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214 Cards in this Set

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What position should you place your client in while performing an enema?
Left Sims
What are some types of cleansing enema solutions?
Tap water & Normal saline, Soap and water, Hypertonic saline, or Mineral, olive, or cottonseed oil
What is a cleansing enema used for?
Cleansing enemas use different types of solution to remove feces from the rectum
What is a retention enema used for?
A retention enema uses a solution held within the large intestine for a specified period, usually at least 30 minutes.
What is one type of retention enema?
Oil retention enema because the fluid instilled is mineral, cottonseed, or olive oil. Oils lubricate and soften the stool, so it can be expelled more easily.
Which cleansing enema is preferred? and Why?
Tap Water and Normal Saline Enemas

Tap water and normal saline solutions are preferred for their nonirritating effects (no more than 3 times)
How does a Hypertonic Saline Enemas work? and its purpose?
A hypertonic saline enema draws fluid from body tissues into the bowel. This increases the fluid volume in the intestine beyond what was originally instilled.
What stage in Erikson's Psychosocial Theory is School age ( 6– 12 years)?
Industry vs. inferiority
What is the major developmental tasks in Erikson's Industry vs Inferiority stage?
To achieve a sense of self-confidence by learning, competing, performing successfully, and receiving recognition from significant others, peers, and acquaintances
What stage of Development in Erikson’s Psychosocial Theory is Adolescence ( 12– 20 years)?
Identity vs. role confusion
What is the major developmental tasks in Erikson's Identity vs. role confusion stage?
To integrate the tasks mastered in the previous stages into a secure sense of self
What stage of Development in Erikson’s Psychosocial Theory is Young adulthood (20– 30 years)?
Intimacy vs. isolation
What is the major developmental tasks in Erikson's Intimacy vs. isolation stage?
To form an intense, lasting relationship or a commitment to another person, cause, institution, or creative effort
What stage of Development in Erikson’s Psychosocial Theory is Adulthood (30–65 years)?
Generativity vs. stagnation
What is the major developmental tasks in Erikson's Generativity vs. stagnation stage?
To achieve the life goals established for oneself, while also considering the welfare of future generations
What stage of Development in Erikson’s Psychosocial Theory is Old age ( 65 years– death)?
Ego integrity vs. despair
What is the major developmental tasks in Erikson's Ego integrity vs. despair stage?
To review one’s life and derive meaning from both positive and negative events, while achieving a positive sense of self- worth
Maslow's Hierarchy of Human Needs
physiologic (first level)
safety and security (second level)
love and belonging (third level)
esteem and self-esteem (fourth level)
self-actualization (fifth level)
The Moro reflex in a baby is what? When does it disappear?
Sudden movement or jarring of position causes extension and adduction of extremities

By age 3 or 4 months
The Tonic neck reflex in a baby is what? When does it disappear?
If head of backlying newborn is turned to one side, infant will extend arm and leg on that side

By age 5 months
The Rooting reflex in a baby is what? When does it disappear?
When newborn’s cheek is gently stroked, infant turns toward that side and opens mouth

By age 4 to 6 months
The Sucking reflex in a baby is what? When does it disappear?
Newborn makes sucking movements when anything touches lips or tongue

Diminishes by age 6 months
The Babinski reflex in a baby is what? When does it disappear?
When newborn’s sole is stroked, toes hyperextend and fan outward; big toe turns upward

By age 3 months
The Palmar grasp reflex in a baby is what? When does it disappear?
Newborn briefly grasps any object placed in hands

