ANSWERs | Nursing Fundamentals Study
Guide Newest Version 2026|A+
Confirmed
tissue integrity - ANSWER-the ability of body tissues to regenerate and/or repair to
maintain normal physiological processes
interventions to maintain tissue integrity - ANSWER-reposition turning adequate
nutrition skin assessments
blanching test - ANSWER-A test of the rate of capillary refill; blanching means to cause
to become pale by applying digital pressure.
Non-blanchable - ANSWER-skins stay very red even with finger pressure; indicates
severe skin injury
Stage 1 pressure ulcer - ANSWER-intact skin with nonblanchable redness
stage 2 pressure ulcer - ANSWER-partial thickness skin loss involving epidermis,
dermis, or both
red/pink noist
blister et shallow crater
stage 3 pressure ulcer - ANSWER-full thickness tissue loss with visible fat
stage 4 pressure ulcer - ANSWER-Full-thickness tissue loss with exposed bone,
muscle, or tendon
debridement - ANSWER-Removal of foreign matter or dead tissue from a wound
promotes healing
eschar - ANSWER-a thick layer of dead tissue and tissue fluid that develops over a
deep burn area
Types of drainage - ANSWER-serous, sanguineous, serosanguineous, purulent
serous drainage - ANSWER-clear, watery fluid
clear yellow
,serosanguineous drainage - ANSWER-thin, watery drainage that is blood-tinged
sanguineous drainage - ANSWER-bloody drainage
purulent drainage - ANSWER-thick green, yellow, or brown drainage
Braden Scale - ANSWER-A tool for predicting pressure ulcer risk
lactose intolerance - ANSWER-The inability to completely digest the milk sugar lactose
symptoms of lactose intolerance - ANSWER-bloating, abdominal discomfort, diarrhea
gas
clear liquid diet - ANSWER-a diet that consists of foods that are liquid at room
temperature and leave little residue in the intestine. Ex: Water, Sprite, Ginger Ale, all
beverages without any residue, broth, Jello
iron rich foods - ANSWER-red Meat, fish, poultry, legumes. spinach, liver or organ
meat, tofu
anorexia nervosa - ANSWER-An eating disorder characterized by an obstinate and
willful refusal to eat, a distorted body image, and an intense fear of being fat
signs of anorexia nervosa - ANSWER-A refusal to keep one's body weight at or above a
normal weight for age and height; extreme weight loss, muscle wasting, eats very little
insufficient nutrition
excessive nutrition - ANSWER-common obesity
weight gain/ nutritional toxicity
excessive calorie intake
FICA - ANSWER-spiritual assessment tool
F in FICA - ANSWER-faith
I in FICA - ANSWER-importance
C in FICA - ANSWER-community
A in FICA - ANSWER-address
questions to assess spiritual needs - ANSWER-do you attend religious regularly
do you have Any spiritual needs we should discuss
in need of spiritual intervention call chaplain
Prayer - ANSWER-An attempt to contact God, usually through words
,Faith - ANSWER-Belief in God
dietary needs food can only come from? - ANSWER-facility no outside food
communication with non speaking English - ANSWER-use interpretive services *never
use family members
Jehovah's Witness - ANSWER-no blood products
if you hear a patient real about a tribal healer - ANSWER-ask about medication and
medication frequency
culture competence first assess - ANSWER-own biases attitude transcultural
perspective
concept attributes culture - ANSWER-learned
changed and adapted
shared beliefs values et behaviors
concept attributes spirituality - ANSWER-universal
impacted by illness
impacted by family and culture
Chinese to american - ANSWER-may avoid eye contact nurses responsibility to make
sure patient understands ask for pat to verbalize back info or ask a question of they
understand
Erickson stages intimacy vs isolation - ANSWER-age group 20 to 25 years
love
sense of the complexity of relationship value of tenderness and loving freely
fear or being alone
developmental needs for elderly - ANSWER-social gathering
reminiscing
2 types of fatigue - ANSWER-mental and psychological
mental fatigue - ANSWER-can be caused by continual mental effort and attention on a
particular task, as well as high levels of stress or emotion. It typically manifests itself as
a lack of mental clarity, concentration difficulties, sleepiness and, in some cases,
memory loss.
psychological fatigue - ANSWER-a stress response causing mental & emotional impact
of exhaustion causing a lack of motivation and inability to concentrate
imbalance of exercise sleep and diet illness not eating
, attributes to fatigue - ANSWER-generalized weakness
easy fatigability
reduce capacity to maintain performance
mental fatigue - ANSWER-impaired concentration loss of memory et emotional stability
focused assessment - ANSWER-assessment conducted to assess a specific problem;
focuses on pertinent history and body regions
Order of Assessment - ANSWER-Inspection, Palpation, Percussion and Ausculation.
EXCEPT with abdomen
cuz you don't wanna mess with the bowels
objective data - ANSWER-information that is seen, heard, felt, or smelled by an
observer; signs
subjective data - ANSWER-things a person tells you about that you cannot observe
through your senses; symptoms
Order of abdominal assessment - ANSWER-Inspect, Auscultate, Percuss, Palpate
assessment of integumentary system - ANSWER-Color: pallor, erythema, jaundice
Conditions that affect the skin: maceration, pruritus, acne
Alterations in skin integrity: abrasions, pressure ulcers
What does PERRLA stand for? - ANSWER-pupils equal, round, reactive to light and
accommodation
location of brachial pulse - ANSWER-medial antecubital fossa near bicep tendon
Location of APICAL PULSE - ANSWER-5th intercostal space, midclavicular line
location of tricuspid valve - ANSWER-4th intercostal space, left sternal border
cyanosis - ANSWER-bluish discoloration of the skin
asthma - ANSWER-wheezing
primary prevention - ANSWER-goodnutrition exercise getting adequate sleep managing
stress vitamin supplements
intervention assessment lifestyle fatigue - ANSWER-exercise rest therapy rest periods
adjust priorities simplify activities save conserve energy sleep hygiene nutrition teaching
Erickson: Identity vs. Identity Confusion - ANSWER-- adolescence