Nursing 101: Test #1 > Test #2 > Flashcards

Test #2 Flashcards

(57 cards)

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1
Q

Describe Jean Watson’s theory of caring how it relates to GSC philosophy.

A

Individuals are unique and worthy of respect. Multi-dimensional (holistic) care = physiological, spiritual, psychological. Holistic care meets needs of diverse population across the lifespan.

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2
Q

Name 7 caring behaviors.

A
  1. Being with/doing for
  2. Touch
  3. Listening
  4. Know the patient.
  5. Spiritual care
  6. Relieving pain/suffering
  7. Family care
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3
Q

What are the four C’s of how to provide care?

A

Courtesy
Comfort
Connection
Confirmation

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4
Q

What is Kristin Swanson’s Theory of Caring?

A

Being with the patient and doing for the patient

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5
Q

What is primary purpose of patient records? Secondary purposes?

A 
Primary = communication
secondary = legal documentation, reimbursement, auditing/monitoring, education, research
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6
Q

What is the golden rule of documentation?

A

If it’s not documented, it has not been done.

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7
Q

Describe TJC-NPSG #2. Give examples

A

Improve effectiveness of communication among caregivers. (do not use list, complete nursing care data.

Trx of info (reporting, change-pf-shift hand off, nursing rounds, pt trx)

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8
Q

What are the 6guidelines/essentials for clinical documentation?

A
  1. Complete
  2. Legible
  3. Organized
  4. Current
  5. Factual
  6. Accurate
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9
Q

What does DARP stand for? Explain what each one stands for.

A

Data - assessment data
Action - nursing intervention
Response - pt’s response to intervention
Plan - future

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10
Q

What does SBAR stand for?

A

Situation, background, assessment, recommendation

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11
Q

What are guidelines for reporting?

A
  1. Essential pt info
  2. Assessment finding/related info
  3. Request/recommendation
  4. Pt’s response to care administered
  5. Identify priorities for next shift.
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12
Q

What are the. steps of the nursing process?

A
  1. Assessment - establish baseline data and rapport/trust with patient
  2. Analysis - identify issues/CC
  3. Planning - create plan of care/establish goals
  4. Implementation
  5. Evaluation
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13
Q

What are the 5 components of critical thinking? KECAS

A 
Knowledge base
Experience
Competencies
Attitude
Standards
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14
Q

What are the 3 levels of critical thinking?

A

Level 1 = Basic
Level 2 = Complex
Level 3 = Commitment

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15
Q

What are the competencies for clinical decision making?

A 
Critical thinking
Problem Solving
Inference
Nursing Process
Diagnostic Reasoning
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16
Q

What is the difference between nursing diagnoses and medical diagnoses?

A

Nursing dx = resp to health alteration/disease and is focused on pt’s health perception.

Medical dx = disease process and focuses on pathophysiology

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17
Q

What are the types of nursing diagnoses?

A 
Actual = impaired tissue integrity (w/signs and symptoms)
Potential = risk for impaired tissue integrity (w/no signs/symptoms)
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18
Q

What does etiology mean?

A

The cause of the diagnosis, where it stems from (“as evidenced by”)

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19
Q

What does SMART stand for? Related to an outcome

A 
Specific
Measurable
Attainable
Realistic
Timely
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20
Q

What are the 7 steps of evidence based practice?

A
  1. Cultivate spirit of inquiry
  2. Ask clinical question (PICOT)
  3. Search for relevant evidence
  4. Critically appraise evidence gathered.
  5. Integrate. evidence with expertise, pt preferences/values to make best clinical decision
  6. Evaluate outcomes of practice change based on evidence
  7. Communicate outcomes of EBP decisions/changes
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21
Q

What does PICOT stand for?

A 
Patient population of interest
Intervention/area of interest
Comparison intervention
Outcome
Time frame
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22
Q

Name the normal breath sounds by name, location, and sound on auscultation.

A
  1. Tracheal
  2. Vesicular
  3. Bronchovesicular
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23
Q

Name the different adventitious breath sounds.

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A
  1. Crackles (rales): wet popping
  2. Wheeze: high-pitched moving through small airway
  3. Rhonchi: continuous low-pitched snore
  4. Stridor: high-pitched crowing - airway obstruction
  5. Pleural Friction Rub: low-pitched due to inflammation
24
Q

Name the normal breath sounds by name, location, and sound on auscultation.

