Fundamentals test 2

Havighurst theorized that learning is a ____?

Lifelong process.

Piaget believed cognitive development requires?

Adaptation, assimilation, and accommodation.

Erikson believed that failure to successfully move through a stage leads to?

Maladjustment.

Striking the bottom of a newborn’s feet checks for?

Reflex responses.

Infant doubles in birth weight by 2 months?

False.

Piaget described infancy phase as?

Sensorimotor phase.

Infants should be assessed every 2, 4, 6, and ____ months?

 12 months.

Drowning = leading cause of accidental death in toddlers?

True.

 Erikson’s initiative versus guilt is the stage where a child develops a?

Conscience.

 Child abuse may be injuries that aren’t well explained by parents?

True.

Ask an older adult to perform a task; it takes a long period of time to complete. Best nurse response?

Reaction time slows in older adults.

Most challenging for older adults?

Chronic health problems causing loss of independence.

 Theory of aging focuses on the accumulation of metabolic wastes?

Wear and tear.

A sedentary lifestyle increases the risk of aging-related diseases & premature death?

True.

Which instruction would the nurse give an older adult to promote wellness?

Engage in physical activity.

Which chronic diseases are leading causes of death among older adults?

 Heart disease, diabetes, strokes, cancer.

 Dry skin is a normal developmental change of aging?

 True.

Assessing for depression should be part of older adults assessment?

True.

Priority nursing intervention for an older adult abuse victim?

 Ensure safety of victim.

Nurse performs physical exam to?

 Establish baseline data, screen for health problems, identify nursing diagnosis.

What would you tell the older adult to reduce the risk of disability?

Workout to stay fit.

Age-related integumentary changes in older adults?

Dry skin, nail thickening, hair thinning.

Erikson’s developmental theory identifies integrity versus despair for older adult?

True.

Agnosia is?

The impaired ability to recognize or identify objects.

When nurse prepares for physical assessment of a client, they should consider?

Theoretical knowledge, self-knowledge, knowledge about client situation.

Signs of cyanosis are?

Blue tinge on skin, blue tinge on tongue, blue tinge on mucous membranes.

When teaching a patient on Lantus administration, it is best to?

 Get a return demonstration from patient.

Self-efficacy is the client’s perceived ability to successfully perform a task?

True.

Some factors that affect client learning are?

 

Motivation, timing, readiness to learn.

Lecturing & audiovisuals are most effective means of presenting information to class size groups?

 True.

 Nurse should include in plan of care as a teaching goal for a patient with heart failure?

Patient will not return to hospital w/in 30 days.

Nurse will complete teaching on how to check for radial pulse by the client when?

 

the client recognizes the need to learn the skill.

Some components of a learning assessment are?

What are the client’s cognitive abilities; How does client learn best; client’s ability to see, hear, & grasp knowledge.

What statement by nursing student warrants further education? “Since medication is over the counter, it’s okay to be given by the CNA.”

This statement warrants further education.

Pharmacokinetics refers to the ___ of a drug.

Absorption, metabolism, distribution, excretion.

Metabolism mainly takes place in liver (first pass effect)?

True.

Medications can be detoxified in liver and?

Kidneys, lungs, blood, plasma.

Medication errors are caused by?

Lack of info, equipment errors, faulty communications, calculation errors.

you cant crush enteric coated meds?

True.

Six rights of med administration include?

 

Right drugs, right dose, right time, right route

 Buccal & sublingual meds are absorbed in?

Mucous membranes.

Examples of parenteral routes for medication administration?

 Intradermal, subcutaneous, intramuscular, transdermal.

Always rotate insulin injection sites?

 True.

 First action that should be taken with allergic reaction from IV?

 Stop infusion.

2 sites best absorption of insulin are?

 

Arms, abdomen.

Client can best assure their meds are safe by?

Telling their provider every med they are taking, check drug info prior to leaving the pharmacy, ask how & when client should take meds, only take meds as prescribed.

Most important nursing action related to medication is administering drugs safely?

True.

Drugs that are inactivated through the liver before reaching systemic circulation?

First pass effect.

Client on low protein diet, affect which pharmacokinetic process?

Distribution.

Therapeutic range is a range of therapeutic concentrations?

True.

Trough level occurs when drug is at lowest concentration, right before next dose due?

True.

