Foundations of Nursing | Grand
Canyon University – 200 Questi,
Exams of Nursing
Section 1: The Nursing process & critical thinking
you need to consume over a 24 hour period for your body to maintain its
internal working activities while at rest simple carbohydrate -
ANSWER//classification for both monosaccharides and dissacharides trace
elements - ANSWER//less than 100 mg is needed daily triglycerides -
ANSWER//circulate in the blood and are composed of 3 fatty acids attached
to a glycerol vitamins - ANSWER//organic substances present in small
amounts in foods that are essential to normal metabolism water-soluble
vitamins - ANSWER//b and c complex body does not store; need to intake in
daily food bacteremia - ANSWER//bloodstream infection bacteriuria -
ANSWER//bacteria in the urine catheter-associated urinary tract infection
(CAUTI) - ANSWER//the presence of an indwelling urinary catheter causing
UTI fourth leading cause of health care-associated infections in acute care
hospitals catheterization - ANSWER//the placement of a tube through the
urethra into the bladder to drain urine cystitis - ANSWER//irritation of the
bladder urgency, frequency, incontinence, suprapubic tenderness dysuria -
ANSWER//pain with urination hematuria - ANSWER//blood in the urine
micturation - ANSWER//act of urination nephrostomy - ANSWER//small tubes
that are tunneled through the skin into the renal pelvis drain the renal pelvis
when the ureter is obstructed pelvic flood muscle training -
ANSWER//teaching patients how to identify and contract the pelvic floor
muscles in a structured exercise program kegel exercises achieve continence
postvoid residual (PVR) - ANSWER//the amount of urine left in the bladder
after voiding and is measured with either ultrasonography or straight
cateterization proteinuria - ANSWER//protein in the urine pyelonephritis -
ANSWER//serious upper UTI suprapubic catheter - ANSWER//urinary
drainage tube inserted surgically into the bladder through the abdominal wall
above the symphysis pubis ureterostomy - ANSWER//ileal conduit permanent
incontinent topic 4 objectives - ANSWER//1. Examine the factors that place
clients at risk for impaired skin integrity. 2. Apply the elements of a
comprehensive wound assessment. 3. Utilize the planning component of the
nursing process to demonstrate nurse's role and responsibilities for skin and
wound care. 4. Determine nursing interventions that promote healing and the
prevention of wound infections in clients with impaired skin integrity. layers of
skin - ANSWER//epidermis dermal-epidermal junction dermis subcutaneous
layer pressure injuries pathogenesis - ANSWER//pressure intensity (tissue
ischemia, blanching), pressure duration, tissue tolerance pressure injuries risk
factors - ANSWER//impaired sensory perception, impaired mobility, alteration
in LOC, shear, friction, moisture inability to perceive pressure,
incontinence/moisture, decreased activity level, inability to reposition, poor
, nutritional intake, friction and shear stage 1 pressure injury - ANSWER//non-
blanchable erythema of intact skin stage 2 pressure injury - ANSWER//partial-
thickness skin loss with exposed dermis stage 3 pressure injury -
ANSWER//full-thickness skin loss stage 4 pressure injury - ANSWER//full-
thickness skin and tissue loss unstageable pressure injury - ANSWER//full-
thickness skin and tissue loss obscured by slough or eschar medical device-
related pressure injuries (MDRPI) - ANSWER//occurs when the skin or
underlying tissues are subjected to sustained pressure or shear from medical
devices or equipment medical adhesive-related skin injury (MARSI) -
ANSWER//occurs from tape and other medical adhesives ex: securing ostomy
devices partial-thickness wound repair - ANSWER//wounds that involve only a
partial loss of skin layers (the epidermis and superficial dermal layers) shallow
in depth, moist, and painful, and the wound base generally appears red full-
thickness wound repair - ANSWER//wounds that involve total loss of the skin
layers (epidermis and dermis) extends into the subcutaneous layer and can
be painful, and the depth and tissue type vary depending on body location
primary intention healing - ANSWER//wound that is closed ex: hematoma,
surgical incision that is sutured or stapled healing occurs by epithelialization;
heals quickly with minimal scar formation secondary intention healing -
ANSWER//wound edges not closed or approximated ex: surgical wounds that
have tissue loss or contamination wound heals by granulation tissue formation,
wound contraction, and epithelialization. tertiary intention healing -
ANSWER//wound that is left open for several days; then wound edges are
approximated ex: wounds that are contaminated and require observation for
signs of inflammation closure of wound is delayed until risk of infection is
resolved complications of wound healing - ANSWER//hemorrhage, infection,
dehiscence, evisceration prediction and prevention of pressure injuries -
ANSWER//risk assessment, economic consequences of pressure injuries
braden risk assessment scale - ANSWER//pressure injury risk assessment 6
subscales: sensory perception, moisture, activity, mobility, nutrition,
friction/shear factors influencing pressure injury formation and wound healing
- ANSWER//nutrition, tissue perfusion, infection, age, psychosocial impact of
wounds implementation for risk of pressure injuries - ANSWER//nutrition,
topical skin care and incontinence management, positioning, support surfaces
implementing acute wound care - ANSWER//comfort measures, cleaning skin
and drain sites, basic skin cleaning, irrigation, skin closures, drainage
evacuation, bandages, binders, slings, heat and cold therapy abrasion -
ANSWER//superficial with little bleeding and is considered a partial-thickness
wound often appears "weepy" because of plasma leakage from damaged
capillaries approximated - ANSWER//closed wound edges risk of infection is
low blanchable hyperemia - ANSWER//erythema that blanches transient and
is an attempt to overcome the ischemic episode blanching - ANSWER//when
the normal red tones of the light-skinned patient are absent debridement -
ANSWER//the removal of nonviable, necrotic tissue necessary to rid the
wound of a source of infection, enable visualization of the wound bed, and
provide a clean base necessary for healing dehiscence - ANSWER//partial or
total separation of wound layers epithelialization - ANSWER//wound
resurfacing part of proliferation eschar - ANSWER//black, brown, tan, or
necrotic tissue evisceration - ANSWER//protrusion of visceral organs through
a wound opening exudate - ANSWER//fluid from wound excessive = infection