Download Factors Affecting Oxygen Saturation and Fall Prevention in Older Adults and more Exams Nursing in PDF only on Docsity!
Question & Answers 2024
Want to make your next semester with HESI easier? Read and sign this!! https://www.change.org/p/usf-sonhp-change-so2- fundamentals-hesi - correct answers ✅Thanks, much love :) Health - correct answers ✅-A state of complete physical, mental, and social well-being -Not merely the absence of disease or infirmity Health Promotion - correct answers ✅-The process of enabling people to increase control over, and to improve, their health -Moves beyond a focus on individual behavior towards a wide range of social and environmental interventions -Examples: diet, exercise, sleep, stress management, hygiene, social support Disease - correct answers ✅A malfunctioning or maladaptation of a biological or psychological process Illness - correct answers ✅-A state in which a person's physical, emotional, intellectual, social, developmental, or spiritual functioning is diminished or impaired -More about how a person reacts to having a disease Risk Factors - correct answers ✅Any internal or external variable that makes a person or group more vulnerable to illness or an unhealthy event
Question & Answers 2024
Illness Prevention - correct answers ✅Includes health education programs and/or activities that are directed toward protecting pts. from actual or potential threats to health and minimizing risk factors Patient Centered Care - correct answers ✅Recognizing the pt. as the source of control and full partner in providing compassionate and coordinated care based on respect for pts. preferences, values, and needs Patient Safety - correct answers ✅The avoidance and prevention of pt. injuries or adverse events resulting from the process of health care delivery Adverse Event - correct answers ✅-An injury caused by care delivered that delays discharge and/or results in disability -Opposite of pt safety Infection - correct answers ✅The invasion of a susceptible host by pathogens or microorganisms resulting in disease Colonization - correct answers ✅-The presence and growth of microorganisms within a host but without tissue invasion or damage -No signs/symptoms present Communicable Disease - correct answers ✅-Can be passed from person to person
Question & Answers 2024
What are bloodborne pathogens? - correct answers ✅Infectious microorganisms in human blood that can cause disease in humans What action is not recommended when bagging a pts linens who is on Isolation Precautions? - correct answers ✅Double bagging What would you assess for when considering a pt's risk for infection? - correct answers ✅-Chronic disease -Lifestyle -Occupation -Diagnostic procedures -Heredity -Travel history -Trauma -Nutrition General Survey - correct answers ✅-A brief study of the whole person's general health state and obvious physical characteristics -Begins the minute you meet your pt Inspection - correct answers ✅-Involves looking, listening, and smelling to distinguish expected findings from unexpected findings -Occurs when interacting with pt.
Question & Answers 2024
Communication - correct answers ✅-A life long learning process -Develops meaningful relationship between nurse and pt./family What are the basic elements of the communication process? - correct answers ✅-Referent: motivates one person to communicate with another -Sender: person who encodes and delivers a message -Receiver: person who receives and decodes the message -Message: content of the communication -Channels: means of sending and receiving messages through senses -Feedback: message a receiver returns from the sender -Interpersonal variables: factors within both the sender and receiver that influence communication -Environment: setting for sender-receiver interaction What are the five levels of communication and their uses in nursing? - correct answers ✅-Intrapersonal: aka self-talk, used as a nurse -Interpersonal: one-on-one interaction between nurse and pt., usually occurring face to face -Small group: occurs when a small number of people meet -Public: interaction with an audience -Technology: email, call, etc.
