Pop Quiz 2 Overview Topics

Which clients are at the highest risk for falls?

Older adults, confused patients, patients with weakness, dizziness, poor vision, or a history of falls.

What medications can increase fall risk?

Sedatives, opioids, antihypertensives, and other medications causing dizziness or drowsiness.

What are important fall prevention interventions?

Keep bed low and locked, call light nearby, nonskid footwear, clear pathways, and assist with ambulation.

What should a nurse do before allowing a high-risk patient to walk?

Assess gait, balance, strength, and need for assistance or assistive devices.

What are common skin complications of immobility?

Pressure injuries, redness, skin breakdown, and wounds.

What respiratory complications can result from immobility?

Atelectasis and pneumonia.

What cardiovascular complications can result from immobility?

Deep vein thrombosis, orthostatic hypotension, and decreased circulation.

What findings suggest a possible DVT?

Unilateral leg swelling, warmth, redness, and pain.

What musculoskeletal complications can result from immobility?

Muscle atrophy, weakness, and contractures.

What gastrointestinal complication is common with immobility?

Constipation.

What urinary complications can result from immobility?

Urinary stasis, UTIs, and kidney stones.

What are the four stages of sleep?

NREM N1, NREM N2, NREM N3, and REM.

What happens during NREM N1?

Light sleep and transition from wakefulness to sleep.

What happens during NREM N2?

Deeper sleep with decreased heart rate and body temperature.

What happens during NREM N3?

Deep sleep when physical restoration and tissue repair occur.

What happens during REM sleep?

Dreaming, increased brain activity, and temporary muscle paralysis.

Which sleep stage is associated with the deepest sleep?

NREM N3.

Which sleep stage is most associated with vivid dreaming?

REM sleep.

How long does a typical sleep cycle last?

Approximately 90 to 110 minutes.

What interventions promote sleep?

Reduce noise and light, establish routines, manage pain, and limit nighttime interruptions.

Why should nurses cluster nighttime care?

To reduce interruptions and promote uninterrupted sleep.

What should patients avoid close to bedtime?

Caffeine, excessive screen stimulation, and long daytime naps.

What is a defense mechanism?

An unconscious way of protecting oneself from anxiety or emotional stress.

What is denial?

Refusing to accept or acknowledge reality.

What is repression?

Unconsciously blocking painful thoughts or memories.

What is projection?

Attributing one's own unacceptable feelings to another person.

What is displacement?

Redirecting emotions from the original source to another person or object.

What is rationalization?

Making excuses to justify unacceptable behavior or feelings.

What is regression?

Returning to behaviors associated with an earlier developmental stage.

What is sublimation?

Redirecting unacceptable impulses into socially acceptable activities.

What is compensation?

Focusing on strengths to make up for perceived weaknesses.

What are the four levels of anxiety?

Mild, moderate, severe, and panic.

What characterizes mild anxiety?

Increased alertness and awareness with the ability to learn.

What characterizes moderate anxiety?

Narrowed attention and difficulty concentrating.

What characterizes severe anxiety?

Very limited attention, difficulty processing information, and physical symptoms.

What characterizes panic-level anxiety?

Extreme fear, inability to process information, and loss of control.

What nursing interventions help with mild anxiety?

Encourage learning, problem-solving, and coping skills.

What nursing interventions help with moderate anxiety?

Speak calmly, provide simple directions, and redirect attention.

What nursing interventions help with severe anxiety?

Stay with the patient, reduce stimuli, and use short, clear directions.

What nursing interventions help with panic anxiety?

Remain with the patient, maintain safety, and provide calm, simple directions.

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

Alarm, resistance, and exhaustion.

What happens during the alarm stage of GAS?

Fight-or-flight response occurs with increased heart rate, blood pressure, and adrenaline.

What happens during the resistance stage of GAS?

The body attempts to adapt to the stressor and maintain functioning.

What happens during the exhaustion stage of GAS?

The body's resources become depleted, increasing vulnerability to illness.

What are the four common stages of acute illness?

Preclinical, prodromal, illness, and convalescence.

What happens during the preclinical stage?

Disease is developing, but noticeable symptoms are absent.

What happens during the prodromal stage?

Early, vague symptoms such as fatigue or mild fever appear.

What happens during the illness stage?

The disease produces its characteristic symptoms.

What happens during the convalescence stage?

The patient begins recovering and symptoms decrease.

What are the five levels of Maslow's hierarchy?

Physiological, safety, love and belonging, esteem, and self-actualization.

What are examples of physiological needs?

Oxygen, food, water, sleep, elimination, and temperature regulation.

What are examples of safety needs?

Protection from injury, security, and a safe environment.

What are examples of love and belonging needs?

Family, friendships, relationships, and social connection.

What are examples of esteem needs?

Self-confidence, independence, achievement, and respect.

What is self-actualization?

Reaching one's full potential and personal goals.

Which Maslow level generally takes priority in an emergency?

Physiological needs, such as airway, breathing, and circulation.

What is Erikson's developmental stage for middle adulthood?

Generativity versus stagnation.

What is the main developmental task of middle adulthood?

Contributing to society, raising children, mentoring, and helping future generations.

What is Erikson's developmental stage for older adulthood?

Integrity versus despair.

What is the main developmental task of older adulthood?

Reflecting on life and accepting one's experiences and accomplishments.

What does integrity mean in older adulthood?

Feeling satisfied with life and accepting one's life experiences.

What does despair mean in older adulthood?

Experiencing regret, dissatisfaction, or disappointment when reflecting on life.

What is culturally respectful nursing care?

Providing individualized care that respects a patient's beliefs, values, and traditions.

How should nurses approach cultural differences?

Ask questions instead of making assumptions or relying on stereotypes.

What should nurses do when a patient has limited English proficiency?

Use a qualified medical interpreter.

How can nurses provide culturally respectful dietary care?

Ask about food preferences and religious or cultural dietary restrictions.

How can nurses respect religious beliefs?

Ask about spiritual practices and accommodate them when possible.

What does T stand for in the TEACH acronym?

Tune into the patient by assessing readiness and current knowledge.

What does E stand for in the TEACH acronym?

Edit the content to match the patient's learning needs.

What does A stand for in the TEACH acronym?

Actively involve the patient in learning.

What does C stand for in the TEACH acronym?

Clarify understanding through questions and teach-back.

What does H stand for in the TEACH acronym?

Help with follow-up and provide additional resources.

What should a nurse assess before patient teaching?

Readiness to learn, literacy, language, pain, fatigue, and anxiety.

What makes patient teaching effective?

Simple language, short sections, demonstrations, repetition, and active participation.

What is the teach-back method?

Asking patients to explain information in their own words to verify understanding.

How should a nurse evaluate whether a patient learned a skill?

Ask the patient to perform a return demonstration.

What does RACE stand for during a fire emergency?

Rescue, Alarm, Contain, Extinguish or Evacuate.

What does Rescue mean in RACE?

Remove anyone in immediate danger.

What does Alarm mean in RACE?

Activate the fire alarm and notify others.

What does Contain mean in RACE?

Close doors and windows to limit the spread of fire and smoke.

What does Extinguish or Evacuate mean in RACE?

Extinguish a small fire if safe and trained, or evacuate as directed.

What does PASS stand for when using a fire extinguisher?

Pull, Aim, Squeeze, Sweep.

Where should a fire extinguisher be aimed?

At the base of the fire.