By age 3 months ( present from age 6 weeks)
What are the stages of grief?
1) Shock and disbelief: refusal to accept that a loved one is about to die or has died
2) Developing awareness: physical and emotional responses such as feeling sick, sad, empty, or angry
3) Restitution period: recognition of the loss
4) Idealization: exaggeration of the good qualities of the deceased
The most common type of therapeutic bath is a sitz bath - which soaks the perianal area & reduce swelling & inflammation & promote healing of wounds. What are some surgical procedures its used for?
hemorrhoidectomy (surgical removal of engorged veins inside and outside the anal sphincter) or an episiotomy (incision that facilitates vaginal birth)
Nocturia (nighttime urination) is unusual because the rate of urine production is normally reduced at night so it suggests an underlying medical problem. What would one of those problems be?
In aging men, an enlarging prostate gland, which encircles the urethra, interferes with complete bladder emptying. As a result, there is a need to urinate more frequently, including during the usual hours of sleep.
Also medication
What coping mechanism is used "Wiping the experience of being sexually abused from conscious memory"?
Repression or Forgetting about the stressor
What coping mechanism is used "Resolving to “sleep on a problem” or turn the problem over to a higher power like God"?
Suppression or Purposely avoiding thinking about a stressor
What coping mechanism is used "Refusing to believe something like a life-threatening diagnosis"?
Denial or Rejecting information
What coping mechanism is used "Blaming failure on a test to the manner in which the test was constructed"?
Rationalization or Relieving oneself of personal accountability by attributing responsibility to someone or something else
What coping mechanism is used "Kicking the wastebasket after being reprimanded by the boss"?
Displacement or Taking anger out on something or someone else who is less likely to retaliate
What coping mechanism is used "Wanting to be bottle-fed like a newborn sibling"?
Regression or Behaving in a manner that is characteristic of a much younger age
What coping mechanism is used "Accusing a person of another race of being prejudiced"?
Projection or Attributing that which is unacceptable in oneself onto another
What coping mechanism is used "Developing diarrhea that conveniently excuses one from going to work"?
Somatization or Manifesting emotional stress through a physical disorder
What coping mechanism is used "Becoming a motivational speaker although physically handicapped"?
Compensation or Excelling at something to make up for a weakness of another kind
What coping mechanism is used "Turning to sportscasting when an athletic career is not realistic"?
Sublimation or Channeling one's energies into an acceptable alternative
What coping mechanism is used "Being extremely nice to someone who is intensely disliked"?
Reaction formation or Acting just the opposite of one's feelings
What coping mechanism is used "Imitating the style of dress or speech of an actor or musician"?
Identification or Taking on the characteristics of another
What Pressure Ulcer Stage is characterized by intact but reddened skin?
Stage I pressure ulcer
The hallmark of cellular damage is skin that remains red and fails to resume its normal color when pressure is relieved.
What Pressure Ulcer Stage is red and accompanied by blistering or a skin tear (shallow break in the skin)?
Stage II pressure ulcer
Impairment of the skin may lead to colonization and infection of the wound.
What Pressure Ulcer Stage has a shallow skin crater that extends to the subcutaneous tissue?
Stage III pressure ulcer
The area is relatively painless despite the severity of the ulcer. It may be accompanied by serous drainage (leaking plasma) or purulent drainage (white or greenish fluid) caused by a wound infection.
What Pressure Ulcer Stage is where the tissue is deeply ulcerated, exposing muscle and bone? The dead or infected tissue may produce a foul odor.
Stage IV pressure ulcers are life threatening. The infection easily spreads throughout the body, causing sepsis (potentially fatal systemic infection).
What are some safety issues during the Toddler ages?
Motor Vehicle Accidents,
Burns,
Poison,
Falls,
Drowning
What can be done to prevent toddler injuries or deaths?
Most accidents are preventable, and prevention requires parental education. The toddler requires constant supervision because there are many hazards both inside and outside the home. Toddlers are incapable of recognizing danger or threats to their safety; this, along with their curiosity, places them at great risk for injury.
Use the acronym RACE to identify the basic steps to take when managing a fire:
• R—Rescue
• A—Alarm
• C—Confine (the fire)
• E—Extinguish
What does the acronym PASS mean?
• P—Point
• A—Aim
• S—Squeeze
• S—Sweep
What increases the risk for fractures, especially in older women?