Question & Answers 2024
-Be an attentive listener -Include family and friends in conversations, especially in subjects known to pt -Use picture or gestures that mimic the action desired Describe effective communication techniques for use with pts who are hard of hearing or deaf - correct answers ✅-Check for hearing aids -Reduce environmental noise -Get pt's attention before speaking -Face pt with mouth visible -Don't chew gum -Speak at normal volume, don't shout -Rephrase rather than repeat if misunderstoof -Provide sign-language interpreter if indicated Describe effective communication techniques for use with pts who are visually impaired - correct answers ✅-Check for use of glasses/contacts -Identify self when enter room, notify pt when leave room -Speak in normal tone -Don't rely on gestures or nonverbal communication -Use indirect lighting, avoid glare -Use at least 14-point print
Question & Answers 2024
Describe effective communication techniques for use with pts who are unresponsive - correct answers ✅-Call pt by name during interaction -Communicate both verbally and by touch -Speak to pt as though he/she can hear -Explain all procedures/sensations -Provide orientation to person, place, time -Avoid talking about pt to others in their presence Describe effective communication techniques for use with pts who don't speak English - correct answers ✅-Speak to pt in normal tone of voice -Establish method for pt to ask for assistance (call light, bell) -Provide professional interpreter as needed -Avoid using family members, especially children, as interpreters -Use communication board, pictures, cards -Translate words from native language into English list for pt to make basic requests -Have dictionary available if pt can read What are therapeutic communication techniques? - correct answers ✅-Active listening → SOLER: sit facing pt, open position, lean toward pt, eye contact, relax -Use of touch -Use of silence
Question & Answers 2024
-Rectal: 37.5C (99.5F) -Axillary: 36.5C (97.7F) Older adult: -Oral/tympanic: 35-36.1C (95-97F) -Cold weather: 35C (95F) Blood Pressure - correct answers ✅-The force exerted on the walls of an artery by the pulsing blood under pressure from the heart -Good indicator of cardiovascular health -Measured in mmHg (millimeters of mercury) What factors influence blood pressure? - correct answers ✅-Age: older = higher -Stress: more = higher -Ethnicity: iffy -Gender: men = higher, women = higher when hit menopause -Daily variation: peak in morning, lowest at night -Medications: varies -Activity and weight: more active = lower; heavier = higher -Smoking: vasoconstriction = higher What is the optimal blood pressure value for adults? - correct answers ✅-Systolic <120 mmHg AND -Diastolic <80 mmHg
Question & Answers 2024
Why does the nurse palpate where the pulse disappears when measuring blood pressure by palpation? - correct answers ✅- Gives you at least systolic if you can't hear through auscultation or can't use an automatic machine -Prevents you from pumping up to the auscultation gap and underestimating the systolic BP Auscultation Gap - correct answers ✅-Typically occurs between first and second Korotkoff sounds -Gap in sounds covers a range of 40mmHg -Causes underestimation of SBP or overestimation of DBP -Be sure to inflate cuff high enough to hear true SBP before gap Ventilation - correct answers ✅-1 of 3 components in respiration -Movement of gases in and out of the lungs -Assessed by determining respiratory rate, depth, and rhythm Diffusion - correct answers ✅-1 of 3 components in respiration -Movement of O2 and CO2 between the alveoli and RBCs Pulse - correct answers ✅-The palpable bounding of blood flow in a peripheral artery -An indirect indicator of circulatory status
Question & Answers 2024
-Body position -Medications -Neurological injury -Hemoglobin function What factors affect oxygen saturation? - correct answers ✅- Interference with light transmission → pt. motion, nail polish, artificial nails -Interference with arterial pulsation → hypothermia, hypotension, peripheral edema, disease and meds that restrict blood flow (vasoconstriction) What is the average value for pulse (P) for the healthy adult? - correct answers ✅-Aka eucardia -60 to 100 bpm -Rhythm: regular What is the average value for respiration (R) for the healthy adult? - correct answers ✅-Aka eupnea -12 to 20 breaths per minute -Depth (normal), rhythm (regular), effort (easy to breath) What is the average value for oxygen saturation (SP02) for the healthy adult? - correct answers ✅-95 to 100% -Value less than 90% is a clinical emergency
Question & Answers 2024
