Quiz 2 Review FUN
Fundamentals of Nursing Study Guide
Chapter 33: Self-Concept
Core Definitions
Self-Concept: How a person thinks about themselves.
Self-Esteem: How a person feels about themselves.
Body Image: A person's attitudes toward their physical body.
Components of Self-Concept
Identity: A sense of individuality.
Role Performance: How a person perceives their ability to carry out significant roles. Stressors include:
Role Conflict: Having to assume two or more conflicting roles.
Role Ambiguity: Unclear expectations for a role.
Role Strain: A combination of role conflict and ambiguity.
Role Overload: Having more responsibilities within a role than one can manage.
Nursing Assessment & Interventions
Assessment of Altered Self-Concept: Watch for key behaviors like avoiding eye contact, slumped posture, unkempt appearance, being overly apologetic, frequent crying, and difficulty making decisions.
Health Promotion: Help the patient identify their personal strengths to build self-esteem.
Chapter 34: Sexuality
Core Concepts Sexuality is part of a person's overall health and can be affected by illness, medication, and different life stages. A nurse's role is to provide a professional and non-judgmental environment to discuss these topics.
Health Promotion & Patient Teaching
Prevention of STIs: Hormonal contraceptives and IUDs do NOT protect against STIs. Condoms should be used consistently to reduce the risk of transmission.
Screening: Annual chlamydia screening is recommended for all sexually active women up to age 25.
Vaccination: The HPV vaccine is recommended for both males and females to decrease the risk of HPV-associated cancers.
Sexual Abuse Nurses are mandated reporters and must report any suspicion of child or elder abuse. Signs can include physical injuries or behavioral changes. Assessments should be conducted in private.
Chapter 35: Spiritual Health
Core Definitions
Spirituality: An individual's inner sense of self and connection to a higher being or purpose.
Atheist: Someone who does not believe in the existence of God.
Agnostic: Someone who believes that nothing can be known of the existence of a higher power.
Spiritual Distress: A disruption in a person's belief system, often caused by illness or loss.
Nursing Assessment & Interventions
Assessment: Use the FICA tool (Faith, Importance, Community, Address in care) and observe for signs of spiritual distress.
Interventions:
Establish Presence: Be with the patient to offer attention and support.
Support Rituals: Accommodate dietary needs like Halal or Kosher meals and provide a quiet environment for prayer.
Collaboration: Involve chaplains or pastoral care as requested by the patient.
Chapter 36: Loss and Grief
Types of Loss & Grief
Types of Loss:
Maturational: Loss from normal life transitions (e.g., a child leaving for college).
Situational: Sudden, unpredictable loss (e.g., an accident).
Types of Grief:
Normal (Uncomplicated): Common emotional responses that gradually lessen over time.
Anticipatory: Grieving that occurs before an expected loss.
Disenfranchised: A loss that is not socially sanctioned.
Complicated: Prolonged, debilitating grief lasting more than a year.
End-of-Life Care
Palliative vs. Hospice: Palliative care focuses on symptom relief at any stage of illness. Hospice care is for patients with a prognosis of less than 6 months.
Promoting Comfort: The priority is to manage symptoms like pain, nausea, and dyspnea. For noisy respirations ("death rattle"), reposition the patient to their side.
Postmortem Care:
Priority: Provide dignified care.
Key Steps: Elevate the head of the bed to prevent facial discoloration. If the family wishes to view the body, leave dentures in place. Wash the body and apply a clean gown.
Chapter 37: Stress and Coping
Core Concepts
General Adaptation Syndrome (GAS): The body's three-stage reaction to stress:
Alarm Stage: The "fight-or-flight" response, where heart rate and blood pressure increase.
Resistance Stage: The body adapts to continued stress.
Exhaustion Stage: Energy is depleted, leading to illness.
Post-Traumatic Stress Disorder (PTSD): A disorder characterized by flashbacks and nightmares after a traumatic event.
Nursing Assessment & Interventions
Assessment: Assess for subjective and objective signs of stress. Patient safety is the #1 priority; directly ask about any thoughts of self-harm.
Health Promotion: Teach relaxation techniques like deep breathing, guided imagery, and physical exercise.
Crisis Intervention: A brief therapy focused on ensuring immediate safety and reducing acute anxiety.
Chapters 38 & 39: Activity, Exercise, & Immobility
Assistive Devices
Walker: Move the walker forward, step with the weak leg, then step with the strong leg.
Cane: Hold the cane on the strong side. Move the cane, then the weak leg, then the strong leg.
Crutches: For stairs, use the mnemonic "up with the good, down with the bad."
Complications of Immobility & Interventions
Skin: Pressure ulcers. Intervention: Reposition every 1-2 hours.
Respiratory: Atelectasis/Pneumonia. Intervention: Encourage coughing, deep breathing, and incentive spirometer use.
Cardiovascular: DVT. Intervention: Apply SCDs, encourage ankle pumps. NEVER massage a leg with a suspected DVT.
Musculoskeletal: Muscle atrophy/contractures. Intervention: Perform passive range-of-motion (PROM) exercises.
Chapter 40: Hygiene
Care for High-Risk Patients
Diabetes/PVD: NEVER soak the feet. Inspect feet daily, file nails straight across, and ensure proper footwear.
Unconscious Patient: The #1 priority is to prevent aspiration. Position the client in a side-lying (lateral) position for oral care.
Bathing and Bed Making
Infection Control: Wash from the cleanest area to the least clean area.
Safety: When making an occupied bed, raise the side rail on the opposite side to prevent falls. Keep the bed in the lowest position when care is complete.