Osteoporosis (loss of bone mass) Osteoporotic fractures may occur with little or no trauma and even without a fall.
Osteoporosis
a marked loss of bone density and an increase in bone porosity that is frequently associated with aging.
Colostomy
surgical creation of an artificial excretory opening between the colon and the body surface.
Polyp
a general term used most commonly to describe mushroom-like growth from the surface of a mucous membrane, such as a polyp in the nose.
Cholecystitis
inflammation of the gallbladder, usually associated with gallstones blocking the flow of bile
Cholelithiasis
the presence of gallstones in the gallbladder or bile ducts.
Arthroscopy
the visual examination of the internal structure of a joint.
Colles’ fracture
fractured wrist; occurs at the lower end of the radius when a person tries to stop a fall by landing on their hands.
Hemiplegia
total paralysis affecting only one side of the body.
Hemiparesis
slight paralysis or weakness affecting one side of the body.
Embolism
sudden blockage of a blood vessel by an embolus.
Thrombosis
abnormal condition of having a thrombus.
Sprain
injury to a joint that usually involves a stretched or torn ligament.
Strain
injury to the body of the muscle or to the attachment of a tendon. (Usually associated with overuse injuries that involve a stretched or torn muscle or tendon attachment).
Epistaxis
nose bleed
Alopecia
baldness
Eclampsia
serious form of preeclampsia; characterized by convulsions and sometimes coma.
Empyema
collection of pus within a body cavity
Myringitis
inflammation of the tympanic membrane
Debridement
removal of dirt, foreign objects, damaged tissue, and cellular debris from a wound to prevent infection and to promote healing.
Pruritus
itching
Placenta previa
abnormal implantation of the placenta in the lower portion of the uterus.
Nosocomial
hospital-acquired.
Diabetes insipidus
caused by insufficient production of the antidiuretic hormone or by the inability of the kidneys to respond appropriately to this hormone.
Type 1 diabetes mellitus
an autoimmune insulin deficiency disorder caused by the destruction of pancreatic islet bets sells.
Type 2 diabetes mellitus
an insulin resistance disorder.
Delusion
a false personal belief that is maintained despite obvious proof or evidence to the contrary.
Hallucination
a sensory perception (sight, touch, smell, taste, sound) experienced in the absence of an external stimulation.
Pyrosis
heartburn; burning sensation caused by the return of acidic stomach contents into the esophagus.
Carcinoma
a malignant tumor that occurs in epithelial tissue.
Metastasize
the process by which cancer spreads from one place to another.
What is a splint?
It is a device used to immobilize and protect an injured body part.
What is the main use of an emergency splint?
They are applied as a first aid device, when sprains or factures are suspected.
What is the main use of an inflatable splint?
They not only immobilize the injured body part, they also control bleeding and swelling.
What is the main use of a traction splint?
A metal device, which immobilizes and pulls on contracted muscles.
What is a cast?
It is a rigid mold placed around an injured body part after it has been restored to correct anatomic alignment.
What is significant about a bivalve cast?
With the approval of the physician, either side of the cast can be removed to perform hygiene. It is very important the front first.
What are some of the guides to keep in mind when taking care of someone with a cast?
• Leave a freshly applied cast uncovered until it is dry
(doing this facilitates assessment & drying)
• Assess circulation & sensation frequently in exposed fingers & toes
(provides comparative data for indentifying neurovascular complications)
• Ensure that the edges of the cast are padded
(padding reduces the risk of skin breakdowns & irritation)
Why is the use of a negative pressure room important when taking care of a client with TB?
It filters the contaminated air without allowing it to pass out of the room, this prevent other clients and workers from becoming exposed, when the door is opened for entry and exit.
What is the incubation period of an infection?
The infectious agent reproduces, but there are no recognizable symptoms. The infectious agent however, exits the host at this time and infect others.
What is the prodromal stage of an infection?
The initial symptoms appear which may be vague and nonspecific. They may include mild fever, headache, and loss of usual energy.
What is the acute stage of an infection?
Symptoms become severe and specific to the tissue or organ that is affected. For example, tuberculosis is manifested by respiratory symptoms.
What is the convalescent stage of an infection?
The symptoms subside as the host overcomes the infectious agent.
What is the resolution stage of an infection?
The pathogen is destroyed. Health improves or is restored.
What are some examples of diseases that require airborne precaution and the protective equipment needed?
Pulmonary Tuberculosis and Measles

