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NUR 242 Exam 1 Questions And All Actual Answers. $11.49   Add to cart

Exam (elaborations)

NUR 242 Exam 1 Questions And All Actual Answers.

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  • NUR 242

ADPIE - Nursing Process - Answer Assessment, Diagnosis, Plan, Intervention, Evaluation World Health Organization definition of health - Answer Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Framework of Healthy Pe...

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  • November 6, 2024
  • 36
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers
  • NUR 242
  • NUR 242
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NUR 242 Exam 1 Questions And All
Actual Answers.
ADPIE - Nursing Process - Answer Assessment, Diagnosis, Plan, Intervention, Evaluation



World Health Organization definition of health - Answer Health is a state of complete physical, mental
and social well-being and not merely the absence of disease or infirmity.



Framework of Healthy People 2030 - Answer Principles

Overarching Goals

Plan of Action

History & Context



Level of Prevention - Answer Primary- Prevention

Secondary- Screening

Tertiary-Rehab



Risk Factors - Answer Modifiable

Non-modifiable



Prevent Constipation in Older Adults - Answer Increase Fiber (35 to 50g) & Fluid Intake (2L), Exercise
Regularly



Common Adverse Drug Events in older Adults - Answer Edema, N/V, Anorexia, constipation,
dehydration, dizziness, syncope, acute confusion, dysrhythmias, urinary retention, and hypotension



Major predictor of morbidity & morality - Answer Delirium



Confusion Assessment Method (CAM) - Answer Acute onset and fluctuating course

,Inattention

Disorganized thinking

Altered level of consciousness



Monitor Older Adults receiving Antipsychotics ADEs - Answer Anticholingeric Effects

ORTHOSTATIC Hypotension

Parkinsonism

Restlessness

Hyperglycemia & DM



When do you assess skin on pt that is reddened? - Answer Every 8 hours



Immobility - Answer Long periods of immobility



Musculoskeletal Immobility - Answer Wasting, Osteoporosis



Integumentary Immobility - Answer Pressure Injuries



GI Immonility - Answer Constipation



Cardiovascular Immobility - Answer orthostatic hypotension, thrombus formation (DVT)



Neurological Immobility - Answer depression, forgetfulness, anxiety, confusion

-pressure on skin will cause nerve pain/damage



Renal/Urinary Immobility - Answer Stones

Incontinence



Respiratory Immobility - Answer atelectasis -> pneumonia

,Metabolic Fluid & Electrolyte Imbalance-Immobility - Answer Dehydration or Fluid Overload



Orthostatic Hypotension - Answer A drop of more than 10 mmHg in systolic or 10 mmHg in diastolic
pressure between positions



Walker Procedure - Answer Lift Walker

Move walker about 2 feet forward

Small Steps

Check Balance Repeat



Proper body Mechanics - Answer Maintain a wide, stable base with your feet

Place the bed at the correct height----waist level while providing direct care and hip level when moving
patients

Keep the patient or work directly in front of you to prevent your spine from rotating

Keep the patient as close to your body as possible to prevent reaching

Use appropriate safe patient -handling equipment



Cane Procedure - Answer Cane in strong hand- use unaffected side

Well Balanced

Cane, Weak Leg, then strong leg



Physiological Effects Immobility - Answer Changes in Sleep/Wake Cycle

Impaired Coping

Changes in Body Image

Anxiety

Depression

Behavioral Changes

, Assessment of skin - Answer Once per shift, upon admission, or nursing instinct

Access individuals with any devices assess skin every 2 hours for skin breakdown



Inspect skin - Answer -Beneath and around compression stockings

•Bony prominences

•Skin to skin areas

•Any areas where the client lacks sensation

•Special attention if the client is getting pain epidural /spinal pain medications

- epidural or spinal caths (monitor and ensure infection free, access toe sensation)

• assess perinuem



Functions of Skin - Answer Protection, Homeostatis (Water Balance), Temperature Regulation, Sensory,
Vitamin Synthesis, Psychosocial



Skin Cultural Assessment - Answer Detective subtle color changes

Assess: Mucous Membranes, Nail Beds & Skin tones



Skin Assessment Process - Answer Skin temperature, tugor (back of hand, head, clavicle), color
(blanchable to nonblanchable), texture, moisture (incontinence, wounds, ostomy, ilesotosmy), integrity,
capillary relief (hypoperfusion), edema



Skin Alterations - Answer White- decreased Hgb & blood flow

Yellow-orange- Jaundice, Cartoenemia, Urochrome level

Red- Vasodilation

Blue- Cyanosis

Reddish Blue- decreased peripheral circulation

Brown- Melanin Production



Assessing skin changes on darker skin tones - Answer Cyanosis- lips or tongue are gray, nail beds are
blue, conjunctiva is white

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