NUR2356: Multidimensional Care I Final
Exam Study Guide What is the nurses priority if a patient falls?(ANS- Assess for injury
What is an injury to the skin and underlying tissue resulting from prolonged pressure on the skin?(ANS- Pressure ulcer
What are precautions a patient with low platelets should take in their everyday life?(ANS- Use electric razors, assess for bruising, and do low impact exercises
What are interventions/preventions for pressure ulcers?(ANS- Reposition the pt. every 2 hours, keep skin clean and dry, keep bony prominences off hard surfaces, ensure adequate proper nutritional status, eliminate friction or shear by limiting linen layers.
What is the best source of information when assessing pain?(ANS- The client
What is PQRST in reference to pain assessment?(ANS-
P: Provocation/Palliation - What makes the pain worse? What helps the pain
subside?
Q: Quality - What does it feel like?
R: Region/Radiation - Where is your pain?
S: Severity - 0 / 10
T: Timing - How long has it been bothering you?
Identify the different types of therapeutic communication (ANS- Active listening Establishing trust Being assertive 1 / 3
Validating messages Exploring issues Using silence Open ended questions
Identify communication enhancements for those with visual, hearing, speech, and cognitive disabilities (ANS- Be positive and patient use gestures use short specific sentences Be concrete and specific Call client by name Minimize environmental noise Face the client when speaking speak slow and clear
What is RACE in fire safety?(ANS- Rescue patient Activate alarm Contain fire Extinguish
What are the ABCs of priority care?(ANS- Airway Breathing Circulation/Cardiovascular function
What medications put a pt. at risk for falling?(ANS- Antihypertensive ACE-inhibitors Diuretics 2 / 3
Antidepressants Opioids
What are examples of interventions for confused pt. that is trying to get out of bed?(ANS- Room near nurses' station Bed and chair alarms Call light within reach Bed lowest height Adequate lighting
The Joint Commission, established in 2003, has implemented what program to address patient safety?(ANS- National Patient Safety Goals
Identify "normal" vitals
Temp:
BP:
Respirations
SPO2:
Pulse:
(ANS-
Temp: 96.4-99.5
BP: 120/80 - systolic: 90-120 / diastolic: 60-80
Respirations: 12-20
SPO2: 94-100%
Pulse: 60-100 bpm
What is a movement that increase the angle between two body parts and straightens the joint?(ANS- Extension
What movement is conducted in a circular manner, often seen at a ball and socket joint?(ANS- Circumduction
- / 3