NURS 2002 Final

Defense Mechanism: Compensation

attempt to make up for perceived weakness

Stimulants

a component of a sleep journal

Length of a Sleep Journal

1-2 weeks

Sleep of Newborns/Infants

12-16 hours of mostly REM

Sleep of School-Aged Child

9-12 hours

Sleep of Young Adults

7-9 hours; 20% REM

Sleep of Middle Adults

decreased stage IV; increased awake time in bed

Sleep of Older Adults

absent stage IV

VS Changes During REM

increase: HR, RR, BP, and body temp

decrease: skeletal muscle tone and DTRs

Perceived Loss

intangible to others; loss of self

Situational Loss

sudden and unpredictable loss

Maturational Loss

the loss of part of your life as you progress throughout life

Bereavement

a state of grieving due to the loss of a loved one

Dysfunctional/Inhibited Greif

distorted grief

Disenfranchised Loss

does not coincide with society’s definition of loss

Emotional Stages of Dying (Kubler-Ross)

denial, anger, bargaining, depression, acceptance

Who Can Diagnose a Terminal Illness

HCP

Who Can Announce Death

HCP and hospice nurse

CN 1

olfactory: sense of smell (sensory)

CN 2

optic: vision (sensory)

CN 3

oculomotor: eye movement, eyelid opening, pupil constriction (motor)

CN 4

trochlear: eye movement (motor)

CN 5

trigeminal: sensation of upper, middle, lower face and mastication (both)

CN 6

abducens: lateral eye movement (motor)

CN 7

facial: taste from anterior 2/3 of tongue, facial expressions, blinking, eye closing, middle ear muscle movement

CN 8

vestibulocochlear: equilibrium and hearing (sensory)

CN 9

glossopharyngeal: sensation of upper pharynx and middle/outer ear, taste from posterior 1/3 of tongue, visceral sensation, elevation of larynx and pharynx, dilation of pharynx (both)

CN 10

vagus: pulmonary, CV, and digestive sensation, outer ear sensation, taste from pharynx, palate, and epiglottis, muscle movement of pharynx, larynx, soft palate, and tongue

CN 11

accessory: nociceptive signals, sternocleidomastoid and trapezius muscles (motor)

CN 12

hypoglossal: tongue movements (motor)

Gaining Bladder Control

4-5 years old

Fiber Requirement

25-38 g/day

Fluid Requirement

2 L/day (women); 3 L/day (men)

Cathartic

medication that promotes peristalsis

Gaining Bowel Control

2-3 years old

Characteristic of a Health Stoma

pink or red, moist, slightly shiny, slightly protruding from abdomen, some mucus production; no excessive pain or foul odor

Components of a Medication Reconciliation

verification, clarification, reconciliation, documentation, communication

NOW

within 90 minutes

STAT

now, as urgently as possible

Time Critical

within 30 minutes

Components of a Hospital Admission Sheet

informer consent, advanced directive, facility-specific information

SC Injection Needle

25-27 G and 1/2-3/8 inch

IM Injection Needle

18-25 G and 1-1 ½ inch

Causes of Infiltration

clogged catheter, catheter dislodgement, leaking from vein irritation

Flushing Capped IVs

flush with 10 mL before and after administration

Flushing IV Medications

flush with 0.9% normal saline at the same rate that the medication was administered

Assessing CN 2

visual acuity; Snellen, Rosenbaum, eye cover, and Ishihara test for distant and hand-held card for near

Assessing CN 2 and 3

pupil assessment; PERRLA

Assessing CN 3, 4, 6

extraocular muscles; 6 cranial eye positions