HESI Fundamentals Test Bank updated Spring 2022.

Reliable Study Materials & Testing Engine Nursing HESI Fundamentals (free download below) HESI Fundamentals Exam Test Bank; Complete Review A+ guide. What can a blood pressure cuff that's too narrow cause? - falsely elevated BP reading this insulin should be drawn up into the syringe first so it doesn't contaminate the other type of insulin - regular rumbling sounds heard on lung auscultation - rhonchi this type of adventitious lung sounds can be more pronounced during expiration than during inspiration - rhonchi forced feeding, usually through a gastric tube - gavage a tube passed into the stomach through the mouth - gastric tube What portion of Maslow's hierarchy of needs has the highest priority? - physiologic needs (air, water, food, shelter, activity, comfort) this is the safest and surest way to verify a patient's identity - check the ID band on wrist What is the primary concern in the therapeutic environment? - patient safety What does fluid oscillation in the tubing of a chest drainage system indicate? - system is working properly What position should a nurse place a patient who has a Sengstaken-Blakemore tube? - semi-Fowlers How can a nurse elicit Trousseau's sign? - occluding the brachial or radial artery What indicates Trousseau's sign? - hand and finger spasms during occlusion What does Trousseau's sign suggest? - hypocalcemia What is the appropriate needle size for adult blood transfusions? - 16 to 20G this type of pain is incapacitating and can't be relieved by drugs - intractable pain How can a consent for treatment be obtained in an emergency? - fax, telephone (or other telegraphic means) the unit of measurement of sound - decibel this is required for any invasive procedure - informed consent What must a patient do who can't write their name to give consent for treatment? - make an X in the presence of two witnesses (such as a nurse, priest, or physician) this IM injection method seals the drug deep into the muscle - Z-track method this IM injection method minimizes skin irritation and staining - Z-track method What length needle is required for the Z-track IM injection method? - 1" or longer What acronym is often used in the event of a fire? - RACE (REMOVE the patient, ACTIVATE the alarm, Attempt to CONTAIN the fire by closing the door, EXTINGUISH the fire if it can be done safely) Who should be assigned to a registered nurse to perform bedside care, such as suctioning or drug administration? - LPN (or licensed vocational nurse) What must be done if the patient cannot void? - bladder palpation to assess for bladder distention What side should the patient who uses a cane carry it on? - unaffected side How should a patient use a cane? - advance it at the same time as the affected extremity How is a supine patient fitted for crutches? - measure from the axilla to the sole and add 2" to the measurement What is the timeline for assessment? - begins with the nurse's first encounter with the patient and continues through the patient's stay How does the nurse obtain assessment data? - health history, physical examination, review of diagnostic studies What is the appropriate size needle for insulin injection? - 25G and 5/8" long What is urine called that remains in the bladder after voiding? - residual urine normal amount of residual urine - 50 to 100 mL 5 stages of the nursing process - assessment, nursing diagnosis, planning, implementation, evaluation (ADPIE) this stage of the nursing process is when the nurse continuously collects data to identify a patient's actual and potential health needs - assessment this stage of the nursing process is then the nurse makes a clinical judgement about individual, family, or community responses to actual or potential health problems or life processes - nursing diagnosis this stage of the nursing process is the stage in which the nurse assigns priorities to nursing diagnoses, defines short-term and long-term goals and expected outcomes, and establishes the nursing care plan - planning this stage of the nursing process is the stage in which the nurse puts the nursing care plan into action, delegates specific nursing interventions to members of the nursing team, and charts patient responses to nursing interventions - implementation this stage of the nursing process is the stage in which the nurse compares objective and subjective data with the outcome criteria and, if needed, modifies the nursing care plan - evaluation What should the nurse do before administering any "as needed" pain medication? - indicate the location of the pain this religious belief believes that they shouldn't receive blood components donated by other people - Jehovah's Witness to test this, the nurse should ask the patient to cover each eye separately and to read the eye chart with glasses and without, as appropriate - visual acuity What must be done when providing oral care for an unconscious patient to minimize the risk of aspiration? - position the patient on the side How far away must a patient stand from the chart when assessing distance vision? - 20 feet What is