Follow standard precautions, keep door closed, confine client to room, wear a N95 respirator or a powered air-purifying respirator, and always place a mask on the client if transport is required.
What are some examples of diseases that require droplet precaution and the protective equipment needed?
Influenza, Rubella, Streptococcal Pneumonia, and Meningococcal Meningitis

Follow standard precautions, leave door open or closed, wear a mask when entering room depending on agency policy, but always when within 3 feet of the client, and place a mask on the client when transporting.
What are examples of diseases that require contact precaution and the protective equipment needed?
Gastrointestinal, respiratory, skin, or wound infections that are drug-resistant, Gas gangrene, acute diarrhea, acute viral conjunctivitis, & draining abscess

Follow standard precautions, Don gloves before entering the room, remove gloves before leaving the room, wear a gown if clothing may touch surfaces in the room, use disposable vital checking equipment & avoid transporting client if at all possible.
What are bolus feedings and main reason for it use?
This is instillation of liquid nourishment in less than 30 mins hour to six times per day, usually involves 250 to 400mL of formula per administration. It is used because it mimics the natural filling and emptying of the stomach, however it causes gastric discomfort and is the least desirable.
What are intermittent feedings and the main reason for its use?
This is the gradual instillation of liquid nourishment four to six times per day, usually administered over 30 to 60 min, which the time most people spend eating a meal. This reduces the bloat feeling often accompanied by bolus feedings.
What are cyclic feedings and the main reason for its use?
This is continuous instillation of liquid nourishment for 8 to 12 hrs, it is followed by a 16 to 12 hr pause. This is often used to wean clients from tube feedings while continuing to maintain adequate nutrition.
What are continuous feedings and the main reason for its use?
This is the instillation of liquid nutrition without interruption; it is administered at a rate of approximately 1.5mL per min. A feeding pump is used to regulate the instillation.
What are some the reasons for gastric and intestinal tubes?
Performing a gavage (providing nourishment)
Administering oral medications that the client cannot swallow
Obtaining a sample of secretions for diagnostic testing
Performing lavage (removing substances from the stomach, typically poisons)
Promoting decompression (removing gas & liquid contents from the stomach or bowel)
Controlling gastric bleeding, a process called compression or tamponade (pressure)
What is Dumping Syndrome?
It is a cluster of symptoms resulting from the rapid deposition of calorie-dense nourishment into the small intestine.
What is the purpose of irrigating a nasogastric tube? Is this a nursing call?
This clears debris which may impair future drainage and
provides evidence that patency is being maintained.
Always fill the irrigating syringe with 30 to 60 mL of normal saline solution, this provides an adequate quantity of isotonic solution to clear the tubing.

No, needs a physicians order
What is a pain assessment?
The American Pain Society has proposed that pain assessment is the fifth vital sign.
What is cutaneous pain?
It is discomfort that originates at the skin level; it is a commonly experienced sensation resulting from some form of trauma.
What is somatic pain?
It is discomfort generated from deeper connective tissue; it develops from injury to structures such as muscles, tendons, and joints.
What is visceral pain?
It is discomfort arising from internal organs; it is associated with disease or injury. It is sometimes referred or poorly localized.
What is referred pain?
It is discomfort perceived in a general area of the body, usually away from the site of stimulation, it is not experienced in the exact site where an organ is located.
What is neuropathic pain?
Is pain with a typical characteristics is also functional pain.
What is phantom limb pain?
Is neuropathic pain in which a person with an amputated limb perceives that the limb still exists and feels burning, itching, and deep pain in tissues that have been surgically removed.
What is acute pain?
Pain that last for a few seconds to less than 6 months.
What is chronic pain?
Pain that last more than 6 months.
What is nursing diagnosis?
It is a health problem that can be prevented, reduced, or resolved through independent nursing measures.
What is the difference between subjective and objective data?
Obj. is facts that are observable and measurable while sub. Is information that only the client feels and can describe
What are some cast complications/risks to watch for?
•Diminished Pedal pulse in extremity in cast
•Capillary refill time diminished
•Client is in severe pain like a 10
Post Op nurse systematically checks the following:
•Level of consciousness
•Vital signs
•Effectiveness of respirations
•Presence or need for supplemental oxygen
•Condition of the wound and dressing
•Location of drains and drainage characteristics
•Location, type, and rate of intravenous fluid
•Level of pain and need for analgesia
•Presence of a urinary catheter and urine volume
Post Op nurse's major responsibilities are:
•ensure a patent airway
•help to maintain adequate circulation
•prevent or assist with the management of shock
•maintain proper positions and function of drains, tubes, & iv infusions
•detect evidence of any complications
When can food and oral fluids given to surgical clients?
1) when they are awake
2) free of nausea and vomiting
3) bowel sounds are active
Post Op Nurses monitor client's urination, when must they urinate?
Report failure to void within 8 hours of surgery. Failure to void indicates urinary retention.
When the nurse assesses a client postoperatively, which assessment is most indicative of shock?

