Nursing 1 > Quiz 3 > Flashcards

Quiz 3 Flashcards

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1
Q

What are the developmental sleep needs for newborns?

A

16 hours

Newborns typically require around 16 hours of sleep.

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2
Q

What is the sleep requirement for toddlers?

A

11-14 hours

Toddlers need between 11 to 14 hours of sleep.

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3
Q

Identify the sleep needs for adolescents.

A

8-10 hours

Adolescents generally require 8 to 10 hours of sleep.

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4
Q

What factors can influence sleep and rest?

A
  • Motivation
  • Culture
  • Lifestyle and habits
  • Activity and exercise
  • Dietary habits
  • Environmental factors
  • Psychological stress
  • Illness
  • Medications

These factors can significantly affect an individual’s ability to rest and sleep.

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5
Q

True or false: Caffeine promotes sleep.

A

FALSE

Caffeine blocks the ability of adenosine to cause drowsiness.

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6
Q

What are the sleep-inducing medications mentioned?

A
  • Nonbenzodiazepines: zolpidem tartrate, zaleplon
  • Benzodiazepines: diazepam, alprazolam, flurazepam, lorazepam, triazolam
  • Selective Melatonin Agonist: ramelteon
  • Barbiturates: amobarbital, phenobarbital, secobarbital
  • Tricyclic Antidepressants: amitriptyline, doxepin, imipramine, nortriptyline
  • Antihistamines: diphenhydramine
  • Melatonin
  • Herbal sleep aids: valerian root, lavender, chamomile tea

These medications can aid in promoting sleep.

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7
Q

What are the characteristics of sleep to assess?

A
  • Restlessness
  • Sleep postures
  • Sleep activities
  • Snoring
  • Leg jerking

These characteristics can provide insights into a person’s sleep quality.

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8
Q

What is insomnia?

A

Difficulty falling asleep, staying asleep, or maintaining sleep

Insomnia affects 30-35% of adults and can be related to disruptions in circadian rhythm.

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9
Q

What is Obstructive Sleep Apnea characterized by?

A
  • Absence of breathing (apnea)
  • Diminished breathing efforts (hypopnea)
  • Respiratory effort-related arousals during sleep
  • Subjective nocturnal respiratory disturbance
  • Observed apnea

This condition is associated with sleepiness, fatigue, and snoring.

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10
Q

Define General Adaptation Syndrome (GAS).

A
  • Alarm Stage
  • Resistance Stage
  • Exhaustion Stage

GAS describes the body’s three-stage response to stress.

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11
Q

What are the nursing interventions to promote sleep?

A
  • Maintaining a brighter room during the day
  • Reducing light exposure at night
  • Decreasing noise levels
  • Bundling care activities
  • Scheduling quiet times

These strategies can help improve patients’ sleep quality.

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12
Q

What is the Local Adaptation Syndrome (LAS)?

A

Localized response to stress, often involving tissue or organ-specific reactions

LAS focuses on a specific area rather than the whole body.

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13
Q

What are the expected findings during a Peripheral Vascular Assessment?

A
  • Normal skin color
  • Capillary refill <3 seconds
  • Warm skin temperature
  • Full range of motion without pain
  • Intact sensation
  • Strong and equal pulses bilaterally
  • No pain or discomfort

These findings indicate healthy peripheral vascular function.

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14
Q

What are the steps utilized in peripheral vascular assessment?

A
  • Inspection
  • Palpation
  • Auscultation

These steps help in systematically assessing peripheral vascular health.

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15
Q

What is the risk for impaired skin integrity related to?

A

Impaired peripheral tissue perfusion

This condition can lead to skin breakdown and ulcers.

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16
Q

What are the nursing interventions to achieve planned outcomes?

A
  • Regularly assess vital signs
  • Peripheral pulses
  • Neurological status
  • Encourage positioning that promotes circulation
  • Administer pain relief medications as prescribed
  • Teach the client about recognizing signs of compromised neurovascular status
  • Work with physical therapy for mobility issues
  • Refer to specialists as needed

These interventions aim to improve the client’s overall health and mobility.

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17
Q

What should be evaluated in the evaluation phase of nursing interventions?

A
  • Changes in vital signs
  • Pulse quality
  • Sensation
  • Pain levels
  • Functionality
  • Client feedback regarding understanding of neurovascular health

Adjust the care plan based on the client’s progress and new findings.

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18
Q

What are the normal age-related variations for infants/children in cardiac assessment?

A
  • Visible cardiac pulsation if the chest wall is thin
  • Sinus dysrhythmia
  • Presence of S3 in about one third of all children
  • More rapid heart rate until about age 8 or 10 years

These variations are important for accurate assessment in younger populations.

