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131 Cards in this Set
- Front
- Back
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Asphyxiation |
Lack of oxygen due to interrupted breathing
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Carbon monoxide |
an odorless, colorless, tasteless gas that is very toxic |
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Chemical restraints |
Medications used to control social disruptive behavior |
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Factors that affect safety |
Age and Development LifestyleHealth status and mobility Altered sensory perception Impaired cognitive awareness Impaired communication Lack of safety info Environmental factors |
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Nursing Diagnosis |
-Risk for injury (global) -Risk for poisoning (toddlers/mentally impaired) -Risk for trauma (kids/teens) -Latex allergy response -Risk for Latex allergy response -Risk for aspiration (elderly/stroke patient) -Risk for Disuse Syndrome( can't use the body like they should be able to i.e. Stroke patients) -Deficient Knowledge (accident prevention) |
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Safety Hazards for Developing Fetus |
-exposure to maternal smoking -alcohol consumption -addictive drugs -x-rays (first trimester) -certain pesticides |
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Safety Hazards for Newborns/Infants |
*accidents -falling -suffocation in crib -placed in the prone position -suffocation when entangled in cords -choking from aspirated milk or ingested objects-burns from hot water or other spilled hot liquids -automobile crashes -crib/playpen injuries -electric shock -poisoning |
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Safety Hazards for Toddlers |
physical trauma from falling -running into objects -aspiration of small toys -getting cut by sharp objects -automobile crashes -burns -poisoning -drowning -electric shock |
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Safety Hazards for Preschoolers |
*accidents -injury from traffic -injury from playground equipment and other objects -choking -suffocation -obstruction of airway or ear canal by foreign objects -poisoning -drowning -fire and burns -harm from people/animals |
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Safety Hazards for Adolescents
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*suicide/homicide
-vehicular crashes (cars, bikes) -recreational injuries -firearms -substance abuse |
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Safety Hazards for Young Adults |
*vehicular accidents -sun exposure -suicide |
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Safety Hazards for Middle-Aged Adults |
*vehicular accidents -fires -falls -burns |
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Safety Hazards for Older Adults |
**falling -burns -pedestrian crashes -automobile crashes -suicide |
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Agency Fires |
Agency Fires R.A.C.E Rescue: remove the client from danger Activate: report the fire Contain: contain the fire Extinguish: extinguish the fire Pull out the extinguisher's safety pin Aim the hose at the base of fire Squeeze handle to discharge the material onto fire Sweep hose from side to side across base until out |
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Falls |
*infants and older adults (leading cause in older adults) -most occur in the home -major threat to older person's independence* -access risk factors-screen clients for fall risks using standard assessment tool (Get Up and Go Tool) |
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Fall Risk Factors |
-Poor Vision -Cognitive dysfunction (confusion, disorientation, impaired memory/judgement) -Impaired gait or balance and difficulty walking b/c of LE dysfunction -Difficulty getting in/out of bed/chair -Orthostatic hypotension -Urinary frequency or receiving diuretics -Weakness from disease process or therapy -Current med regimen that includes sedative, hypnotics, tranquilizers, narcotic analgesics, and diuretics |
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Prevention for Poor Vision |
-ensure eyeglasses are functional -ensure appropriate lighting -mark doorways/edges of steps as needed -keep environment tidy |
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Prevention for Cognitive dysfunction (confusion, disorientation, impaired memory/judgement) |
-set safe limits to activities -remove unsafe objects |
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Prevention for Impaired gait or balance and difficulty walking b/c of LE dysfunction |
-wear shoes or well-fitted slippers c nonskid soles -use ambulatory devices as necessary (cane, crutches, walker, braces, wheelchair) -provide assistance c ambulation PRN -monitor gait/balance -adapt living environment to 1 floor if needed -encourage exercise/activity as tolerated to maintain muscle strength, joint flexibility/balance -ensure uncluttered environment with securely fastened rugs |
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Prevention for Difficulty getting in/out of bed/chair |
-encourage client to request assistance -keep be in low position -install grab bars in bathroom -provide raised toilet seat |
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Prevention for Orthostatic hypotension |
-instruct client to rise slowly from a lying to sitting to standing position, and to stand in place for several seconds before walking |
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Prevention for Urinary frequency or receiving diuretics |
-provide bedside commode -assist with voiding on frequent/scheduled basis |
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Prevention for Current med regimen that includes sedative, hypnotics, tranquilizers, narcotic analgesics, and diuretics |
-attach side rails to be if appropriate -keep rails in place when bed is in lowest position -monitor LOC and Orientation -discuss how alcohol contributed to fall-related injuries-encourage client not to mix alcohol/meds/avoid alcohol -encourage annual or more frequent review of all meds prescribed |
