Rasmussen: PN1-Exam 1 Questions with complete solutions

Rasmussen: PN1-Exam 1 Questions with complete solutions Beneficence •Promotes positive actions to help others •Encourages the nurse to do good for the patient Non-maleficence •Importance of preventingd harm and ensuring the patient's well-being Fidelity •Keeping obligations or promises to patients to follow through with care Veracity •The nurse's obligation to tell the truth to the best his/her knowledge Social Justice •Equality and fairness regardless of age, gender, sexual orientation, religion, race, ethnicity and/or education Autonomy •Making own decision about something. Self-determination Being able to choose something. -Ex. grape juice or orange juice? -Ex. chemo or no chemo? Autonomy vs. Self-determination -Dementia pts. have self-determination but do not get to make autonomic decisions Safety -The condition of being protected from or unlikely to cause danger, risk, or injury. -Basic Human Need -Nurses attend to safety needs of: clients in healthcare setting and healthcare workers, including self. Maslow's Hierarchy of Needs Sentinel event -Any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness -Requires IMMEDIATE attention and response Clinical Judgement ABC's (Airway, Breathing, Circulation) then, Maslow's. Quality and Safety Education for Nurses (QSEN) - Competencies for students to achieve (knowledge, skills, & attitudes): -Pt./family-centered care. -Teamwork and collaboration. -EBP -Quality improve. -Informatics & tech. -Clinical judgement -Ethics. Healthcare disparities -Most common is poor communication (talk to pt. with 8th grade literacy) and lack of access to healthcare. Common health problems of older adults (65+ years) -Decreased nutrition and hydration -Decreased mobility -Stress, loss, coping -Accidents -Drug use and misuse -Inadequate cognitiond -Elder neglect. Carseat Safety -Carseat should be rear-facing in the middle seat in back until 2 years or meets weight requirments. Most reported accident in hospitals?? -FALLLLSSSS!!!!! -More common at shift change, nights, weekends, and holidays. Immobility effect -Decreases peristalsis when you don't move -No moving = no pooping. Falls -Assess why they are a fall risk. -Assess for comfort. -Pt. generally get out of bed because: needs to use bathroom, in pain, or uncomfortable. -Always assess these things before using restraints. -If there is equipment to help or move pt, use the equipment!!! (Hoyer lifts, stand-up lift, gait belts ,etc. Safety hazards in the home -Poisoning: medication, household chemicals, lead, cosmetics. -Carbon monoxide poisoning (treatment- 100% humidified oxygen) -Scalds and burns -Fires -Falls - age 65 at highest risk -Firearms injuries -Suffocation/Asphyxiation: drowning, choking, smoke/gas inhalation (children 0-4yrs at highest risk). -Take home toxins: pathogenic microorganisms, asbestos, lead, mercury, arsenic. Radiation Safety -Clustering of care for patients who have implanted radiation. Safety hazards in the healthcare facility -Falls -Equipment Related Accidents -Fires/Electrical Hazards (RACE: rescue, alarm, confine, extinguish/evacuate) (PASS: pull, aim, squeeze, sweep) -Restraints -Side Rails -Mercury Poisoning Effects on Mobility: Muscle atrophy and joint dysfunction -Confinement = 7-10 % of muscle strength/week -Stiff joints -Deconditioning Effect on Mobility: Compromised respiratory function -Atelectasis *Caused by decrease in chest wall expansion *Diminished breath sounds *Decreased muscle tone, which then leads to inability to cough and deep breath -ENCOURAGE cough and deep breath every hour. Effects of Immobility: Venous Stasis. -Blood pooling, compression of small blood vessels. Effects on Immobility: Increase coagulability -Due to decreased clearance of coagulation factors -Virchows Triad is a combination of blood pooling, compression of small blood vessels and increased coagulability that leads to deep vein thrombosis Effects of Immobility: DVT -Need to assess clients by comparing extremities to look for differences in size; measure the calf and thigh circumference -Treat prophylactically with Lovenox or Heparin -Treat prophylactically with SCDs and/or TED hose to apply pressure Effects on Immobility -Orthostatic hypotension: due to inability to maintain blood pressure -Glucose intolerance: due to decreased need of ATP; slowed metabolic rate; decreased protein production which results in hyperglycemia -Pressure ulcers :Turn immobile clients at least every 2 hours -Constipation / paralytic ileus / decreased peristalsis: encourage high fiber foods, water and juice throughout the day Effects of Immobility -Urinary Tract Infection: Stagnant urine caused by decreased muscle tone to urinate -Renal calculi: Excess calcium that is not used in the body and needs to be excreted -Depression: due to lack of endorphin production, due to isolation -Sleep disturbances: caused by signs of increased anxiety -Activity intolerance caused by disease pain or inability to breathe Factors affecting mobility and activity. -Lifespan -Nutrition -Lifestyle -Trauma -Stress -External environ -Diseases or abnormalities: bone disease deformities (tumors/osteomyelitis), Joint diseases (arthritis, gout), CNS disorders (stroke, head/spinal injury, MS, Parkinson's) Fibromyalgia: non-inflammatory pain syndrome -Cause: by multiple health factors: CFS, lung disease, trauma, & flu like illnesses. -Symptoms: intermittent, mild-severe fatigue, sleep disturbances, headache, jaw pain, GI (abdo pain, diarrhea, heartburn), GU (urine frequency/urgency, pelvic pain , cardiovasc.(dyspnea, CP), blurred vision/dry eyes, neuro(forgetfulness/concentration probs) -Treatment: medication(gabapentin, lyrica, NSAIDS), promote restful sleep habits, avoid alcohol/caffeine, regular exercise/PT, stress management. **MOST COMMON WITH WOMEN AGE 30-50.