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NUR 242 EXAM 1 QUESTIONS WITH COMPLETE SOLUTIONS
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NUR 242 EXAM 1 QUESTIONS WITH COMPLETE SOLUTIONS
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NUR 242 EXAM 1 QUESTIONS WITHCOMPLETE SOLUTIONS
ADPIEd-dNursingdProcessd-dAssessment,dDiagnosis,dPlan,dIntervention,dEvaluation
WorlddHealthdOrganizationddefinitiondofdhealthd-
dHealthdisdadstatedofdcompletedphysical,dmentaldanddsocialdwell-
beingdanddnotdmerelydthedabsencedofddiseasedordinfirmity.
FrameworkdofdHealthydPeopled2030d-dPrinciples
OverarchingdGoals
PlandofdAction
Historyd&dContext
LeveldofdPreventiond-dPrimary-dPrevention
Secondary-dScreening
Tertiary-Rehab
RiskdFactorsd-dModifiable
Non-modifiable
PreventdConstipationdindOlderdAdultsd-
dIncreasedFiberd(35dtod50g)d&dFluiddIntaked(2L),dExercisedRegularly
CommondAdversedDrugdEventsdindolderdAdultsd-dEdema,dN/
V,dAnorexia,dconstipation,ddehydration,ddizziness,dsyncope,dacutedconfusion,ddysrhythmia
s,durinarydretention,danddhypotension
Majordpredictordofdmorbidityd&dmoralityd-dDelirium
ConfusiondAssessmentdMethodd(CAM)d-dAcutedonsetdanddfluctuatingdcourse
Inattention
Disorganizeddthinking
Altereddleveldofdconsciousness
MonitordOlderdAdultsdreceivingdAntipsychoticsdADEsd-dAnticholingericdEffects
ORTHOSTATICdHypotension
,Parkinsonism
Restlessness
Hyperglycemiad&dDM
Whenddodyoudassessdskindondptdthatdisdreddened?d-dEveryd8dhours
Immobilityd-dLongdperiodsdofdimmobility
MusculoskeletaldImmobilityd-dWasting,dOsteoporosis
IntegumentarydImmobilityd-dPressuredInjuries
GIdImmonilityd-dConstipation
CardiovasculardImmobilityd-dorthostaticdhypotension,dthrombusdformationd(DVT)
NeurologicaldImmobilityd-ddepression,dforgetfulness,danxiety,dconfusion
-pressuredondskindwilldcausednervedpain/damage
Renal/UrinarydImmobilityd-dStones
Incontinence
RespiratorydImmobilityd-datelectasisd->dpneumonia
MetabolicdFluidd&dElectrolytedImbalance-Immobilityd-dDehydrationdordFluiddOverload
OrthostaticdHypotensiond-
dAddropdofdmoredthand10dmmHgdindsystolicdord10dmmHgdinddiastolicdpressuredbetweendposit
ions
WalkerdProcedured-dLiftdWalker
Movedwalkerdaboutd2dfeetdforward
SmalldSteps
CheckdBalancedRepeat
ProperdbodydMechanicsd-dMaintaindadwide,dstabledbasedwithdyourdfeetd
Placedthedbeddatdthedcorrectdheight----
waistdleveldwhiledprovidingddirectdcaredanddhipdleveldwhendmovingdpatientsd
Keepdthedpatientdordworkddirectlydindfrontdofdyoudtodpreventdyourdspinedfromdrotatingd
Keepdthedpatientdasdclosedtodyourdbodydasdpossibledtodpreventdreachingd
Usedappropriatedsafedpatientd-handlingdequipment
CanedProcedured-dCanedindstrongdhand-dusedunaffecteddside
WelldBalanced
Cane,dWeakdLeg,dthendstrongdleg
, PhysiologicaldEffectsdImmobilityd-dChangesdindSleep/WakedCycle
ImpaireddCoping
ChangesdindBodydImage
Anxietyd
Depression
BehavioraldChanges
Assessmentdofdskind-dOncedperdshift,dupondadmission,dordnursingdinstinct
Accessdindividualsdwithdanyddevicesdassessdskindeveryd2dhoursdfordskindbreakdown
Inspectdskind-d-Beneathdanddarounddcompressiondstockings
•Bonydprominences
•Skindtodskindareas
•Anydareasdwheredthedclientdlacksdsensation
•Specialdattentiondifdthedclientdisdgettingdpaindepidurald/spinaldpaindmedications
d-depiduraldordspinaldcathsd(monitordanddensuredinfectiondfree,daccessdtoedsensation)
•dassessdperinuem
FunctionsdofdSkind-
dProtection,dHomeostatisd(WaterdBalance),dTemperaturedRegulation,dSensory,dVitamindSy
nthesis,dPsychosocial
SkindCulturaldAssessmentd-dDetectivedsubtledcolordchanges
Assess:dMucousdMembranes,dNaildBedsd&dSkindtones
SkindAssessmentdProcessd-
dSkindtemperature,dtugord(backdofdhand,dhead,dclavicle),dcolord(blanchabledtodnonblanchabl
e),dtexture,dmoistured(incontinence,dwounds,dostomy,dilesotosmy),dintegrity,dcapillarydrelief
d(hypoperfusion), dedema
SkindAlterationsd-dWhite-ddecreaseddHgbd&dblooddflow
Yellow-orange-dJaundice,dCartoenemia,dUrochromedlevel
Red-dVasodilation
Blue-dCyanosis
ReddishdBlue-ddecreaseddperipheraldcirculation
Brown-dMelanindProduction
Assessingdskindchangesdonddarkerdskindtonesd-dCyanosis-
dlipsdordtonguedaredgray,dnaildbedsdaredblue,dconjunctivadisdwhite
Inflammation-dincreaseddwarmth,dshinydordpitting,dassessmentdofdbothdextremitiesd
Jaundice-dyellowdoraldmucousdmembranedordsclera
Bleeding-dswelling,dpetechiae
Drynessd-d-scaling
d-flaking
d-lanolin,dantipruriticdagents,dtopical/doraldantihistamines
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