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CA Falls |
when client falls, the nurse's first duty is to the client. First, assess for injuries. Then, notify primary care provider (729) |
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Seizures |
-protect head/roll on side to keep from aspirating secretions and having the oral airway obstructed by the tongue -don't restrain -don't put anything in the moth -start monitoring (admin O2 if needed) -oral airway keeps tongue from falling back -pad the side-rail (c sheet or blanket) -notify Dr. and admin meds as ordered |
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postictal stage |
they don't remember what happened |
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Two Standards for Restraints |
1. Behavior Management 2. Med/surgical care |
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Behavior Management Standard for Restraints |
-nurse may apply, but physician or other LIP must evaluate client within ONE hour of application -a written order is only valid for FOUR hours -client must be continuously monitored |
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Med/Surgical Care Standard for Restraints |
-Nurse has up to 12 hours to obtain a written order from physician -All orders must be renewed every 24 hours-order must state the REASON/TIME PERIOD -PRN orders are NEVER ALLOWED-should only be used after ALL ALTERNATIVES HAVE BEEN TRIED |
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Alternatives to Restraints |
-place where they can be seen closely -reorient to unfamiliar surroundings -keep half a side rail down to prevent climbing over -keep bed in lowest position -monitor medication -talk for walk -turn on TV -play soft music -try to determine cause of confusion/behavior-monitor changed in physical/cognitive functional abilities/risk factors |
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Restraint Evaluation |
PREVENT INJURY- has outcome been met?-risk still remains? -demonstrated new behavior/skills to prevent injury? |
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A major focus of professional nursing is preventive care. In providing preventive care the nurse should focus on: a) developing nursing diagnoses b) health education c) research and development d) scientific knowledge |
b) health education |
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When evaluating a parent's understanding of safety measures for a toddler, which of the following statements indicates a need for further teaching? a) "I will teach my child to swim." b) "I will obtain a low bed when my child begins to climb." c) "I will teach my child to cross the street safely and obey traffic signals." d) "I will teach my child not to run or ride atricycle into the street." |
c) "I will teach my child to cross the street safely and obey traffic signals." |
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Suicide is the leading cause of death among teenagers. When planning a workshop on adolescent suicide, the nurse knows that which of the following is not among the most common methods of adolescent suicide? a) firearms b) drugs c) automobile exhaust gases d) laceration of radial arteries with a sharpobject |
d) laceration of radial arteries with a sharpobject |
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A nurse is establishing a plan of care for the use of restraints on his client. He should plan to include release of all restraints and range-of-motion exercises at least: a) every 30 minutes b) every 1 to 2 hours c) every 2 to 4 hours d) every 8 hours |
b) every 1 to 2 hours |
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A nurse sees smoke emerging from the suction equipment being used. Which is the greatest priority in the event of a fire? 1. Report the fire. 2. Extinguish the fire. 3. Protect the clients. 4. Contain the fire. |
3. Protect the clients. |
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An 87-year-old man is admitted to the hospital for cellulitis of the left arm. He ambulates with a walker and takes a diuretic medication to control symptoms of fluid retention. Which intervention is most important to protect him from injury? 1. Leave the bathroom light on. 2. Withhold the client's diuretic medication. 3. Provide a bedside commode. 4. Keep the side rails up. |
3. Provide a bedside commode. |
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A mother and her 3-year-old live in a home built in 1932. Which NANDA nursing diagnosis is most applicable for this child? 1. Risk for Suffocation 2. Risk for Injury 3. Risk for Poisoning 4. Risk for Disuse Syndrome |
3. Risk for Poisoning |
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A client is being admitted to the hospital because of a seizure that occurred at his home. The client has no previous history of seizures. In planning the client's nursing care, which of the following measures is most essential at this time of admission? Select all that apply. 1. Place a padded tongue depressor at the head of the bed. 2. Pad the bed with blankets. 3. Inform the client about the importance of wearing a medical identification tag. 4. Teach the client about epilepsy. 5. Test oral suction equipment. |
2. Pad the bed with blankets.5. Test oral suction equipment. |
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Which nursing intervention is the highest in priority for a client at risk for falls in a hospital setting? 1. Keep all of the side rails up. 2. Review prescribed medications. 3. Complete the "get up and go" test. 4. Place the bed in the lowest position. |
4. Place the bed in the lowest position. |
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The nurse assesses a cyanotic appearance and cool temperature in the hand of a client wearing a wrist restraint. The client complains of numbness and tingling in the hand. What should the nurse do first? 1. Remove the restraint and call the physician. 2. Reapply the restraint in a different area of the wrist. 3. Leave the restraint in place and notify the physician.4. Loosen the restraint and exercise the limb. |
