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exam 1
| Question | Answer |
|---|---|
| 49. Types of mode of transmission and what we need to do to protect ourselves? | Contact- direct contact: draining wounds, secretion, and supplies Use gloves and gown: usually it will be VRE, C.diff, RSV Airborne- pathogens spread in air- ventilation, shaking, sweeping Gown, gloves, and mask- TB Droplet- pathogens spread through m |
| 48. What are the 6 links of infection | - Infectious agent - Reservoir - Port of exit - Mode of transmission - Port of entry - Susceptible host |
| 47. What are the stages of infection? | Incubation: the host is infected and doesn’t know, it is a good time to infect others primordial- symptoms and signs are starting to appear. illness- signs and symptoms are present decline- pathogen and illness starts to decline convalescence- tissue |
| 46. What is encoding? | - A sender being selective of words used, gestures, tones to transmit or send a message. |
| 45. What is decoding? | The interpretation of a message |
| 44. What factors affect communication? | - Environment - Sociocultural factors - Personal space - Roles and relationships - Developmental variations - Gender |
| 43. What are the barriers of therapeutic communication? | - Asking too many questions - Fire hosing - Changing subject inappropriately - Patronizing language - Stereotyping - Advice - Failing to probe - Asking why |
| 42. What are the phases of therapeutic communication | - Pre-interaction- gathering info about client and looking at chart - Orientation- introducing yourself to client and building a rapport - Working- the active stage of the relationship making sure we restate, clarify, and validate - Termination- end of |
| 41. What is SBARQ? | - Situation - Background - Assessment - Recommendation - Question |
| 40. A wound appears to be healing is no longer beefy and red and bleeding. Would considered what stage of healing? | - Maturation/ remodeling |
| 39. The nurse assists the pt to imagine they are on a beach instead of the hospital? | - Guided imagery |
| 38. The inflammatory stage of wound healing is the first stage, the cleansing stage and it last 1-5 days? | - True |
| 37. What are the intrinsic factors for pressure injury development? | - Immobility - Impaired sensation - Dehydration - Edema |
| 36. Nurses should assess wounds for the following. | - Location - Size - Pain - Appearance |
| 35. What factors affect skin integrity? | - Age - Nutrition - Hydration - Circulation - Infection - Medication - Moisture |
| 34. when someone has impaired cognition, the following should be followed when communication with the individual? | - Always communicate - Address the pt - Use yes or no question |
| 33. What are all the factors affecting verbal communication? | - Vocabulary - Place of conversation - clarity - humor |
| 32. The only purpose of nursing care is health promotion. | - False |
| 31. Important qualities for nurses? | - Critical thinking - Listening - Caring and compassionate - Being patient - Organized |
| ADPIE is assessment, diagnosis, planning, intervention, and evaluation? | - True |
| 29. What key interventions can a nurse take to prevent tissue injury or improve pt risk of further injury to already broken injury? | - Bathing, q 2hr repositioning, adequate nutrition, educate, therapeutic mattress. |
| 28. What are the common methods of debriding a wound? | - Mechanical wound vac, enzymatic- topical treatments, auto-lysis dressing, biotherapy shock wave, light therapy, and surgical procedure. |
| 27. What are the 2 tools used for skin assessment? | - Braden risk assessment - Push tool for wounds |
| 26. What is the treatment of dehiscence? | - Using a sterile 4x4 over area and monitor for drainage, report to dr on rounds. |
| 25. What are the complications of wound healing? | - Infection, hemorrhage, evisceration, dehiscence, and fistula formation. |
| 24. What are the types of exudates and what do the look like? | - Serous: yellow straw colored, thin drainage - Sanguinous: bloody drainage - Serosanguinous: mix of blood and yellow straw-colored drainage - Purulent: pus, yellow and thick |
| 23. What are the founding leaders and what did they do? | Florence nightingale: consider the founder of modern nursing. Was also considered the lady with the lamp by wounded soldiers. Help developed the nursing process. Dorthea dix- superintendent army nurse Clara Barton – American red cross Mary Mahoney: |
| 22. What are the stages of pressure injury: | Stage 1: intact skin and nonblanchable redness. Firm, soft, warmer, and discolored. Looks like a rash. Stage 2: open and shallow but shallow, with red/ pink wound bed loss of dermis skin. Maybe a blister burst Stage 3: deep crater damage with necrotic |
| What are the stages of healing? | INFLAMATORY PHASE: takes 1-5 days Hemostasis: injury causes blood vessels to be destroyed, the allows blood to leak into the wound area. So, to limit the blood leakage the blood vessels constrict. Platelets move in towards the wound and aggregate to slow |
| 20. What is a wound healing classification called tertiary intention mean? | - Tertiary intention means that the Wound clean edges, left open, granulation partially fills but then later it is sutured together |
| 19. What is wound healing classification called secondary intention mean? | - Secondary intention means the wound is gaping and has tissue loss, like abscess, can’t be sutured, increased scarring, and risk for infection. |
| 18. What is a wound healing classification called primary intention mean? | - Primary intention means you have clean wound/ edges together by sutures, causing minimal scarring and low risk for infection. |
| 17. Secondary factors causing skin breakdown | - Ischemia (decreased circulation), medication, moisture, fever, infection, lifestyle. |
| 16. What factors improve skin health and decrease risk for tissue injury? | - Proper nutrition- protein, vit C, Zinc, Copper, and plenty of water to drink. |
| What is the greatest risk for a PT causing tissue injury? | - Decreased sensation |
| 14. What is the body’s first line of defense against infection? | - Skin |
| 13. During inflammation what chemical defenses are involved and what does it do? | - Histamine: increases blood flow to the area causing erythema and heat - Bradykinins: increasing fluid to the area allowing increase permeability this causes edema - Serotonin: increases WBC’s thus causing pain. |
| 12. What type of medication is often mixed with local anesthetic and why? | - Vasoconstrictors to reduce loss if blood at the site |
| 11. What are the signs of the non-verbal pt with pain? | - Changes in Vital signs, behavioral, posture, body positions, and facial expression |
| 10. The nurse assessing the confused PT in trying to determine the pain level the nurse should. | - Observe pt’s behavior changes, vital signs, and use wrong baker scale. |
| 9. What does OLD CARTS mean? | - Onset - Location - Duration - Characteristics - Aggravated/ alleviating - Radiating/relieving - Timing, severity, treatment |
| 8. What is idiopathic pain? | - Pain with an unknown cause |
| 7. What is nociceptive pain? | - Injury to tissue: typically considered aching and throbbing pain |
| 6. What is visceral pain? | - Pain in the organs (abdominal) |
| 5. What is somatic pain? | - Pain in the muscle, skin, bone, tendon, ligaments, fracture, arthritis. Typically considered achy pain. |
| 4. What is cutaneous pain? | - Pain caused by injury to superficial tissue |
| 3. What is pain? | - Unpleasant sensory/ emotional discomfort caused by illness, injury, or trauma; it is whatever the pt says it is. |
| 2. What type of pain scale do we use for patients who can comm clearly? | - Numerical scale |
| .What pain scale do we use for nonverbal or child’s PT’s? | - Wrong baker scale |
Created by:
lauren90
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