NUR 242 EXAM 1 QUESTIONS WITH COMPLETE SOLUTIONS

NUR 242 EXAM 1 QUESTIONS WITH
COMPLETE 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