4. Loosen the restraint and exercise the limb. |
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Which statement by a father indicates understanding of safety measures for his 3-year-old child? 1. "I shouldn't give him ice cream bars on a stick." 2. "He knows how to swim, so I usually read a book by the pool." 3. "I can leave him for a few minutes only when he is asleep." 4. "He can cross the street by himself to play with his best friend." |
1. "I shouldn't give him ice cream bars on a stick."Preschool-age children are active and clumsy. The stick in an ice cream bar could injure the child if he fell. Parents should always have their eyes on a child in a swimming pool. A child should never be left alone, even when asleep. The child should be helped to cross the street.Evaluation; Safe, Effective Care Environment; Analysis |
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When planning a safety seminar in the workplace for a group of middle-aged adults, what should be a primary focus? 1. Motor vehicle accidents 2. Occupational accidents 3. Falls 4. Fires |
2. Occupational accidents |
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What test would be most appropriate to perform on an elderly person on admission to a care facility?1. The Get Up and Go test2. The sundowner's test3. The Denver Developmental Screening test4. A vision screening exam |
1. The Get Up and Go test |
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What statement by a nurse to a new nurse, orienting to the unit, is correct regarding seizure precautions? 1. Any seizure can lead to status epilepticus. 2. Apply oxygen if the client turns cyanotic. 3. Do not force a tongue depressor between the teeth. 4. Administering an anticonvulsant drug is not beneficial. |
3. Do not force a tongue depressor between the teeth. |
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An imaginary vertical line drawn through the body's center of gravity is called... |
line of gravity. |
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The point at which all of the body's mass is centered is... |
the center of gravity. |
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When a person is inactive, the joints are pulled into a flexed, or bent position. If this tendency is not counteracted with exercise and position changes, the muscles permanently shorten, and the joint becomes fixed in a flexed position. This is called a... |
A contracture |
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Lordosis |
An exaggerated anterior/inward curvature of the lumbar spine |
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Orthopneic Position |
Client sits either in bed or on the side of the bed with an overbed table across the lap |
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Paresis |
Muscle that is paralyzed |
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Proprioception |
term used to describe awareness of posture, movement and changes in equilibrium and knowledge of position, weight, resistance of objects in relation to the body |
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Supine Position |
Lying on back |
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Sims' Position |
Semiprone position; halfway between lateral and prone positions |
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Semi-Fowler's Position |
Head and trunk raised 15 to 45 degrees |
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Prone Position |
client positioned on the abdomen with the head turned to one side |
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Low Fowler's Position |
Head to be elevated 30 degrees |
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High Fowler's position |
Head and Trunk are raised 60-90 degrees |
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Isokinetic (Resistive) Exercise |
Muscle contraction or tension against resistance |
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Isometric (static or setting) Exercise |
Muscle contraction without moving the joint |
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Isotonic (Dynamic) Exercise |
Those in which the muscle shortens to produce contractions and active movement |
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During strenuous exercise, the metabolic rate can increase as much as... |
20 times the normal rate. |
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While going down the stairs with crutches, the patient moves the ____ on the steps first. |
crutches and affected leg |
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While going up the stairs with crutches, the patient assumes the tripod position and moves the ____ on the steps first. |
unaffected leg. The affected leg is always supported by the crutches. |
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The shoulder rest of crutches should be ____ below the axilla while the patient is standing erect. |
three finger widths, or 1 - to inches |
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This semi-prone position assumes a posture halfway between the lateral and the prone positions, and may be used for unconscious patients because it facilitates drainage from the mouth and prevents aspiration. |
Sims' position. This position is also used for administering enemas and is found to be comfortable for pregnant women. |
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This position facilitates respiration by allowing maximum chest expansion. |
orthopneic position |
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Activity intolerance level 1... |
Walks regular pace on level ground indefinitely; climbs one flight of stairs or more but more short of breath than normally. |
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Activity intolerance level 2.. |
Walls one city block of 500 feet on ground level; climbs one flight of stairs slowly without stopping. |
