Main Study Guide for Exam 2

A patient on bed rest is at risk for which urinary complication caused by immobility?

Urinary stasis, which increases risk for UTI and renal calculi

Which exercise involves muscle contraction and joint movement, such as walking?

Isotonic exercise

Which exercise strengthens muscle without moving the joint, such as a quad set?

Isometric exercise

Which exercise uses a machine to provide constant resistance during movement?

Isokinetic exercise

What is the safest body-mechanics position before lifting or moving a patient?

Use a wide base of support, keep the load close, bend the knees, and avoid twisting

Which complications should the nurse monitor for in an immobile patient?

DVT/PE, orthostatic hypotension, atelectasis/pneumonia, constipation, urinary stasis/UTI, muscle atrophy, contractures, osteoporosis, pressure injuries, and depression

Which intervention helps prevent Deep Vein Thrombosis (DVT) in an immobile patient?

Early ambulation, leg exercises, SCDs or compression stockings, and fluids if not contraindicated

Which interventions reduce respiratory complications of immobility?

Turn at least every 2 hours, encourage coughing and deep breathing, use incentive spirometry, and elevate the head of bed

How can the nurse help prevent constipation in an immobile patient?

Encourage fluids, fiber, activity as tolerated, and privacy for elimination

How often should an immobile patient generally be repositioned to prevent pressure injuries?

At least every 2 hours, with skin checks every shift and pressure-relieving surfaces as appropriate

Which nursing activities may be delegated to UAP for a stable patient with mobility needs?

Turning/repositioning, ambulation, ROM, applying SCDs or compression stockings, and assistance with ADLs

Which responsibilities must the RN retain when caring for a patient with mobility problems?

Assessment, care planning, teaching, evaluation, and care of unstable patients

What is the difference between active and passive ROM?

Active ROM is performed by the patient, passive ROM is performed by a caregiver for the patient

What is the purpose of ROM exercises?

Maintain joint mobility and muscle tone, prevent contractures, and improve circulation

How should ROM be performed and when should it stop?

Move joints slowly and smoothly through the range 3–5 times, support the joint, and stop at pain or resistance

Moving a limb away from the body's midline is called what?

Abduction

Moving a limb toward the body's midline is called what?

Adduction

Turning the palm downward is called what?

Pronation

Turning the palm upward is called what?

Supination

Pointing the toes upward toward the shin is called what?

Dorsiflexion

Pointing the toes downward is called what?

Plantar flexion

Turning the sole inward is called what?

Inversion

Turning the sole outward is called what?

Eversion

What is the safest way to give directions to a patient with dementia?

Face the patient, use their name, speak calmly in short simple phrases, give one step at a time, and phrase directions positively

When should restraints be considered?

Only as a last resort to prevent harm or removal of life-sustaining equipment after less restrictive alternatives fail

Can restraints be used for staff convenience or as punishment?

No, restraints must never be used for convenience or punishment

What is required before applying restraints?

A time-limited provider order, PRN restraint orders are not allowed

What is the first action before using restraints when the patient is not in immediate danger?

Try less restrictive alternatives such as reorientation, sitter/family supervision, alarms, diversion, scheduled toileting, frequent rounding, and a low bed

Why can raising all four side rails be considered a restraint?

It restricts the patient's ability to leave the bed

Where should a restraint be secured?

With a quick-release knot to the bed frame, never to a side rail

How much space should be left between a restraint and the patient's skin?

About 1–2 fingers

How often should restraints be released for ROM according to the study guide?

At least every 2 hours

What should the nurse assess distal to a restraint?

Pulse, color, temperature, sensation, and circulation

What care must continue while a patient is restrained?

Food, fluids, toileting, hygiene, repositioning, monitoring, and documentation

Which seizure precautions should be available at the bedside?

Oxygen, oral airway, suction, padded side rails, clear surroundings, and assistance with ambulation/transfers

What should the nurse do first when a patient begins having a seizure?

Stay with the patient and call for help while protecting them from injury

What position should the nurse place a patient in during a seizure when possible?

Side-lying to protect the airway and allow secretions to drain

What must the nurse never do during a seizure?

Never restrain the patient or put anything in the patient's mouth

What information should the nurse observe during a seizure?

Onset and duration, movement pattern, eye deviation, consciousness, airway/color, and incontinence

What is the postictal phase?

The period after a seizure when the patient may be confused and sleepy

What should the nurse assess after a seizure?

Airway, mental status, vital signs, and pulse oximetry, keep the patient side-lying and provide a quiet environment

Which fall-risk factor is the strongest predictor of future falls?

A history of falls

Which interventions are universal fall precautions?

Bed low and locked, call light/items within reach, nonskid footwear, good lighting, clutter-free dry floor, orientation, handrails, and hourly rounding

What does RACE mean during a fire?

Rescue, Alarm, Confine, Extinguish or Evacuate

What does PASS mean when using a fire extinguisher?

Pull the pin, Aim at the base, Squeeze the handle, Sweep side to side

Which fire extinguisher class is used for paper, wood, cloth, and trash?

Class A

Which fire extinguisher class is used for flammable liquids and gases?

Class B

Which fire extinguisher class is used for electrical equipment?

Class C

Which extinguisher can be used for Class A, B, and C fires?

An ABC extinguisher

What is the body's circadian rhythm?

