Exam 1

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1.

Who is
Florence
Nightingale

Founder of modern nursing

2.

What does
her theory
include?.

holistic thinking, health and wellness, she

introduced cleanliness and other antiseptic
techniques to nursing practices and started
nursing education.

What is
critical
thinking in
nursing?

Looking at situations objectively

Determining pertinent information
Recognizing problems or needs
Prioritizing those needs
Considering various actions and probable
outcomes
Making informed decisions re: needed
interventions based on knowledge, experience,
judgment, research
Evaluating outcomes

3.

basic
principles
of Critical
Thinking

Intuition, Reflection, Knowledge, Experience.

Scientific method, perseverance

identify
critical
thinking
attitudes

responsibility, authority, accountability

What is
Informed
Consent?

It is a process of communication between a

patient and physician that results in the
patient's authorization or agreement to undergo
a specific medical intervention.

When is
delegation
to a CNA or
LPN
acceptable?

As long the patient is stable, 5 rights: right task

right circumstance, right person, right
direction/comm right supervision, use good
judgment, experience of NAP, make sure its
within NAP scope of practice, NAP can not do
ADPIE or assessment.

8.

libel

a tort consisting of false and malicious

publication printed (written) for the purpose of
defaming a person's name

9.

slander

an abusive attack on a person's character or

good name (verbal)

4.

5.

6.

7.

10.

veracity

adherence to the truth; truthfulness

11.

malpractice

professional wrongdoing that results in injury or

damage, not doing what you are supposed to be
doing

12.

beneficence

the quality of being kind or helpful or generous,

to the benefit of the pt even if it causes pain or
discomfort, doing whats best for pt

13.

assault

threatening someone, attempting to harm

someone

14.

battery

harming, physically

15.

Patient Selfdetermination
Act

requires healthcare facilities to provide written

information on the patient's right to execute
advance directives, living will, poa & to
accept or refuse medical treatment

16.

HIPAA

The Health Insurance Portability and

Accountability Act, a federal law protecting
the privacy of patient-specific health care
information and providing the patient with
control over how this information is used and
distributed.

17.

scope of
practice

legal description of what a specific health

professional may and may not do

18.

scope of
practice: CNA

...

19.

scope of
practice: RN

...

20.

scope of
practice: LPN

...

21.

scope of
practice:
Nursing
student

...

22.

What is
accreditation?

a voluntary process a health care

organization undertakes to prove they are
providing an acceptable standard of practice
and quality of care.

23.

What is the
most
frequently
used
accrediting
body?

The Joint Commission, TJC

24.

Difference
between
medical
practice &
nursing
practice?

Med practice diagnoses the illness and

nursing practice diagnoses the reaction to the
illness or treatment

25.

Purpose of
Nursing
Process

purpose is identification & treatment of client

needs in response to illness. Is client
centered, goal oriented method of providing
care. A systematic, rational approach to
panning and providing individualized nursing
care which provides a framework for nursing
practice.

26.

Steps of the
Nursing
Process

A ssessment
D iagnosis - (NANDAs)
P lanning (Goals & Desired
Outcomes,Interventions to achieve those
goals)
I mplementation/intervention
E valuation

27.

Step 1.
Assessment

Systematic data collection to determine client

needs. Includes:
Health History
Current chief complaint, present & past history
Family hx, allergies, meds
Lifestyle, Functional status
Social Data
Psychosocial Data, Coping
Patterns of healthcare
Determine client current health status
Determine current & prior level of functioning
normal or altered
Determine risk status
use data format required by institution
Validate observations and inferences. Consider
cultural or ethnic factors.

28.

objective
data

Findings with physical assessment, measurable

SIGNS of health problems, diagnostic test
results. Example? restless, unable to turn,
taking vital signs.

29.

subjecive
data

what patient/family tells you. Patient health

history, SYMPTOMS of health problems. Pain
level, general feelings of symptoms.

30.