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Activity intolerance level 3... |
Walks no more than 50 feet on level ground without stopping and unable to climb one flight of stairs without stopping. |
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Activity intolerance level 4... |
Dyspnea and fatigue at rest. |
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Turing the sole of the foot outward by moving the ankle joint is called... |
enversion. |
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Turning the sole of the foot inward by moving the ankle joint is calles... |
inversion. |
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Resident Flora |
The collective vegetation in a given area |
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Infection |
An invasion of body tissue by microorganisms and their growth there |
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Virulence |
The microorganisms ability to produce disease |
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Communicable Disease |
Communicable Disease The infectious agents ability to be transmitted to an individual by direct or indirect contact or as an airborne infection |
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Pathogenicity |
The ability to produce disease |
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Opportunistic Pathogen |
Causes disease only in a susceptible individual |
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Asepsis |
The freedom from disease-causing microorganisms. |
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Medical Asepsis |
Includes all practices intended to confine a specific microorganism to a specific area, limiting the number, growth, and transmission of microorganisms |
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Surgical Asepsis |
Also known as Sterile Technique. Refers to those practices that keep an area or object free from an area or object free of all microorganisms. |
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Local Infection |
limited to the specific part of the body where the microorganisms remain |
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Systemic Infection |
The microorganisms spread and damage different parts of the body |
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Septicemia |
When bacteremia results in systemic infection |
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Nosocomial Infection |
Nosocomial Infection Infections that originate in the hospital |
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Endogenous Source |
When infections originate from the clients themselves |
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Exogenous Source |
When infections originate from the hospital environment and hospital personnel. |
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Iatrogenic Infection |
The direct result of diagnostic or therapeutic procedures |
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Vehicle-Borne Transmission |
Any substance that serves as in intermediate means to transport and introduce an infectious agent into a susceptible host through a suitable portal of entry. (e.g., fomites, blood, water, food) |
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Vector-Borne Transmission |
An animal or flying or crawling insect that serves as an intermediate means of transporting the infectious agent |
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Droplet Nuclei |
The residue of evaporated droplets emitted by an infected host such as someone with TB. |
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Nonspecific Defenses |
Protect the person against all microorganisms, regardless of prior exposure |
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Specific (Immune) Defenses |
Directed against identifiable bacteria, viruses, fungi, or other infectious agents |
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Exudate |
Fluid that escaped from the blood vessels, dead phagocytic cell, and dead tissue cells and products that they release |
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Regeneration |
The replacement of destroyed tissue cells by cells that are identical or similar in structure and function |
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Granulation Tissue |
Fragile, gelatinous tissue, appearing pink or red because of the many newly formed capillaries. The early stages of forming fibrous (scar) tissue |
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Autoantigen |
When the proteins of an antigen originate in a person's own body |
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Humoral Immunity |
Also known as Circulating Immunity. These defenses reside ultimately in the B lymphocytes and are mediated by antibodies produced by B cells |
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Circulating Immunity |
Also known as Humoral Immunity. These defenses reside ultimately in the B lymphocytes and are mediated by antibodies produced by B cells |
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Antibodies |
Also known as Immunoglobulins. are part of the body's plasma proteins |
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Active Immunity |
The host produces antibodies in response to natural antigens |
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Passive Immunity |
Also known as Acquired Immunity, the host receives natural or artificial antibodies produced by another source |
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Antiseptics |
Agents that inhibit the growth of some microorganisms |
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Standard Precautions |
Used in the care of all hospitalized persons regardless of their diagnosis or possible infection status. Applies to blood, ALL bodily fluids, secretions, and excretions (except sweat), non intact skin, and mucous membranes. |
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Factors Influencing Individual Hygienic Practices |