•Bounding pulse
•Slow respirations
•Low blood pressure
•High body temperature
A dropping blood pressure frequently suggests that the client is going into shock.

A systolic pressure of 90 to 100 mm Hg indicates shock is approaching. Below 80 mm Hg, shock is present.

Other signs of shock include a rapid, thready pulse; pale, cold, and clammy skin; rapid respirations; a falling body temperature; restlessness; and a decreased level of consciousness.
Why would a nurse teach her patient to sit on the edge of the bed before standing?
This is called dangling it helps to normalize blood pressure, which may drop when the client rises from a reclining position

and...

it will minimize falls
When performing an IV Pylligram to xray kidney with contrast, what does a nurse encourage afterwards?
fluids
Whats is acultural nursing care?
Care that avoids concern for cultural differences and promoting.
What is culturally sensitive nursing care?
Care that respects and is compatible with each client’s culture.
What is culture?
Values, beliefs, and practices of a particular group
Anglo Americans?
Generally make and maintain eye contact throughout communication
Latinos?
Are comfortable sitting close to interviewers and letting interactions unfold slowly
Asian Americans?
May not openly disagree with authority figures, such as physicians and nurses because of their respect for harmony
Native Americans?
tend to be private and may hesitate to share personal info with strangers; they may interpret questioning as prying or meddling; impatience disrespectful; and strong hand shake if offensive
Narrative charting?
Style of documentation generally used in source oriented records involves writing information about the client and client care in chronologic order.
Soap charting?
Documentation style more likely to be used in a problem oriented record.
S.O.A.P. or Soap charting?
S=subjective, O=objective, A=analysis, P=plan
Focus charting?
Modified form of soap charting uses the word focus rather than problem
Pie charting?
Method of recording the client progress under the headings of
Charting by exception?
Is a documentation method in which nurses chart only abnormal assessment findings of care that deviates from the standard.
Computerized charting?
Documenting client information electronically is most useful for nurses when a terminal is available at the point of care or bedside
Snellen eye chart?
Tool for assessing far vision is a more objective technique best for visual acuity or central vision
Paracentesis?
Is a procedure for withdrawing fluid from the abdominal cavity, and is always performed with the assistance of a nurse
Crutches?
Ambulatory aids generally used in pairs are constructed of wood or aluminum.
Axillary crutches?
Standard type of crutches under arm pit; hand grip 30 degrees of elbow flexion and 15 degrees of wrist hyperextension
Forearm crutches?
Crutches that have an arm cuff but no axillary bar ex; Lofstrand and Canadian
Platform crutches?
Crutches that support the forearm are used by clients who can not bear weight with their hands and wrist.
What learning domain is a style of processing information by listening or reading facts and descriptions?
The cognitive domain
What learning domain is a style of processing that appeals to a person's feelings, beliefs, or values?
The affective domain
What learning domain is a style of processing that focuses on learning by doing?
The psychomotor domain
What are the S/S of infiltration?
Swelling at the site
Discomfort
Decrease in infusion rate
Cool skin temperature at the site
What are the causes of infiltration?
Displacement of the venipuncture device
What action do you do for infiltration?
Restart the IV.
Elevate the arm.
What are the four basic physical assessment techniques?
inspection, percussion, palpation, and auscultation
What is Inspection?
purposeful observation
What is Percussion?
is striking or tapping part of the client's body with the fingertips to produce vibratory sounds