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19
Q

What are the normal age-related variations for older adults in cardiac assessment?

A
  • Difficult to palpate apical pulse
  • Difficult to palpate distal arteries
  • More prominent and tortuous blood vessels
  • Increased systolic and diastolic blood pressure
  • Widening pulse pressure

These changes can affect cardiovascular assessments in older adults.

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20
Q

What does inspection involve in musculoskeletal assessment?

A

Deliberate, purposeful observations in a systematic manner

This process is crucial for identifying abnormalities.

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21
Q

What are the steps utilized in musculoskeletal assessment?

A
  • Assess ability to assume positions
  • Inspect and palpate muscles for symmetry and tenderness
  • Palpate bones for contour and symmetry
  • Inspect and palpate joints for range of motion
  • Inspect spinal curves

These steps help in evaluating musculoskeletal health.

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22
Q

What are the expected findings of musculoskeletal assessment?

A
  • Pain location, intensity, duration, and nature
  • Mobility issues
  • Previous injuries or surgeries
  • Activity level impact on symptoms

These findings guide further assessment and intervention.

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23
Q

What is the Chain of Infection?

A
  • Infectious agent
  • Reservoir
  • Portal of exit
  • Means of transmission
  • Portal of entry
  • Susceptible host

Understanding this chain is essential for infection control.

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24
Q

What are the stages of infection?

A
  • Incubation period
  • Prodromal stage
  • Full stage of illness
  • Convalescent period

Each stage has distinct characteristics and implications for treatment.