Purpose of
nursing
diagnosis

1.identify and label client response to health

problems.
2. Basis for choosing nursing interventions.
3. Defines body of knowledge for which nurse is
held accountable. (Differs from medical
management, identifies nursing knowledge
leading to greater accountability and
professional autonomy), client centered, goal
oriented

31.

What may
cause
errors in
diagnostic
statements?

being judgmental. Using legally liable terms,

using medical terms for diagnosis or etiology.
Not collecting enough data from the patient, not
clarifying the information with the patient.

32.

What is
Maslow's
hierarchy?

ABC first, pain/ physiological, safety, love and

belonging, self esteem, self actualization

33.

Chemical
name

drug name for chemical composition and

molecular structure( 2-p-isobutylphenylpropionic
acid)

34.

generic
name

Name given by the United States Adopted Name

Council (ibuprofen)- non proprietary name

35.

trade name,
proprietary,
brand name

indicated that the drug is registered and that its

use is restricted to the owner of the drug.
legally on record for 17 years. Use of name
restricted by the drug's owner (motrin, advil)

Appropriate
Diagnostic
statement

Statement includes
1. NANDA
2. Related to (R/T)
3. Secondary to (S/T)
4. As evidenced by (AEB)

36.

37.

Planning
Goals and
Outcome

Nursing care should always be goal directed.

Should provide direction for planning nursing
interventions.
provides criteria for evaluating client progress
enables determining if problem is resolved
motivates client and nurse to progress
Goal is a positive reflection of the problem or
NANDA. Realistic, Understandable to client,
Measurable, Believable, Achievable.
Client oriented.

38.

Appropriate
Interventions

Actions performed to measure or achieve

client outcomes (resolve NANDA) Based on
clinical knowledge and judgment, research
based, nurse prescribed, collaborative
(physician prescribed and implemented by
nurse) made specific to pt, note amount,
frequency. Includes observation, treatment,
prevention, health promotion.

39.

Categories of
interventions

Assessment, therapeutic, educational,

referral or health promotion.

40.

Prioritizing
nursing
diagnosis &
nursing
actions?

Priority ALWAYS ABCs,

Pain is next priority.
Client driven (what's important to client may
differ from nurse's priorities)

41.

Maslow's
hierarchy

1. PHYSIOLOGICAL- breathing, food, water,

sex, sleep, homeostasis, excretion.
2. SAFETY-security of body, of employment,
of resources, of morality, of the family, of
health, of property.
3. LOVE/BELONGING-friendship, family,
sexual intimacy
4. ESTEEM- self-esteem, confidence,
achievement,respect of others, respect by
others.
5. SELF-ACTUALIZATION- morality, creativity,
spontaneity, problem solving, acceptance of
facts.

42.

Phases of
Nursing
Processs

Assessment, diagnosis, planning,

intervention, evaluation.

43.

Routes of drug
administration

Oral, parenteral, topical, nasal, lungs,

vaginal, rectal.

44.

First pass
effect

Oral Route.Passes through portal circulation

before going into bloodstream.

45.

Drugs that
should never
be crushed or
broken?

Time released drugs(, enteral type drugs

(drugs with special coating)

46.

Drug
classifications

1. Pharmacological
Classification(grouped by physiologic
activity and mechanisms of action,
calcium channel blockers
2. Therapeutic Classification (Grouped
by similar therapeutic indications such
as anti-coagulatns, anti-anxiety antiinfectives)
3. Chemical Classification(grouped by
chemical structure regardless of
differences in pharmacologic activity)

63.

Adverse drug
reactions

severe, unexpected, undesirable response

64.

toxic
effect/toxicity

medication accumulates in the blood stream

65.

allergic
reaction

unpredictable hypersensitivy response to a

medication

66.

symptoms of
anaphylactic
reaction?

breathing issues, swelling, rash, hives, severe

allergic reaction

67.

Actions a
nurse can
take help
with
anaphylactic
reaction to
drug?

