NUR 3040 Study Guide 1 Questions
and All Actual Answers.
Assessment - Answer § Includes health history, physical assessment, relevant information
from family, health care team, medical record
§ Collect subjective and objective data
Diagnosis - Answer § Based on the collection and analysis of assessment data
§ Actual or potential health problems
Planning - Answer § Prioritization using Maslow hierarchy
§ Establish expected outcomes (S.M.A.R.T)
§ Goals can be short term and long term
Implementation - Answer § Carry out the plan of care
§ Goals are used as a focus
§ Interventions should be patient focused, and outcome directed
§ "ongoing" assessment
Evaluation - Answer § Allows nurse to determine patients' response to interventions
§ If goals aren't met plan of care is either revise or a new plan of care is made
what is delirium? - Answer a. Is a state of temporary but cute mental confusion
b. Common in older adults who have a short-term illness such as:
i. Lung or heart disease
ii. Infections
iii. Poor nutrition
iv. Drug interaction
Causes of delirium - Answer Lung or heart disease, infections, poor nutrition, drug
interaction, head trauma, sensory deprivation or overload, medication or alcohol toxicity,
dehydration, fecal impaction, lack of environment cues
Early signs of Delirium - Answer · Inability to concentrate
· Irritability
, · Insomnia
· Loss of appetite
· Restlessness
· Hyper-activity
Cognitive impairment
Late signs of delirium - Answer Agitation
misperception
mininterpretation
hallucinations
delusion, fear
anxiety and paranoia
Nursing management involved in treating delirium - Answer a. Focus en eliminating
precipitating factors and treat the underlying cause
b. Antibiotic therapy is started if delirium is secondary to infection
c. Reorientation and behavioral interventions should be used In all patients with delirium
d. The patient experiencing delirium is also at risk for immobility and skin breakdown
e. Nurse should focus on supporting the family and caregivers
prevention of delirium - Answer a. Therapeutic activities
b. Reorientating the patient
c. Ensuring early mobilization
d. Pain control
e. Minimized the use of psychoactive drugs
f. Prevent sleep deprivation
g. Enhance communicating methods for visions and hearing impairment
h. Maintain oxygen levels and fluid/electrolyte balance
Delirium vs Dementia - Answer a. Delirium
i. Abrupt onset
ii. Last up to three days
iii. Linked to a cause
b. Dementia
and All Actual Answers.
Assessment - Answer § Includes health history, physical assessment, relevant information
from family, health care team, medical record
§ Collect subjective and objective data
Diagnosis - Answer § Based on the collection and analysis of assessment data
§ Actual or potential health problems
Planning - Answer § Prioritization using Maslow hierarchy
§ Establish expected outcomes (S.M.A.R.T)
§ Goals can be short term and long term
Implementation - Answer § Carry out the plan of care
§ Goals are used as a focus
§ Interventions should be patient focused, and outcome directed
§ "ongoing" assessment
Evaluation - Answer § Allows nurse to determine patients' response to interventions
§ If goals aren't met plan of care is either revise or a new plan of care is made
what is delirium? - Answer a. Is a state of temporary but cute mental confusion
b. Common in older adults who have a short-term illness such as:
i. Lung or heart disease
ii. Infections
iii. Poor nutrition
iv. Drug interaction
Causes of delirium - Answer Lung or heart disease, infections, poor nutrition, drug
interaction, head trauma, sensory deprivation or overload, medication or alcohol toxicity,
dehydration, fecal impaction, lack of environment cues
Early signs of Delirium - Answer · Inability to concentrate
· Irritability
, · Insomnia
· Loss of appetite
· Restlessness
· Hyper-activity
Cognitive impairment
Late signs of delirium - Answer Agitation
misperception
mininterpretation
hallucinations
delusion, fear
anxiety and paranoia
Nursing management involved in treating delirium - Answer a. Focus en eliminating
precipitating factors and treat the underlying cause
b. Antibiotic therapy is started if delirium is secondary to infection
c. Reorientation and behavioral interventions should be used In all patients with delirium
d. The patient experiencing delirium is also at risk for immobility and skin breakdown
e. Nurse should focus on supporting the family and caregivers
prevention of delirium - Answer a. Therapeutic activities
b. Reorientating the patient
c. Ensuring early mobilization
d. Pain control
e. Minimized the use of psychoactive drugs
f. Prevent sleep deprivation
g. Enhance communicating methods for visions and hearing impairment
h. Maintain oxygen levels and fluid/electrolyte balance
Delirium vs Dementia - Answer a. Delirium
i. Abrupt onset
ii. Last up to three days
iii. Linked to a cause
b. Dementia
