adult /elder

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A patient ability to function may be more important than simply knowing their diagnoses

health history factors

• physical status

• mood

• mental status

• ADL’S

• dressing

• bathing

• eating

somatic

where - skin ,muscle,bone, joints

feel-sharp, aching, throbbing

can point to it

viscreal

where -internal organs

feel- deep,cramping,pressure

hard to locate

neuropathic

where- nerves/CNS

feel- burning ,shooting ,electric, numb

nerve pain

Which 3 systems are involved in stress?

1. nervous system

2. endocrine system

3. immune system

What is a physiologic response ?

This is what is happening inside the body of the person due to stress

What is an example of physiologic response

You get called on unexpectedly in class

Your brain thinks - oh no i’m not ready

• may sweat

• heart beating faster

• muscles tense up

what are some effects of stress on health ?

• increased blood pressure

• muscle tension

• increased heart rate

• changes in breathing

What are some long -term effects on stress?

• poor concentration

• memory problems

• hypertension

• sleep disturbances

A nurse is assessing a patient using the Braden Scale. Which factor is NOT included in the Braden Scale?

1. A patient has a Braden Scale score of 17. What is the patient's risk level?

what is the score for mild risk?

15-16

what is the score for moderate risk?

12-14

what is score for severe risk?

less then 11

What are the 6 categories that make up the Braden Scale?

• sensory perception

• moisture

• activity

• mobility

• nutrition

• friction & shear

The nurse assesses an area of red, intact skin that does not blanch when pressure is applied. Which stage is this?( damage of epidermis)

stage 1 pressure

1 layer of damage of epidermis, red skin that is NON-blanchable & NOT broken

stage 2 pressure

partial - thickness skin loss affecting both the epidermis & dermis

stage 3 pressure

full-thickness skin loss into the subcutaneous fat

stage 4 pressure

extends all the way down into muscle,bone , and tendon

eschar

black/brown dead necrotic tissue

slough

yellow stringy

deep tissue

fatty tissue ( dark purple )

What is HIV?

hiv damages and destroys CD4+T cells weakening the immune system

A nurse is caring for a patient with HIV. As the patient's immune function decreases, what is the patient at increased risk for?

A nurse is teaching a patient about antiretroviral therapy (ART) for HIV. What is the main goal of ART?

acute HIV

2-4 weeks after infection may resemble the flu

asymptomatic HIV

may still have fatigue ,headache ,low grade fever night sweats

A patient with HIV has a CD4 count of 350 cells/μL and is experiencing infections and other complications. Which stage is this?

symptomatic HIV

CD4 decreases to about 200-500 cells

AIDS HIV

CD4 less than 200 cells

A patient with HIV has a CD4 count of 175 cells/μL. How should the nurse interpret this finding?

A nurse is teaching a student about healthcare-associated infections (HAIs). Which statement correctly describes an HAI?

what are some examples of (HAIs)

hospital care, procedures, devices, and healthcare exposure.

CAUTI stands for

(Catheter-Associated Urinary Tract Infection)

CLABSI stands for

(Central Line-Associated Bloodstream Infection)

SSI stands for

Surgical Site Infection

VAP stands for

(Ventilator-Associated Pneumonia) / VAE

A nurse is caring for a patient with an infection. Which action is included in standard precautions?

Standard Precautions =Used with ALL patients

Transmission-Based Precautions: Used for patients with specific infections.

what is the range for ph

7.35 -7.45

What is the range for paCO2

35 -45

what is the range for HCO3

22-26

what is the full compensation range?

normal range ph 7.35 -7.45

uncompensated range

ph abnormal either co2 or co3 one has to be normal and other abnormal

if ph is high what is it

alkalosis

Is it respiratory or metabolic is PaCO₂ out of range

respiratory

if ph is low what is

acidosis

partical compensation range

PH is not normal

hyper

high

hypo

low

what do IADls assess?

independent living such as managing medications,finances,shopping

name several physical manifestations that may cause stress

tachycardia, muscle tension,sleeping ,headaches

Question 1

pH: 7.30
PaCO₂: 40
HCO₃⁻: 18 What is the correct interpretation?

pH: 7.28
PaCO₂: 30
HCO₃⁻: 18

potassium range

3.5-5.0

potassium K+

function -pumps the heart

HYPERkalemia over 5.0

=heart peaked t waves severe v fib

muscle weakness

causes renal failure low aldosterone

HYPOkalemia below 3.0

=shallow respirations most deadly

decreased DTR

causes fluid loss/electrolyte loss ( diarrhea,diet,DKA)

sodium range

135-145

sodium NA+

function -maintain bp,bv,ph balance

HYPERnatremia over 145

body =edema swollen, red , increased muscle tone

cause -diabetes insipidus think dry inside

HYPOnatremia below 135

brain=headache = cerebral edema

respiratory arrest

cause sweating ,excess water intake

magnesium mg + range

range 1.3 -2.1

magnesium mg +

function - mellows the muscles

HYPER magnesemia over 2.1

heart= high mellow

Hyporeflexia ( decreased DTR)

cause - renal failure, alcoholism

HYPOmagnesmia below 1.3

heart= torsades de pointes top tested

cause - Crohn’s disease, celiac disease

calcium ca range

9.0 -10.5

calcium ca

function -keeps 3bs bone blood, and beats ( heart )

HYPERcalcemia over 10.5

high calm- kidney stones, bone pain, constipation

cause - hyperparathyroidism, high PTH

HYPOcalcemia below 9.0

low calm - t-trousseau’s sign, c -chvostek,s sign

weak b’s bones blood,beats ( heart)

cause -hypoparathyroidism, renal failure TEST TIP

Chronic kidney disease (CKD)

A patient is 24 hours postoperative after abdominal surgery. The nurse observes redness, warmth, swelling, and tenderness around the incision. Which physiologic process best explains these findings?

A nurse is assessing a patient with an acute inflammatory response. Which finding would the nurse expect to be systemic rather than local?

3. A patient has a traumatic wound with extensive tissue loss, irregular wound edges, and a large amount of exudate. Which type of healing should the nurse expect?

A patient has a contaminated wound that cannot be immediately closed. The wound is allowed to develop granulation tissue before the edges are surgically closed. How should the nurse classify this healing process?

A nurse is caring for a patient with a soft-tissue injury. Which intervention is most appropriate during the initial management of the injury?

A patient with a chronic wound asks why adequate protein and fluid intake are important. Which response by the nurse is most appropriate?

A nurse is teaching students about infection terminology. A community reports a sudden increase in cases of the same infectious disease within a specific geographic area.

Which term best describes this situation?

1. A nurse is caring for a patient with an infection. Which action is included in standard precautions?

A patient with HIV has a CD4 count of 180 cells/uL. Which interpretation by the nurse is most accurate?

1. A patient with HIV asks why the nurse is monitoring both the CD4 count and viral load.
   Which explanation is best?

1. A patient with diabetes reports pain in both feet. The patient describes the pain as
   "burning and shooting, almost like electric shocks." The patient also reports areas of numbness and increased sensitivity to touch. Which type of pain should the nurse recognize?

primary

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