Why does the nurse perform an assessment? - correct answers ✅-To determine pt's current/past health, functional status, pts current/past coping patterns -Make clinical judgements or diagnoses about person's state of health Differentiate subjective and objective assessment data - correct answers ✅-Subjective: aka symptom, what pt tells you -Objective: aka sign, what the observer sees, labs, head-to-toe Describe cultural considerations and needs of the older adult with physical assessment - correct answers ✅-Respect cultural differences; consider: health beliefs, use of alternative therapies, nutrition habits, relationships with family, comfort with physical closeness -Sensory + physical limitations may affect ability to respond quickly → be patient; adjust head-to-toe pace -Have experienced a lot of loss → family + friends -Signs and symptoms tend to be subtle -Observe for signs of fatigue: sighing, grimacing, irritability, leaning against objects for support, drooping head and shoulders -Allow pauses or rest periods as needed Describe these three levels of consciousness (LOC): alert, lethargic, obtunded - correct answers ✅-Alert: eyes open at approach or spontaneously; oriented to person, place, time; can follow verbal commands appropriately
Question & Answers 2024
Anisocoria - correct answers ✅5% of adult population has one pupil that is normally larger than the other Accomodation - correct answers ✅-Adaptation of eye for near vision -With focus on distant object → pupils dilate -With focus on near object → pupils constrict -Don't assess to test neuro status, more a test of aging What are the key elements of cognition? - correct answers ✅- Orientation -Registration -Attention and calculation -Recall -Language Mini-cog - correct answers ✅-Screens for cognitive impairment in otherwise healthy older adults -Used with various language, culture, and literacy levels -Takes 3-5 min to administer -Consists of a 3-item recall test and clock drawing test (CDT) Note: example of a periodic assessment
Question & Answers 2024
Is it expected that as a person ages, he/she will live in pain? - correct answers ✅NO Acute pain - correct answers ✅-Short term (<6 months) -Identifiable cause -Self limiting (goes away on its own) -Self protective (body is trying to protect itself by warning you that something is wrong) Chronic pain - correct answers ✅-6 months or longer, ongoing -Malignant: associated with cancer -Nonmalignant: noncancerous -Doesn't always have an identifiable cause -Not self protective (doesn't tell you if a new problem has arisen) Discuss the relationship between cultural sensitivity and pain assessment - correct answers ✅-Everyone doesn't respond the same way -Expressions of pain differ -Cultural beliefs and values affect how individuals cope with pain What is the fifth vital sign? - correct answers ✅Pain What did Pasero and McCaffery say about pain? - correct answers ✅"A patient's self-report of pain is the single most reliable indicator of its existence and intensity"
Question & Answers 2024
Range of Motion - correct answers ✅-Assessment of mobility -An exercise that moves a joint through the extent of its limitations -Normal: no tenderness, pain, crepitation (sign of arthritis) Internal Rotation - correct answers ✅-Term used to describe ROM -Turning of a limb about its axis of rotation toward the midline of the body Adduction - correct answers ✅-Term used to describe ROM -Movement of a limb toward the body Abduction - correct answers ✅-Term used to describe ROM -Movement of a limb away from the body External Rotation - correct answers ✅-Term used to describe ROM -Turning of a limb about its axis of rotation away from the midline of the body What are the tests of mobility? - correct answers ✅-Range of motion (ROM) -Balance -Gait
Question & Answers 2024
-Coordination -Activity tolerance -Functional ability (activities of daily living, ADLs) Balance - correct answers ✅-Assessment of mobility -Romberg test: ask person to stand feet together, arms at side, close eyes → hold position, wait 20 sec (count in head); stand in front in case of fall -Negative result (normal): hold posture and balance, correction upon swaying Gait - correct answers ✅-Assessment of mobility -Describes a particular manner or style of walking -Ask person to walk 10-20 ft away from you, turn, return to starting point -Normal: free, easy, steady Coordination - correct answers ✅-Assessment of mobility -Tandem walking test: ask person to walk straight line heel-to-toe tandem fashion (6-7 steps); pt looks forward -Normal: able to walk tandem Functional Ability - correct answers ✅-Assessment of mobility -Measures a person's ability in the areas of physical health (ADLs) -Use the Katz' Index to assess