Assist with breathing issues, address swelling,

address rash and hives. stop med
immediately, contact physician

68.

Parts of head
to toe
assessment

Head& Neck, Eyes, Mouth, Oral Pharynx,

Upper Extremities, Thorax and Lungs, Cardiac
& Peripheral Vascular assessment, Abdomen,

47.

Pharmacokinetics

The study of how medications enter the

body, how the medication is absorbed
and distributed into cells, tissues, or
organs. How the medication alters
physiological functions.

48.

absorption

rate at which drug leaves site of

administartion

49.

Distribution

how the drug is transported to where it's

needed

50.

Metabolism

How the drug is broken down(liver)

69.

PERRLA

51.

Excretion

How the leftover drug is excreted

(kidney)

Pupils equal, Round, Reactive to light &

accommodation.

70.

How to
access
PERRLA?

Dim lights to dilate pupils. Test

accommodation by having pt. focus on distant
object causing pupils to dilate. Have them
shift gaze to finger 3-4 inches from nose.Test
is done to see if pupil constriction is affected
by medications, cataraacts, light,
inflammation.

52.

Onset

The time it takes for a medication to

produce a response

53.

Peak

Time at which a medication reaches its

highest effective concentration. (If too
high may have toxic effects)

54.

Duration

The time medication concentration is

sufficient to produce therapeutic
response

71.

Landmarks
for heart &
lung sounds

Aortic area Pulmonic area, Erb's Poin,

Tricuspid, Mitral/Apical Area (A Pig, Eats, Ten,
Melons)

55.

Half-Life

Time for serum drug concentration to be

halved. Time for 1/2 of original or
remaining amount of drug to be
eliminated from the body.

72.

S1 & S2

56.

Trough

The minimum blood serum concentration.

57.

Idiosyncratic
response

An over or under reaction to a

medication, or a peculiar response.

S1= first heart sound. The beginning of

systole. Produced by closer of mitral and
tricuspid valves, coincides with carotid artery
pulsation.
S2= Second heart sound. The end of systole.
Produced by closure of aortic and pulmonic
valves. May be split-normal.

73.

58.

Synergisitc

The combined effect of two medications.

Effect of medications is greater than
effect of medications given separately.

Where is S1
sound heard
at?

Best heard in mitral or apex area. low pitched

ad dull (lub)

74.

59.

Bioequivalent

2 medications have the same bioavailability or med has same bioavailability by different routes (example,
cipro has the same bio availability by IV
or oral route)

Where is S2
sound heard
at?

Heard at the aortic area. higher pitched and

shorter (dub) Heard best at base of heart

75.

S1 and S2
indicate
what?

The interval between S1 and S1 show if there

is a regular rhythm between each sequence of
beats. Can indicate dysrhthmia if there is
failure or regular intervals.

76.

Adventitous
breath
sounds?

Abnormal breath sounds in addition to

underlying breath sounds (superimposed).
Crackles (alveoli popping open) heard in
COPD, pneumonia, CHF. Wheezes (due to
narrow airways) high pitched sounds like
squeaks. Gurgles/Rhonchi (cleared by
coughing) low-pitched, course, loud. Heard
during expiration.

60.

Pharmacodynamics

The study of what the drug does to the

body. The drug action (how does the
drug work?) Therapeutic effect( What
does drug do specific to your client?)

61.

Therapeutic effect

expected or predictable desired

response

62.

Side effects

predictable, often unavoidable,

secondary effect.

77.

78.

Bell of stethoscope

Diaphragm of
stethoscope

Heard for low and medium pitched

sounds and murmurs. Bell used to hear
soft, low-pitched sound such as
vascular sounds and extra heart
sounds.
Used to detect S1 and S2 as well as
diastolic and 3RD heart sounds. Higher
pitched murmurs are also
detectable.Diaphragm used to hear high
pitched sounds such as breath and
bowel sounds.

79.

what are clubbing of

the fingers?

when the base of the nail is greater

than 180 degrees. Caused by long term
lack of oxygen.

