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
