139 notecards = 35 pages (4 cards per page)
12 cranial nerves
Variations in vital signs
Normal vital infant
T - 98.7 -100.5
rbm - 20-40
bp - 85/37
A man age 61 years is distraught because he has just learned that his most recent computed tomography (CT) scan shows that his colon cancer has metastasized to his lungs. Which of the following nursing aims should the nurse prioritize in the immediate care of this patient?
A student nurse understands that the primary aim of the Healthy People 2020 initiatives is
The nurse conducts a home safety assessment for a client. Which statement best explains the standard of care being implemented?
The nurse promotes a safe environment
The need for university-based nursing education programs was brought to light during which important historical time?
World War II
The registered nurse is teaching a community health class about illness prevention. Which of the following statements reflects understanding of this concept?
"It is important to enroll in a smoking cessation class."
_______—collecting, validating, and communicating of patient data
______________—analyzing patient data to identify patient strengths and problems
________________—specifying patient outcomes and related nursing interventions
____________________—carrying out the plan of care
______________—measuring extent to which patient achieved outcomes
(Survival): food, fluids, oxygen, elimination,
warmth, physical comfort
Human Need Maslow
What is the nurse’s role in the Assessment phase of the Nursing Process?
What type of data is collected?
What are the different types of Nursing Assessments?
What is the purpose of the Nursing Diagnosis?
How does the nurse develop the Nursing Diagnosis?
What is the difference between a Nursing Diagnosis and Medical Diagnosis?
What is the difference between an Actual Nursing Diagnosis, Risk Nursing Diagnosis, Possible Nursing Diagnosis, Wellness Diagnosis, and Syndrome Nursing Diagnosis?
Problem --->> Etiology----->> Characteristics
How do you Know What is Occurring
What are the parts of a nursing diagnosis?
What is the purpose of Planning?
How does the nurse prioritize the nursing diagnosis?
What is the difference between Short and Long term outcomes (goals)?
What is the difference between Cognitive, Psychomotor, and Affective outcomes/goals?
How are Outcomes/Goals written?
Assessment is done
Determine the patient’s new or continuing need for
Implementing the care plan
Cognitive—increase in patient knowledge
4 Types of outcomes
Delete or modify the nursing diagnosis.
Revisions in the Care Plan
How do you know the problem is occurring (Hint: objective and
what is the cause (etiology) of the problem?
Mr. Smith is a 68 year old male who is post op day 4 from
right hip replacement. Prior to surgery Mr. Smith was active and
completed all ADLS independently. Mr. Smith’s physician ordered to
resume is home medications; Lipitor (cholesterol med) and Lopressor
(heart medication) and also added Percocet 4 times a day PRN pain
and Protonix (anti ulcer medication).
You are developing the plan of care for Mr. Smith who was admitted 3 days ago after a stroke. Assessment findings include CN X deficit, hoarse voice, and left sided hemiplegia. Mr. Smith is married, with three adult daughters and is a retired school teacher. Vital signs: BP 128/78 HR 88 RR 16 equal and unlabored and Temp 98.7 F (oral)
You are revising the plan of care for Mr. Smith, who had a stroke 5 days ago. Assessment: lung sounds crackles in right lower base, “wet” voice. BP 136/80 RR 22 equal, unlabored, HR 92, T 99.8 F (axillary).
______________—a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity
_________________—the unique response of a person to a disease; an abnormal process involving changed level of functioning
_____________—an active state of being healthy by living a lifestyle promoting good physical, mental, and emotional health
Physical: genetic inheritance, age,
developmental level, race, gender
Interdependent parts that make up the whole person, influences illness and illness behaviors
Basic human needs
Which of the following is an example of an acute
Generally has a rapid onset of symptoms and lasts only a relatively
A broad term that encompasses many different physical and mental
alterations in health
It is a permanent change.
Characteristics of chronic illness
Stages of Illness behavior
Tell whether the following statement is true or
Answer: B. Assuming the sick role
A person who defines himself as sick and self-medicates or visits a doctor is said to be in stage 2 of illness behavior: assuming the sick role.
Factors that the client cannot
non modifiable risk factors
Factors that the client can change
Modifiable risk factors
______________: the behavior of an individual that is motivated by a personal desire to increase well-being and health potential. Education is a health promotion activity.
_________________: the behavior motivated by a desire to avoid or detect disease or to maintain functioning with the constraints of illness or disease. A diabetic patient looks at the soles of his feet with a mirror weekly
_______ directed to health promotion and the preventing the development of disease; interventions that prevent actual occurrence of a specific illness or disease; may focus on individuals or groups.