Least Used
What is Palpation?
lightly touching or applying pressure to the body
What is Light palpation?
It involves using the fingertips, back of the hand, or palm of the hand
When is Light Palpation used?
It is best used when feeling the surface of the skin, structures that lie just beneath the skin, pulsations from peripheral arteries, and vibrations in the chest.
What is Deep palpation?
It is performed by depressing tissue approximately 1 inch (2.5 cm) with the forefingers of one or both hands
What order do you use when accessing the abdomen?
Inspect
then auscultate
then palpation or percussion
The abdomen is divided into four quadrants, listen in each?
5 minutes
Bowel Sounds are:
hyperactive - frequent
hypoactive - long intervals of silence
absent - if not heard for 5 min
To check the pulse you:
compress a superficial artery against an underlying bone with the tips of the fingertips, count for 1 minute
Where are some peripheral pulse sites?
What type of burn is a skin injury caused by flames, hot liquids, or steam and is the most common form of burn?
A thermal burn
Uses for Heat Application?
* Provides warmth
* Promotes circulation
* Speeds healing
* Relieves muscle spasm
* Reduces pain
How long should heat application be used?
never longer than 20 minutes
What is a Collaborative Intervention?
It usually occurs when the nurse and physician share information and exchange findings with other health care workers.
Explain Radiation as a sterile technique
Ultraviolet radiation can kill bacteria, especially the organism that transmits TB. This technique is often used with other sterile techniques.
Explain Boiling Water as a sterile technique
This is a convenient way to sterilize items in the home. To be effective, contaminated equipment needs to be boiled for 15 mins at 212 F (100 C). Longer in places at higher altitudes.
Explain Free-Flowing Steam as a sterile technique
Items are exposed to the heated vapor that escapes from boiling water in this method. It requires the same time and temperature as the boiling method.
Explain Dry Heat as a sterile technique
Dry heat, or hot air sterilization, is similar to baking items in an oven. To destroy microorganisms with dry heat, temperatures of 330 to 340 F (165 to 170 C) are maintained for at least 3 hrs. This is a good technique for sterilizing sharp instruments and reusable syringes because moist heat damages cutting edges and the ground surfaces of glass.
Explain Steam under Pressure as a sterile technique
This is most dependable method of destroying all forms of organisms and spores.

The autoclave is the type of pressure steam sterilizer that most health care agency use.
Explain chemical Sterilization
Both gas and liquid chemicals are used to sterilize invasive equipment. Gas is preferred if heat and moisture is likely to damage items or if no better method is available.
What are steps to the admissions process?
1) Welcome the client (most important step)
2) Orient the client (this will prevent falls b/c the client is more familiar w/ surroundings)
3) Safeguard valuables & clothing (items are temporarily placed in a safe & the items are noted in the patient’s medical record
4) Help the client undress (this helps w/ the physical examination)
5) Compile the nursing database
What are the steps in discharge planning?
This is a process that improves client’s outcomes by predetermining his or her post discharge needs in a timely manner, and coordinating the use of appropriate community resources to provide a continuum of care.

Also, remember to provide an opportunity for questions before discharge.
What are the steps to transferring a client?
•Make sure there is a physician order for the transfer
•Inform the client and family about the transfer
•Complete a transfer summary ( written review of the client’s current status) briefly describing the client’s current condition and reason for transfer
•Speak with a nurse on the transferring unit to coordinate the transfer
•Transport the client with his or her belonging, medications, nursing supplies, & chart to the other unit
What happens if there is an Electolyte imbalance?
dangerous physiologic problems due to changes in fluid volume
What does a nurse do for an electrolyte imbalance?
give IV fluids
Intoductory Phase?
Period of getting acquainted
Working Phase?
Period during which tasks are performed involves mutually planning the clients care and enacting the plan. During the working phase the nurse tries not to retard the client independence; doing too much is as harmful as doing too little
Terminating phase?
Period when the relationship comes to an end
Cognitive domain?
Is a style of processing information by listen or reading facts and descriptions
Affective domain?
Is a style of processing that appeals to a persons feelings, beliefs or values
Psychomotor domain?
Is a style of processing that focuses on learning by doing
Pedagogy?
Is the science of teaching children or those with cognitive ability comparable to children; Motivated to learn by potential rewards or punishment; respond to competition; short attention span
Androgogic?
Is the principles of teaching adult learners; active; think abstractly; longer attention span
Gerogogy?
Is the techniques that enhance learning among older adults; crisis learners; attention affected by low energy level, fatigue, and anxiety; concrete abstract
Feedback loop?
Is the mechanism for controlling hormone production. Most hormones are secreted in response to negative feedback; when a hormone level decreases the releasing gland is stimulated
Hans Selye?
Canadian physician who lived in early 1900s devoted much of his life to researching the collective physiologic processes of the stress response, which he called the general adaptation syndrome.
Alarm stage?
At the immediate onset of a stress response, storage vesicles within sympathetic nervous system neurons rapidly release norepinephrine. Shortly thereafter, the adrenal glands secrete additional norepinephrine and epinephrine. These stimulating neurotransmitters and neurohormones prepare the person for a fight or flight response.
Stage of resistance?
Is characterized by restoration to normalcy.
Stage of Exhaustion?
Adaptation is unsuccessful and death ensues
Coping mechanisms?
Sigmund Freud posited that humans use coping mechanisms unconscious tactics to defend the psyche to prevent their ego or reality base, from feeling inadequate
Endorphins?
Are natural body chemicals that produce effects similar to those of opiate drugs such as morphine
Asian Americans?
Uphold the Yin/Yang Theory, which refers to the belief that balanced forces promote health.
Latinos?
Embrace a similar concept referred to as the hot/cold theory
Jehovah’s Witnesses?
Refuse blood transfusions even in life-threatening situations because they believe that blood is the source of the soul
Curandero?
Latino practitioner who is thought to have spiritual and medicinal powers
Shaman?
Holy man with curative powers, or an herbalist, many people in the US also turn to alternative quasi-medical therapy
How do you auscultate the chest?
With your stethescope, listen on the anterior side of the chest start in area above the clavicle on the R side.
AMA?
against medical advice unless mentally incompetent or court order
How do you access skin turger? On older adult?
Pull skin up on hand