Culture, Religion, Environment, Developmental level, Health and energy, and Personal preferences. |
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Complete bed bath |
The nurse washes the ENTIRE body of a dependent client in bed. |
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Self-help bed bath |
Clients confined to bed are able to bathe themselves with help from the nurse for washing the back and perhaps the feet. |
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Partial bath (abbreviated bath) |
Only the parts of the client's body that might cause discomfort or odor, if neglected, are washed: the face, hands, axillae, perineal area, and back. Omitted are the arms, chest, abdomen, legs, and feet. |
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Bag bath |
Prepared product that contains 10-12 presoaked disposable washcloths that contain no rinse cleanser solution. |
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Towel bath |
Uses regular towels. Useful for clients who are bedridden and clients with dementia. The client is kept warm throughout the bathing process by a bath blanket. The nurse replaces the bath blanket with a large towel that has been soaked with warm water and no-rinse soap. |
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Water for a bath should feel warm to the client. Generally the temperature should be: |
110F- 115F |
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Therapeutic baths |
Given for physical effects, such as to soothe irritated skin or to treat an area (EX: the perineum). Generally taken in a tub one third or one half full. Client often remain in the bath from 20-30 minutes |
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Cerumen |
Ear wax |
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Halitosis |
bad breath |
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Glossitis |
inflammed tongue |
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Cheilosis |
Cracking of lips |
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Stomatitis |
Inflammation of oral mucosa |
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Parotitis |
inflammation of parotid salivary glands |
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AMMONIA DERMATITIS |
caused by skin bacteria reacting with urea in the urine. skin becomes reddened and sore |
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A client can bathe most of her body except for the back, hands, and feet. She also can walk to and from the bathroom and dress herself when given clothing. Which functional level describes this client? 1. Totally dependent (+4) 2. Moderately dependent (+3) 3. Semidependent (+2) 4. Independent (0) |
3. Semidependent (+2) |
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*The client is unresponsive and requires total care by nursing staff. Which assessment does the nurse check first before providing special oral care to the client? 1. Presence of pain 2. Condition of the skin 3. Gag reflex 4. Range of motion |
3. Gag reflex |
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*A client with diabetes has very dry skin on her feet and lower extremities. The nurse plans to inform the client to do which of the following to maintain intact skin? 1. Soak her feet frequently. 2. Use a nonperfumed lotion. 3. Apply foot powder. 4. Avoid knee-high elastic stockings. |
2. Use a nonperfumed lotion. |
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*The client wears an in-the-ear (ITE) hearing aid and because of arthritis needs someone to insert the hearing aid. Which action does the nurse teach the unlicensed assistive personnel (UAP) to do before inserting the client's hearing aid? 1. Turn the hearing aid off. 2. Soak the hearing aid in soapy solution to clean it. 3. Turn the volume all the way up. 4. Remove the batteries. |
1. Turn the hearing aid off. |
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The client is in surgery and will be returning to his bed via a stretcher. Which bed option reflects that the nurse appropriately planned ahead for this client? 1. Open bed in low position. 2. Occupied bed in low position. 3. Closed bed in high position. 4. Surgical bed in high position. |
4. Surgical bed in high position. |
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*The client is complaining of shortness of breath. His respirations are 28 and labored. The bed is currently in the flat position. The nurse puts the bed in which position? |
1. Fowler's |
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Benefits of Bathing |
-cleanses skin-stimulates blood circulation-produces sense of well-being for client-gives nurse an opportunity to assess the skin |
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*An expected outcome for a client with a nursing diagnosis of Self-care Deficit related to cognitive impairment would beA. The client will bathe herself dailyB. The client will verbalize an understanding of the importance of bathingC. The client, with supervision, will brush her teethD. The client will eliminate safety hazards from her environment |
C. The client, with supervision, will brush her teeth |
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*Which situation could pose a threat to a client's personal hygiene?A. A client has a newly formed ileostomyB. A client performs meticulous foot careC. A French client refuses to bathe dailyD. A client's room temperature is set at 72° F |
A. A client has a newly formed ileostomy |
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*Which nursing intervention would take priority when bathing a surgical client on his first postop day?A. Apply lotion to dry skinB. Use warm water to bathe clientC. Raise side rails while gathering suppliesD. Assess skin integrity |
D. Assess skin integrity |
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A client who is NPO, comatose, and receiving oxygen has cracked lips, dry mucus membranes, swollen gums, and caked mucus on the tongue and teeth. The best intervention is to: |
Swab the oral cavity with a water-soaked sponge as needed. |