 Peak level occurs when drug at highest concentration?

 True.

Adverse reactions are?

Harmful, unintended reactions to a drug.

 Tolerance is decreasing response to repeated doses of medication?

True.

Doctor orders medication wrong, you should?

Clarify order w/ the doctor.

 Osmosis equalizes the solution on each side of membrane?

True.

ADH?

Helps regulate the amount of water in the body.

Hyperkalemia causes large T waves on EKG?

True.

“Three Checks” — Check medication each 3 times:

1. BEFORE you pour

2. AFTER you prepare

3. AT THE BEDSIDE

6 Rights of Medication

Right medication

Right patient

Right dose

Right route

Right time

Right documentation

Patients’ Rights — Research participation

Right reason

Right to know

Right to refuse

What does the right to refuse mean in research?

Refuse/withdraw from research studies.

Right to self-determination means?

Right to say no.

Macule →

Flat + changed color

NOT raised

Example: freckle

Think: “MACule = Mark”

Papule →

Small + raised + solid

Usually < 1 cm

Example: small pimple

Think: “PAPule = Pops up”

Petechiae →

Tiny, flat, pinpoint areas of bleeding under the skin

Usually red, purple, or brown

Do not blanch when pressed

Can be associated with low platelets or other bleeding problems

Think: “Petechiae = Pinpoint bleeding”

 Informed Consent —

Right to not be harmed

Outlines safety protocols of study.

Informed Consent —

Right to full disclosure

Have right to get answers to all questions about study.

 Informed Consent —

.

 Right to self determination Right to say no

informed Consent —

Rights of privacy/confidentiality

 Identity protected.

Whistleblowing?

 Identification of an unethical or illegal situation. (Can be person or group.)

 Autonomy

 Person’s right to choose; act on that choice.

Nonmaleficence

Do no harm, prevent harm.

Beneficence

Promote good.

Fidelity

Keep promises.

Veracity

Tell truth.

Justice

Be fair.

What are the main characteristics of good nursing documentation?

Factual, accurate, complete, and timely.

What does FACT stand for in documentation?

F = Factual
A = Accurate
C = Complete
T = Timely

When should nursing care be documented?

As soon as possible after the care or assessment is completed.

Should a nurse document care before performing it?

No. Never document something before it has actually been completed.

What type of information should nurses document?

Objective, factual, relevant information about assessments, interventions, and patient responses.

Should judgmental statements be included in documentation?

No. Use objective descriptions rather than personal opinions.

How should a nurse correct a documentation error?

Follow the facility's approved correction procedure and never attempt to hide or falsify the original documentation.

Why is documentation important legally?

It provides a record of the patient's condition and the care that was provided.

How should teaching and nursing care be modified for children?

Use age-appropriate language, involve parents/caregivers, give simple explanations, and offer appropriate choices.

Is disease considered a normal part of aging?

No. Aging causes normal physiologic changes, but disease should not automatically be attributed to aging.

What sensory changes may occur with aging?

Decreased vision, hearing, taste, smell, and touch.

Why are older adults at increased risk for medication complications?

Age-related changes can affect medication absorption, distribution, metabolism, and excretion, and many older adults take multiple medications.

Why are older adults at increased risk for falls?

Changes in vision, balance, strength, mobility, medications, and orthostatic hypotension can increase fall risk.

What is orthostatic hypotension?

A drop in blood pressure associated with changing position, especially when standing.

Nurse Safe Harbor is a

legal/process protection that can help protect a nurse when they believe an assignment or requested action could violate their duty to provide safe patient care.

What should the nurse consider when administering vaccines?

Age, vaccine history, allergies, contraindications, health status, and the recommended immunization schedule.

What are examples of live vaccines?

MMR, varicella, and intranasal influenza vaccine (FluMist).

What should the nurse check before administering a live vaccine?

Contraindications such as significant immunosuppression and pregnancy, depending on the vaccine.

What vaccine helps prevent shingles?

Herpes zoster vaccine.

What vaccine helps prevent HPV-related cancers?

HPV vaccine.

What vaccine protects against measles, mumps, and rubella?

MMR.

What vaccine protects against chickenpox?

Varicella.

What should the nurse assess before beginning patient teaching?

Readiness, motivation, current knowledge, literacy, language, cognitive/physical ability, and barriers to learning.