Exam #3 (Week 5)

1.What is the highest priority in Maslow’s hierarchy?

Physiologic needs → oxygen + water + food + elimination + temperature + rest

2.A patient needs oxygen and emotional support. Which comes first?

Oxygen → physiologic needs are addressed before psychosocial needs

3.What is the second priority in Maslow’s hierarchy?

Safety and security → protection from injury + infection + harm

4.A patient is lonely in isolation but another patient is at risk for DVT. Who is priority?

Patient at risk for DVT → physiologic need comes before love and belonging

5.What does self-actualization mean?

Reaching maximum potential → creativity + problem-solving + personal growth

6.What nursing action supports self-actualization?

Focus on patient strengths + abilities → offer direction and hope

7.What happens when basic needs remain unmet?

The risk of illness increases → unmet lower-level needs take priority

8.What is a family?

Any group the patient identifies as family → provides physical + emotional + financial support

9.What is family durability?

Support and structure that continue despite major life changes

10.What is family resiliency?

Ability to adapt and cope with expected or unexpected stressors

11.What is family diversity?

Uniqueness of each family’s structure + culture + strengths + challenges

12.A patient identifies a close friend as family. What should the nurse do?

Respect the patient’s definition of family → include the friend if appropriate

13.What is a nuclear family?

Two parents + their children

14.What is an extended family?

Nuclear family + relatives such as grandparents + aunts + uncles + cousins

15.What is a blended family?

Parents and children from previous relationships living together

16.What is a single-parent family?

One parent raising children → may result from divorce + separation + death + never marrying

17.What is an alternative family structure?

Cohabitating adults + communal groups + grandparents raising grandchildren

18.What is the family’s physical function?

Provides food + shelter + safety + comfort

19.What is the family’s economic function?

Provides financial support for members

20.What is the family’s reproductive function?

Having and raising children

21.What is the family’s affective and coping function?

Provides emotional comfort + helps members manage stress

22.What is the family’s socialization function?

Teaches values + beliefs + attitudes + problem-solving

23.A family comforts a child after surgery. Which function is demonstrated?

Affective and coping

24.A family teaches a child cultural beliefs. Which function is demonstrated?

Socialization

25.What characterizes a healthy family?

Open communication + support + adaptability + shared time + resource use

26.What is family structure?

Membership and relationship patterns within the family

27.What is family function?

Processes used to communicate + make decisions + adapt

28.What family structure may impair functioning?

Structure that is too rigid or too flexible → limits adaptation during crisis

29.What is the family-as-context approach?

Focus on the individual patient → family is background

30.What is the family-as-patient approach?

Focus on family communication + roles + coping patterns

31.What is the family-as-system approach?

Focus on the patient and family unit simultaneously

32.What is the first step of the nursing process with a family?

Assess patient + family + culture + resources + discharge needs

33.What is the best planning approach with a family?

Create a mutually agreed plan → ask for family ideas + offer choices

34.What is a priority nursing intervention for caregiver strain?

Listen to concerns + divide tasks + provide respite resources

35.A caregiver is exhausted and arguing with family members. What should the nurse assess?

Caregiver role strain → stress + sleep + nutrition + support system

36.What is respite care?

Temporary relief for caregivers → prevents exhaustion and supports continued caregiving

37.What are family-centered nursing responsibilities?

Provide information + reassurance/support + family involvement

38.How can the nurse promote family closeness?

Include family in care when appropriate → empower them as care partners

39.What developmental task applies to families with adolescents?

Balance freedom and responsibility + maintain open communication

40.What developmental task applies to families with older adults?

Adjust to retirement + cope with loss + maintain independence

41.What is a psychosocial family-health risk factor?

Inadequate childcare + divorce + unemployment

42.What is an environmental family-health risk factor?

Unsafe housing + pollution + lead + neighborhood violence

43.What is a lifestyle family-health risk factor?

Poor nutrition + inactivity + tobacco + substance use

44.What is a developmental family-health risk factor?

Teen pregnancy + new baby + launching children + aging

45.What is a biologic family-health risk factor?

Genetic predisposition → family history of heart disease

46.A working couple lacks childcare. What type of risk factor is this?

Psychosocial → inadequate childcare

47.What community factors directly affect health?

Social support + health care structure + economic resources

48.How does social support improve health?

Buffers stress → provides help during illness or crisis

49.What does health care accessibility mean?

Ability to obtain needed services → availability + affordability + location

50.How can poverty affect health?

Limits access to food + housing + medications + health care

51.What is environmental health?