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A
  1. Tracheal/Bronchial: expiration longer than inspiration
  2. Vesicular: inspiration longer than expiration
  3. Bronchovesicular: equal inspiration/expiration
25
Name the normal breath sounds by name, location, and sound on auscultation.
1. Tracheal/Bronchial: expiration longer than inspiration 2. Vesicular: inspiration longer than expiration 3. Bronchovesicular: equal, inspiration/expiration
26
Describe the location and origin of vesicular breath sounds.
Inspiration longer than expiration. Created by air moving through smaller airways. - soft, low pitched
27
Describe the location and origin of bronchovesicular breath sounds.
Inspiration equal to expiration. Created by air moving through large airways. - Medium pitched
28
Describe the location and origin of tracheal/bronchial breath sounds.
Expiration longer than inspiration. Created by air moving through trachea close to chest wall. - Loud and high pitched
29
What is the term for absence of breath?
Apnea
30
What is the term for higher than normal respirations?
Tachypnea
31
What is the term for lower than normal respirations?
Bradypnea
32
Describe crackles.
r/l lung bases
33
What are the accessory muscles of breathing?
Sternocleidomastoid, trapezius, abdominal muscles. (Do not usually move with normal passive breathing)
34
What is the correct gait sequence when using crutches going down stairs
Crutches forward first, then strong leg, then weak leg.
35
How frequently should an immobile patient be turned and repositioned?
Every 2 hours
36
Therapeutic position where head of bed is 45-60 degrees
Fowler's
37
Paralysis of the lower extremities
Paraplegia
38
Positioning patient on side of bed w/legs in a dependent position
Dangle
39
Abnormal drop in blood pressure when pt moves from bedrest to sitting/standing position
Orthostatic Hypotension
40
Paralysis of one side of the body
Hemiplegia
41
Weakness of one side of the body
Hemiparesis
42
Permanent shortening of muscles/ligaments that restrict movement of a joint
Contracture
43
Leg that goes first when ambulating a patient who has a walker and right leg weakness
Right leg
44
Force exerted against skin while skin remains stationary but the boney structures move.
Shearing force
45
What does manifestation mean in regards to analysis?
Manifestations = symptoms of actual problems -Example = swollen right leg (fractured right femur)
46
What do we inspect the thorax for during head-to-toe assessment?
Symmetry, configuration | - posterior thorax for bony prominences
47
Which areas do you auscultate the lungs posteriorly?
1. To the right/left of C7 2. T3 3. T4 5. T10 6. Sometimes T12 if patient is tall
48
Which areas do you auscultate the lungs anteriorly?
1. Both sides of trachea (bronchial) 2. Apices (midclavicular line - distant bronchovesicular) 3. 2nd ICS (btw 2/3 rib, midclavicular line - bronchovesicular) 4. 4th ICS (btw 4/5 rib, midclavicular - vesicular) 5. 6th ICS (btw 6/7 rib, midclavicular - vesicular) 6. Midaxillary line @ 8th ICS
49
What type of questions would you ask a patient before performing a chest/respiratory assessment?
Ask if they have any hx of COPD, asthma, pneumonia. Ask if they're having SOB, smoke cigarettes chest pain, family hx.
50
What are the different quadrants of the abdomen called? And which organs are located in each quadrant?
Lower right - secum, appendix, Upper right - liver, gallbladder Upper Left - stomach, spleen, pancreas, liver Lower Left - sigmoid colon
51
Which areas of the abdomen do you auscultate with the bell of your stethoscope? Where are they located? What sound are we looking for?
1. Abdominal aorta - 2 inches above umbilicus 2. Renal arteries - 2 inches above/to the right & left of umbilicus 3. Iliac arteries - 2 inches below/to the right & left of umbilicus **Looking for bruit sound. Should hear nothing if normal.
52
What does "motility" mean?
How food is moved through GI tract through peristalsis.
53
What are things to take note of when inspecting the abdomen?
Scars, bruises, lesions, stretch marks, bulging, visible masses, symmetry, distention, swelling/red or enlarged umbilicus.
54
What is the normal range for bowel sounds?
5-30 times per minute
55
What does hyperactive bowel sounds indicate?
Increased motility or peristalsis of the bowels. Could indicate diarrhea
56
What does hypoactive bowel sounds indicate?
Decreased bowel sounds that occur less than 1 minute. Listen for bowel sounds for 5 minutes (1 min 15 sec each quadrant) to confirm absence of bowel sounds
57
What is the purpose of palpating the abdomen?
Making sure patient doesn't have any rebound tenderness, masses, rigidity, guarding,
Nursing 101: Test #1
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