The internal 24-hour clock controlled by the hypothalamus

Which hormone promotes sleepiness and is released by the pineal gland in darkness?

Melatonin

What is the usual length of a sleep cycle and how many occur nightly?

About 90 minutes per cycle, with roughly 4–6 cycles per night

Which sleep stage is the light transition from wakefulness and is very easy to awaken from?

NREM Stage I

In which sleep stage does the patient fall into true sleep and can be aroused with relative ease?

NREM Stage II

Which sleep stage begins deep sleep, with decreased vital signs and muscle tone?

NREM Stage III

Which stage is the deepest and most restorative in the study guide, with growth hormone release?

NREM Stage IV

Which sleep stage includes dreaming, rapid eye movements, active brain activity, and temporary muscle paralysis?

REM sleep

How much sleep do adults generally need according to the study guide?

About 7–9 hours per day

How much sleep do adolescents generally need according to the study guide?

About 8–10 hours per day

What is a recommended intervention to improve sleep in older adults?

Increase physical activity during the day and maintain a consistent sleep-wake schedule

How can the nurse reduce hospital-related sleep disruption?

Keep the room dark, quiet, and comfortable, cluster care, support bedtime routines, manage pain, and avoid unnecessary awakenings

What is insomnia?

Difficulty falling asleep or staying asleep despite adequate opportunity to sleep

What is narcolepsy?

A neurologic disorder causing excessive daytime sleepiness and sudden uncontrollable sleep attacks

What is cataplexy?

Sudden loss of muscle tone, often triggered by strong emotion

What is obstructive sleep apnea?

Repeated upper-airway collapse during sleep that interrupts breathing, often for 10 seconds or longer

What is the main treatment for obstructive sleep apnea listed in the guide?

CPAP

Which findings suggest obstructive sleep apnea?

Loud snoring, witnessed pauses in breathing, gasping/choking, daytime sleepiness, and morning headache

What is restless legs syndrome?

Uncomfortable crawling or tingling in the legs with an urge to move, worse at rest/evening and relieved by movement

What should a sleep diary include?

Bedtime, time to fall asleep, awakenings, wake time, stressors, food/drink, medications, activities before bed, and worries

What is stress?

A state in which normal balance is disrupted by a real or perceived demand or threat

What is a stressor?

Anything that causes stress

What is adaptation?

A change in response to a stressor that helps restore balance or homeostasis

What is the difference between a developmental and situational stressor?

Developmental stressors are expected at life stages, situational stressors are unpredictable events that can happen at any time

What is the Local Adaptation Syndrome (LAS)?

A short-term response affecting one body part, such as a reflex pain response or local inflammation

What are the three stages of General Adaptation Syndrome (GAS)?

Alarm, resistance, and exhaustion

Which findings are expected in the alarm stage of GAS?

Fight-or-flight response with tachycardia, rapid breathing, increased blood pressure, dilated pupils, restlessness, and increased blood glucose

What happens during the resistance stage of GAS?

The body adapts and copes, vital signs move toward normal while resources are being used

What happens during the exhaustion stage of GAS?

Adaptive resources are depleted, increasing fatigue, frequent illness, headaches, muscle tension, and stress-related disease

How does anxiety differ from fear?

Anxiety is unease from an unclear or unknown source, fear is a response to a specific identifiable threat

At which anxiety level is learning and problem-solving often best supported?

Mild anxiety

How should the nurse respond to severe anxiety?

Stay with the patient, reduce stimuli, and give simple, direct instructions

What is the priority response to panic-level anxiety?

Ensure safety, stay with the patient, provide brief calm directions, and create a quiet setting

What is problem-focused coping?

Taking direct action on the stressor, such as making a plan or getting information

What is emotion-focused coping?

Managing feelings caused by a stressor, such as relaxation, exercise, talking, or crying

What is appraisal-focused coping?

Changing how the person views a stressor through reframing, positive thinking, or humor

A patient insists a new myocardial infarction is only indigestion. Which defense mechanism is this?

Denial

A patient angry with a provider yells at the nurse. Which defense mechanism is this?

Displacement

A person blames another person for feelings they themselves have. Which defense mechanism is this?

Projection

A person gives a logical-sounding excuse for a failure. Which defense mechanism is this?

Rationalization

A person acts overly kind to someone they dislike. Which defense mechanism is this?

Reaction formation

A child returns to bedwetting after a new sibling is born. Which defense mechanism is this?

Regression

A person unconsciously blocks a painful memory. Which defense mechanism is this?

Repression

A person consciously chooses not to think about a problem. What is this called?

Suppression

A person channels anger into boxing or another acceptable activity. Which defense mechanism is this?

Sublimation

A person buys a gift to make up for an unacceptable action. Which defense mechanism is this?

Undoing

What is caregiver burden?

Physical, emotional, social, and financial strain from caring for an ill or dependent family member

What is the priority supportive intervention for caregiver role strain?

Offer respite care, support groups, teaching, community resources, and encourage self-care

What are effective healthy stress-management strategies?

Exercise, adequate sleep, nutrition, social support, relaxation, meditation, guided imagery, humor, time management, and journaling

What are the five crisis-intervention steps?

Identify the problem, list alternatives, choose an alternative, implement the plan, and evaluate the outcome

How does health differ from wellness?

Health includes physical, mental, and social well-being, wellness is an active state of living a health-promoting lifestyle