Human health affected by physical + chemical + biologic + psychosocial surroundings

52. What are physical environmental hazards?

Noise + radiation + extreme heat or cold

53.What are chemical environmental hazards?

Pollutants + pesticides + lead + carbon monoxide

54. What are biologic environmental hazards?

Bacteria + viruses + mold + disease-carrying insects

55.What are psychosocial environmental hazards?

Stress + crowding + violence + social isolation

56.What indoor pollutants can worsen respiratory disease?

Tobacco smoke + mold + carbon monoxide + radon

57.Which patients are most vulnerable to heat-related illness?

Older adults + children + chronically ill + low-income + unhoused patients

58.What should the nurse teach during poor air quality?

Limit exposure + monitor air-quality alerts + avoid outdoor exertion

59.What is an intentional wound?

Planned therapeutic wound → surgical incision + venipuncture

60.What is an unintentional wound?

Unexpected traumatic wound → irregular edges + uncontrolled bleeding

61.What is an open wound?

Break in skin or mucous membrane → increased infection risk

62.What is a closed wound?

Tissue injury without an open skin break → contusion or hematoma

63.What is an acute wound?

Wound that usually heals within days to weeks through normal stages

64.What is a chronic wound?

Wound lasting over 30 days → delayed or interrupted healing

65.What is a pressure injury?

Localized ischemic damage caused by pressure → reduced blood flow + oxygen + nutrients

66.Where do pressure injuries usually occur?

Over bony prominences → sacrum + coccyx + trochanter + heels

67.How quickly can a pressure injury develop?

As little as 1–2 hours without movement or repositioning

68.What is the main cause of a pressure injury?

External pressure compresses capillaries → ischemia → hypoxia → necrosis

69.What is friction?

Two surfaces rub together → heat + superficial skin damage

70.A patient pushes up in bed using the heels. What injury risk increases?

Friction injury → use lifting equipment or a draw sheet

71.What is shear?

One tissue layer slides over another → blood vessels stretch or tear

72.A patient slides down in bed with the head elevated. What force is occurring?

Shear → tissue layers move in opposite directions

73.What is microclimate?

Skin temperature and moisture → excess moisture increases skin breakdown

74.What are major pressure-injury risk factors?

Aging skin + immobility + malnutrition + incontinence + altered consciousness

75.What is Stage 1 pressure injury?

Intact skin with nonblanchable erythema (superficial redness of skin or mucous membrane)

76.What is Stage 2 pressure injury?

Partial-thickness skin loss with exposed dermis

77.What is Stage 3 pressure injury?

Full-thickness skin loss without exposed fascia

78.What is Stage 4 pressure injury?

Full-thickness skin and tissue loss → deeper structures may be exposed

79.What is an unstageable pressure injury?

Full-thickness tissue loss obscured by slough or eschar

80.What is a deep tissue pressure injury?

Persistent nonblanchable deep red + maroon + purple discoloration

81.What does blanchable erythema suggest?

Skin temporarily reddens but turns pale with pressure → not Stage 1

82.What is the Braden Scale used for?

Predicting pressure-injury risk → assess on admission and regularly

83.What senses are used during wound assessment?

Sight + smell + touch

84.What local factors delay wound healing?

Pressure + dehydration + maceration + trauma + edema + infection + necrosis

85.What systemic factors delay wound healing?

Poor circulation + malnutrition + immunosuppression + corticosteroids + age

86.Why is protein important for wound healing?

Supports tissue repair + collagen formation + immune function

87.What are major wound complications?

Infection + hemorrhage + dehiscence + evisceration + fistula

88.What is wound dehiscence?

Separation of wound edges

89.What is wound evisceration?

Internal organs protrude through a separated wound → cover with sterile saline dressings and notify provider

90.What is healing by primary intention?

When clean wound edges are brought together and closed (such as with stitches, staples, or glue), so the skin heals quickly with minimal scarring

91.What is healing by secondary intention?

When an open wound is left unstitched to heal naturally from the inside out through granulation, contraction, and new skin growth.

92.What is a chronic wound commonly associated with?

Vascular compromise + reinjury + chronic inflammation

93.What is the priority when applying an elastic bandage?

Ensure it is not too tight → prevent impaired circulation

94.What is the purpose of wound irrigation?

Remove debris and microorganisms while preventing additional tissue trauma

95.How does a DuoDERM hydrocolloid dressing work?

Absorbs exudate → forms moist gel → supports autolytic debridement + protects from friction