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25
What are the **five moments for hand hygiene**?
* Before touching a patient * Before a clean or aseptic procedure * After body fluid exposure risk * After touching a patient * After touching patient surroundings ## Footnote These moments are critical for preventing infection transmission.
26
What are **restraints** in a healthcare context?
* Physical devices * Chemical means used to limit a patient's freedom and movement ## Footnote Restraints should only be used when absolutely necessary and with proper justification.
27
What should be included in the **implementation protocol** for restraints?
* Informed consent * Clear documentation of rationale * Regular assessment of the patient's condition ## Footnote This ensures ethical use and monitoring of restraints.
28
What constitutes **false imprisonment** in healthcare?
Unjustified retention or prevention of movement without proper consent ## Footnote Restraints must not be used for coercion or convenience.
29
What is **asepsis**?
The absence of illness-causing microorganisms ## Footnote Asepsis is crucial for preventing infections in healthcare settings.
30
What is the difference between **medical asepsis** and **surgical asepsis**?
* Medical Asepsis: Reduces microorganisms * Surgical Asepsis: Removes all microorganisms ## Footnote Both are essential for infection control but serve different purposes.
31
What is the **normal range** for white blood cell count?
5,000 to 10,000/mm3 ## Footnote Elevated white blood cell count may indicate infection or inflammation.
32
List the **five moments for hand hygiene**.
* Before touching a patient * Before a clean or aseptic procedure * After a body fluid exposure risk * After touching a patient * After touching patient surroundings ## Footnote These moments are critical for preventing infection transmission.
33
What is **medical asepsis**?
The use of precise practices to reduce the number, growth, and spread of microorganisms ## Footnote It is essential for infection control in healthcare settings.
34
What are the **types of reactions** to latex allergies?
* Irritant contact dermatitis * Allergic contact dermatitis * Latex allergy ## Footnote Recognizing these reactions is crucial for patient safety.
35
What should be worn for **Contact Precautions**?
* Gloves * Gowns ## Footnote These precautions are necessary for infections spread by direct contact.
36
What is the purpose of **Droplet Precautions**?
To prevent the spread of infections transmitted by large-particle droplets ## Footnote Examples include rubella and mumps.
37
What is the **Hemostasis Phase** in wound healing?
Immediate response to injury aimed at stopping bleeding and activating white blood cells ## Footnote Involves blood vessel constriction and clot formation.
38
What occurs during the **Inflammation Phase** of wound healing?
White blood cells migrate to the wound, clearing bacteria and debris ## Footnote This phase lasts about 2 to 3 days and includes pain, heat, redness, and swelling.
39
What is **Primary Intention** in wound healing?
Wounds heal with minimal scarring and epidermal cells seal within 24 to 48 hours ## Footnote Collagen synthesis peaks at 5 to 7 days.
40
What is the **Maturation Phase** of wound healing?
Begins about 3 weeks after injury and can last for months or years ## Footnote Involves remodeling of collagen and scar tissue formation.
41
Identify **local factors** affecting wound healing.
* Pressure * Desiccation * Maceration * Trauma * Edema * Infection * Excessive bleeding ## Footnote These factors can significantly delay healing.
42
What is the role of **Personal Protective Equipment (PPE)**?
To protect healthcare workers and patients from potential pathogens ## Footnote Appropriate PPE varies based on the type of precautions required.
43
What is the definition of **surgical asepsis**?
The use of practices to remove all microorganisms from an object or area ## Footnote It is critical in surgical settings to prevent infection.
44
True or false: **Hand hygiene** is the most critical aspect of medical asepsis.
TRUE ## Footnote Effective hand hygiene is essential for preventing infection transmission.
45
What should be done with **contaminated waste**?
Dispose of in designated biohazard containers ## Footnote Proper disposal is crucial for infection control.
46
What is the **proliferation phase** in wound healing?
The phase where fibroblasts build new tissue to fill the wound ## Footnote This phase involves collagen synthesis and granulation tissue formation.
47
Fill in the blank: **Asepsis** is the absence of __________.
illness causing microorganisms ## Footnote Aseptic techniques are vital in healthcare to prevent infections.
48
What are the **local factors** that can impede wound healing?
* Pressure * Desiccation * Maceration * Trauma * Edema * Infection * Excessive bleeding * Necrosis/Necrotic Tissue * Biofilm ## Footnote These factors disrupt blood supply, cause tissue damage, or introduce infection, all of which delay healing.
49
What are the **systemic factors** affecting wound healing?
* Age * Circulation to and oxygenation of tissues * Nutritional status * Wound etiology * General health status and disease state * Immunosuppression * Proinflammatory conditions * Extent of systemic inflammation * Medication use and other therapies * Adherence to treatment plan ## Footnote Systemic factors can influence the body's overall ability to heal wounds.
50
What are the **components of a physical assessment** for a wound?
* Size * Depth * Color * Drainage * Odor * Signs of infection (redness, swelling, warmth, increased pain, fever) * Surrounding skin integrity ## Footnote A thorough assessment is crucial for effective wound management.
51
What are some **diagnoses** related to wound care?
* Impaired skin integrity * Risk for infection * Disturbed body image * Anxiety related to healing process ## Footnote These diagnoses help guide the nursing care plan for clients with wounds.
52
What should be included in the **planning phase** for a client with a wound?
Develop specific, measurable goals for the client ## Footnote Goals should be tailored to the individual needs and circumstances of the client.
53
What are the **steps in wound care implementation**?
* Clean and dress the wound using aseptic technique * Administer prescribed medications * Offer emotional support * Encourage expression of concerns * Provide referrals if needed ## Footnote Implementation combines physical care with psychosocial support.
54
What are the **types of drainage** observed in wound care?
* Serous drainage * Sanguineous drainage * Serosanguineous drainage * Purulent drainage ## Footnote Each type of drainage provides information about the wound's healing status and potential complications.
55
What does **erythema** indicate in wound assessment?
Redness in lightly pigmented skin ## Footnote Erythema can be a sign of inflammation or infection.
56
What is the definition of **eschar**?
A type of necrotic tissue; hard, dry, dark covering made of dried blood and tissue ## Footnote Eschar is usually firmly adhered to the wound bed and requires debridement for healing.
57
What is **dehiscence** in wound healing?
Partial or total separation of wound layers ## Footnote Dehiscence can occur due to stress on unhealed wounds.
58
What are the **symptoms of neurovascular impairment** related to tight bandaging?
* Pain * Pallor * Pulselessness * Paresthesia * Paralysis * Temperature changes * Swelling * Delayed capillary refill ## Footnote These symptoms indicate compromised circulation and require immediate attention.
59
What is the **purpose of sterile procedures** in wound care?
Aims for complete sterility ## Footnote Sterile procedures are crucial for preventing infection during wound care.
60
What is the **function of granulation tissue** in wound healing?
New connective tissue with microscopic blood vessels and myofibroblasts that develop at the wound site ## Footnote Granulation tissue is essential for the healing process.
61
What is the **definition of a fistula**?
An abnormal passage from an internal organ/vessel to the outside of the body or from one organ/vessel to another ## Footnote Fistulas can complicate wound healing and require medical intervention.
62
What is the **role of nutritional status** in wound healing?
* Healing needs proteins, carbs, fats, vitamins, and minerals * Calories and protein necessary to rebuild cells and tissue * Vitamin A and C needed for epithelialization * Zinc needed for proliferation * Fluids needed for cell function ## Footnote Adequate nutrition is vital for effective wound healing.
Nursing 1
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