80.

What is a barrel
chest?

when width and depth are equal and

ribs are horizontal. related to chronic
lung hperinflation (emphysema)

81.

What type of
patients have sx of
clubbing

patients that are experiencing sx of

chronic pulmonary disease, hypoxia,
long term

82.

How to assess
circulation to the
extremities?

assess color, temperature, cap refill.

CMS

83.

What symptoms
cause concern when
assessing
circulation to the
extremities?

swelling, tenderness, redness, warmth

of lower extremties, symptoms of DVT,

84.

What symptoms
require immediate
intervention when
acessessing
circulation to the
extremities?

cold, discoloration, tingling, numbness

85.

How do you assess

for anemia, pallor,
jaundice?

by inspecting and palpating the skin

and mucous membranes. eyes for
jaundice.

86.

How to assess for

anemia, pallor,
jaundice for
someone with
darker skin?

through the eyes.

87.

other abnormal
assessment
findings?

Splinting of respirations due to pain.

Pain, fever, or anxiety causing an
increased breathing.
Symptoms of hypoxia,
Cool and clammy skin,

88.

How to access
circulation to the
extremities?

Inspect extremities.. assess color,

temperature, cap refill.
Skin cool & clammy - due to shunting
O2 to core,
Cyanosis (bluish discoloration of
nailbeds, oral mucosa, conjunctiva)
clubbing - sx of chronic pulmonary
disease, hypoxia
cap refill should be <3 sec.

89.

where to
auscultate the
Aortic area?

2nd Intercostal Space, Right Sternal Border

90.

where to
ausculate the
pulmonic
area?

2nd intercostal space, Left sternal border.

91.

Erb's Point or
secondary
pulmonary
ausculatation?

3rd intercostal space, left sternal border.

92.

Tricuspid
auscultation?

5th intercostal space, left sternal border.

93.

Mitral/Apical
area
auscultation?

5th intercostal space, midclavicular line or

slightly medial.

94.

SX of fluid
overload and
CHF?

dyspnea on exertion,
orthopnea,
fatigue,
crackles in lungs.
pitting edema,
High BP bounding pulse initially and
progressing to weak pulse and low BP.
S3 gallop,
tachycarida.
Jugular vein distension,
skin pale, gray, cyanotic,
dilated pupils (sympathetic nervous system),
nausea & vomiting,
ascites(accumilation of fluid in peritonial
cavity)

95.

types of
nursing
diagnosis?

actual (defining characteristics or signs and

symptoms)
risk for or potential diagnosis(risk factors
evident, but no sx yet present)
health promotion diagnosis(pt express desire
to increase well-being)
wellness diagnosis( pt express desire to
transition to higher level of wellness"

96.

step 2.
Nursing
Diagnosis

Reviewing and analyzing clustered

assessment data to determine client problems
and areas of strenth. Choose diagnosis
based on presence of "defining
characteristics" or signs and symptoms.
Nursing diagnosis describes clients actual or
potential response to health problems that the
nurse is educated, licensed and competent to
treat.

97.

how to avoid
diagnostic
errors?

Verify data with pt/family, diagnostic tests

Know normals for population, individual
Consult resources - texts, journals,
colleagues
Look at patterns, not individual incidents

98.

Step 3.
Planning care

1. Prioritize Nursing Diagnosis

2. Establish goals & outcomes
3. Plan interventions or actions to achieve
goals

99.

what are interventions?

Actions performed to measure or achieve client outcomes(resolve NANDA)

Assessment
Therapeutic
Educational
Referral or health promotion

100.

Step 4. Implementation

Implementing the planned nursing interventions.

Requires:
Intellectual skills
Interpersonal skills
Technical skills
Cognitive skills

101.

Step 5. Evaluation of effectiveness of care

Nursing process is an on-going cycle.

Continue to assess and collect data.
Progress of pt must be communicated and documented.
Plan must be assessed and reassessed, revised as needed.