a doctor's order.
Independent: Order not needed. Nurse is accountable.
BREATH SOUNDS: Describe rhonchi, wheezing, and stridor.
Rhonci- Low pitched, gurgling caused by secretion in lrg airway.
Wheezing- High pitched, narrowing airway.
Stridor- Piercing sounds. Usually in infants with resp. distress or obstructed airway.
A patient has had a 101 F fever for the past 24hrs. How often should the nurse monitor the pt's temp?
A: Every 2hrs
B: Every 4hrs
C: Every 6hrs
D: Every 8hrs
B: Every 4hrs.
This is an appropriate interval of time for routine monitoring of body temp. It is frequent enough to identify trends in changes in body temp while limiting unnecessary assessments.
A pt requests pain medication for severe pain. Which should the nurse do FIRST when responding to the pt's request?
A: Use distraction to minimize the pt's perception of pain.
B: Place the pt in the most comfortable position possible.
C: Administer pain med to the pt quickly.
D: Assess the various aspects of the pt's pain.
D: All the factors that affect the pain experience should be assessed. This would include location, intensity, quality, duration, pattern, aggravating and alleviating factors, and physical, behavioral, and attitudinal responses. Assessment must precede interventions.
What are 3 categories of pain stimuli?
Mechanical
Thermal
Chemical
What are the 5 rights of delegation?
Right task
Right circumstance
Right person
Right direction/communication
Right supervision/Evaluation
Name all the pulse locations... in order from head to toe.
Temporal, carotid, brachial, radial, femoral, popliteal, dorsalis pedis, tibial.
A nurse is planning care for a pt who has intolerance to activity. Which is the FIRST assessment that should be made by the nurse?
A: Range of motion
B: Pattern of vital signs
C: Impact on functional health patterns
D: Influence on the other family members
B: Pattern of vital signs
Activity intolerance is related to the inability to maintain adequate oxygenation to body cells, which is associated with respiratory and cardiovascular problems. Obtaining vital signs will provide valuable information about these systems.
SELECT ALL THAT APPLY!
A nurse is assessing a pt experiencing chronic pain. Which characteristics are more common with chronic pain than with acute pain.
A: Gradual Onset
B: Long Duration
C: Anticipated End
D: Psychologically depleting
E: Responds to conventional interventions.
A: Chronic pain has a gradual progressive onset because it usually is related to a long-term problem. Acute pain has a rapid onset because it usually is related to abrupt trauma to the body.
B: Chronic pain is categorized as pain longer than 6 months duration. Acute pain is categorized as pain shorter than 6 months.
D: Chronic pain is psychologically depleting because it drains both physical and emotional resources; this is related to the unrelenting nature of the pain and that it usually continues for life.
What is the difference between Core temp and Surface temp?
Core Temp- Normal internal temp.
Surface Temp- SKIN!! Feel of skin temp.
The special needs assessment focuses on what areas?
Nutrition, pain, cultural/spiritual, psychosocial.
When it comes to breathing, what is the difference between inspiration and expiration?
Inspiration- Drawing air into the lungs.
Expiration- Expulsion of air from lungs.
SELECT ALL THAT APPLY!
A nurse is interviewing a newly admitted pt. Which words used by the pt describe data associated with the defervescence phase (fever, flush phase)?
A: Cold
B: Achy
C: Warm
D: Sweaty
E: Thirsty
C: Warm- Feeling warm is associated with this phase because of sudden vasodilation.
D: Sweaty- Occurs during this phase because of the body's heat loss response.
A nurse is assessing a pt in pain. Which word might the nurse use when documenting the pattern of a pt's pain?
A: Tenderness
B: Moderate
C: Episodic
D: Phantom
C: Episodic
The word "episode" refers to an incident occurrence, or time period; therefore, the word "episode" refers to a pattern of pain and is concerned with time of onset, duration, recurrence, and remissions.
In step 3 of the nursing process, what is the difference between a short term goal and a long term goal.
Short term- Expected to be achieved within a few hours or days.
Long term- Expected to be achieved within a longer period. Weeks, months, or longer.