______________ focuses on screening for early detection of disease with prompt diagnosis and treatment
_____________ directed towards recovery or rehabilitation of a disease or illness has developed
1.) A nurse is administrating immunizations at a back to school fair.
2.) The nurse is performing a skin assessment for a patient that works outside in the sun.
3.) A nurse is monitoring the progress of a patient participating in Cardiac Rehab.
1.) A nurse is teaching a class on Heart Healthy Nutrition to a group of middle aged adults
2.) The nurse is completing the health assessment on a patient that includes cholesterol screening and blood pressure measurements.
3.) The nurse is teaching the patient how to take the prescribed cholesterol medicine and dietary restrictions.
Which of the following is an example of a nursing activity that
promotes secondary prevention as a level of preventive care?
Answer: B. Performing a blood pressure screening at a local
Care must be sensitive to needs of individuals, families, or groups
from diverse cultures.
culturally competent nursing care
Cultural background of each participant
Factors That Affect Culturally Diverse Interactions
Shared system of beliefs, values, and behavioral
Large group of people who are members of a larger cultural
_________________ (usually largest group)
Cultural Assimilation (acculturation)
Belief that everyone should conform to the majority belief system
Ignores differences and proceeds as if they did not exist
Belief that one’s ideas, beliefs, and practice are the best or superior, or are most preferred to those of others
Sense of identification with a collective cultural group
One assumes that all members of a culture or ethnic group act
People become aware of differences and feel
cultural influences in health care
Develop cultural self-awareness.
Guidelines for Providing Culturally Competent Nursing Care
Recognize each person holds various beliefs about pain.
Culturally Sensitive Nursing Care—Patient in Pain
Infectious agent—bacteria, viruses, fungi
Components of the Infection Cycle
Bacteria—most significant and most prevalent
in hospital settings
Number of organisms
Factors Affecting Potential to Produce Disease
Possible Reservoirs for Microorganisms
Common portals of exit
Means of transmission
Incubation period—organisms growing and
Stages of infection
Body’s normal flora
Body’s Defense Against Infection
Intact skin and mucous membranes
Factors Affecting Host Susceptibility
Elevated white blood cell count—normal is 5,000 to
Laboratory Data Indicating Infection
Includes all activities to prevent or break the chain of
Use of invasive medical devices
Factors Predisposing Patients to Nosocomial Infections
Measures to Reduce Incidence of Nosocomial Infections
what does the state's nurse practice act do?
establishes the criteria for the education & licensure of its nurses enforces rules for the profession legally determines what who can and cannot do.
what phenomena underlies the present and predicted nursing shortage in the US?
aging of the population increased prevalence of chronic
is known as founder of modern nursing
is known for organizing hospitals and nurses
is known for she reformed treatment for the mentally ill.
is known for the first trained nurse in the USA
is Known for the founder of public health nursing
Marya Elizabeth Mahoney
is known for the first African-American nurse
Nora Gertrude Livingston
is known for established the first 3 year nursing program in North America
Isabel Hampton Robb
is known for founder of the ANA -American Nurses Association
Mary Adelaide Nutting
is known for: published the History of Nursing
is known for: established the first midwifery school in the US - Frontier Nursing Service
is known for: founded Planned Parenthood
name the 4 essential competencies nurses use:
define cognitive competency:
offer a a scientific rationale for a patient's plan of
define technical competency
the ability to use and creatively adapt technical equipment
define interpersonal competency
interact with patients
In what culture is good health achieved by the proper balance of yin and yang
In what culture do granny women or folk healers provide care and may be consulted even if the patient is also receiving traditional care
In what culture is self- diagnosis and use of over the counter medication often used, also dieting and extensive use of exercise are common
White middle class
In what culture is the patient's illness viewed as part of the whole. emphasis is placed on preventive medicine
In what culture may a patient refuse to allow the nurse to draw blood for a test- because he believes blood is the body's life force and cannot be regenerate
What is the most basic culturallly competent nursing care
Treating each person as an individual
What disorder might you screen for in an African American man
Keloid formations, hp, stroke and sickle cell anemia
Held the belief that illness was caused by sin and the gods' displeasure; theory of Animism
Pre civilized nursing
The roles of the physician and the nurse were separate and distinct.
Physician= Medicine man who treated dz with chanting , inspiring
fear, opening the skull to release evil spirits.
Theory of Animism
The belief that everything in nature was alive with invisible forces and endowed power. Good spirits brought health; evil spirits brought sickness and death.
Early Civilization Nursing
Temples became centers of medical care because of belief that illness
was caused by sin and was the gods' punishment.