Pull skin up on chest
After brushing the teeth of an unconscious patient, why do you instill water and suction it with a bulb syringe?
To remove debris and reduce the potential for aspiration
How or why do you check for a Homans' sign?
Dorsiflexing the foot and note if client experiences pain in the calf, report a positive finding - could be a thrombophlebitis
Restraints
devices or chemicals that restrict movement. They are used with the intention to subdue a client’s activity.
What are some restraints?
They include cloth limb restraints, bedrails, chairs with locking lap trays, and sedative drugs.
What can unnecessary or unprescribed restraints can lead to?
charges of false imprisonment, battery or both.
If less restrictive alternatives are unsuccessful, what does a nurse do?
must obtain medical order before each and every instance of restraints.
The Nursing Home Reform Act of Omnibus Budget Reconciliation Act (OBRA) states?
clients have the right to be free of, and the facility must ensure freedom from, any restraints imposed or psychoactive drug administered for purposes of discipline or convenience, and not required to treat the residents’ medical symptoms.
Research indicates that restrained clients have these negative effects?
increasingly confused, suffer chronic constipation, incontinence, infections such as pneumonia and pressure ulcers, and experience a progressive decline in their ability to perform their ADL’s
How is Medicare funded?
Funded primarily from an employed persons income
What does Medicare Part A cover?
acute hospital care, rehabilitative care, hospice, and home care services
What does Medicare Part D cover?
relieves financial burden on older Americans and those with low incomes and disabilities who require prescription drugs. Everyone eligible for Medicare can receive prescription drug coverage regardless of income, resources, health status, or current prescription expenses.
What restricts Privacy?
Hippa requires health agencies to safeguard written, spoken, and electronic health info.
How is privacy protected?
• Submitting a written notice identifying the uses and disclosures of client’s health info. Such as to third parties. • Obtain client’s signature indicating they have been informed of the disclosure info. And their right to learn who has seen their record. • Limiting released info. From a health record, it’s inappropriate to release the entire health record when only portions or isolated pieces of info are needed. • Documents must be kept of people who have accessed clients record • Fax machines, filing cabinets, and medical records must be located in areas off-limits to public.
Other things to remember about restraints?
Physician must write restraint order, or nurse must obtain one by phone. Should be last resort. In the case of client attempting to remove endotracheal tube, personnel must first attempt less restrictive measures, such as having someone sit with the client.
What is Medicare?
federal program that finances health care cost of persons 65 yrs and older, permanently disabled workers of any age and their dependents and those with end- stage renal disease.
What does MedicarePart B cover?
(purchased at additional fee) covers physician services, outpatient care, lab test, durable medical equipment and other selected services. (Doesn’t cover long-term care, limits coverage for health promotion and illness prevention)
What are some ways clients' privacy can be maintained in a clinic or hospital?
• Clients names’ on charts can’t be visible
• Clipboards must obscure names of clients & their private info.
• Whiteboards must be free of info linking clients w/ diagnosis, procedures, or treatment
• Conversations regarding clients must take place where they can’t be overheard
• Nurse closes room doors unless safety issues require observation. Doors may be open at clients request but this results in patient being observed by passerbys
• Computer screen must be oriented away from public view