the ideal room temperature for a geriatric patient or one who is extremely ill? - 66 to 76 F What is normal room humidity? - 30% to 60% this is the single best method of limiting the spread of microorganisms - hand washing How long must hands be washed once gloves are removed after routine contact with a patient? - 10 to 15 seconds What position should a nurse place a woman to perform catheterization? - dorsal recumbent (lithotomy) How are electrolytes measured in a solution? - milliequivalents per liter What is a milliequivalent? - number of milligrams per 100 mL of a solution What might a positive Homan's sign indicate? - thrombophlebitis 2 phases of metabolism - anabolism, catabolism the constructive phase of metabolism - anabolism the destructive phase of metabolism - catabolism the amount of energy needed to maintain essential body functions - basal metabolic rate When is basal metabolic rate measured? - patient awake and resting, not eaten in 14-18 hours, in a comfortable and warm environment how basal metabolic rate is expressed - calories consumed per hour per kilogram of body weight this supplies bulk, maintains intestinal motility, helps to establish bowel habits - dietary fiber (roughage) Where is alcohol metabolized primary? Where is it metabolized in smaller amounts? - primarily in the liver, smaller amounts by the kidney and lungs tiny, round, purplish red spots that appear on the skin and mucous membranes as a result of intradermal or submucosal hemorrhage - petechiae a purple discoloration of the skin that's caused by blood extravasation - purpura this should never be done with needles after using them and is the cause of most needle sticks - recap needles what a nurse uses to administer a drug by IV push to deliver the dose directly into a vein, IV tubing, or catheter - needle and syringe What should be done when changing the ties on a tracheostomy tube? - leave the old ties in place until the new ones are applied What is always used for blood transfusions? - filter this ambulatory device is indicated when a patient needs more stability than a regular cane can provide - quad (four-point) cane a good way to begin a patient interview - "What made you seek medical help?" the most abundant cation in intracellular fluid - potassium (K+) in this gait, the patient first moves the right crutch followed by the left foot and then the left crutch followed by the right foot - four-point or alternating gait in this gait, the patient moves two crutches and the affected leg simultaneously and then moves the unaffected leg - three-point gait in this gait, the patient moves the right leg and the left crutch simultaneously and then moves the left leg and the right crutch simultaneously - two-point gait the Vitamin B complex, water soluble vitamins that are essential for metabolism - thiamine (B1), riboflavin (B2), niacin (B3), pyridoxine (B6), cyanocobalamin (B12) how the patient should be dressed when being weighed - lightly dressed and shoeless what should be done before taking an adult's oral temp - nurse should ensure that the patient hasn't smoked or consumed any hot/cold substances in the previous 15 minutes when the nurse should not take an adult's rectal temp - patient has cardiac disorder, anal lesions, bleeding hemorrhoids, or recently undergone rectal surgery taking adult's rectal temp in a patient that has a cardiac disorder - may stimulate a vagal response and lead to vasodilation and decreased cardiac output how the nurse should record pulse amplitude and rhythm - 0 absent pulse; 1+ thready or weak pulse; 2+ normal pulse; 3+ bounding pulse this period begins when a patient is transferred to the operating room bed and ends when the patient is admitted to the postanesthesia care unit - intraoperative period what should be done the morning of a patient's surgery - consent form signed, patient hasn't taken anything by mouth since midnight, taken a shower in microbial soap, mouth care w/o swallowing water, removed common jewelry, received preoperative meds as prescribed, vital signs taken and recorded, (artificial limbs and other prostheses are usually removed) comfort measures that may decrease the patient's need for analgesics or may enhance their effectiveness - positioning, rubbing the patient's back, providing a restful environment a drug's three names - generic, trade/brand, chemcial how a patient should take a liquid iron preparation - through a straw to avoid teeth staining what injection method should be used when administering iron dextran (Imferon) IM - Z-track method (IM) where an organism can enter the body - nose, mouth, rectum, urinary or reproductive tract, skin levels of consciousness in order - alertness, lethargy, stupor, light coma, deep coma portion of the stethoscope used to hear high-pitched sounds, such as breath sounds - diaphragm differences in the BP between the right and left arms - slight difference is normal (5-10 Hg) where to place BP cuff - 1" above the antecubital fossa what to do when instilling ophthalmic ointments - waste the first bead of ointment, then apply the ointment from the inner canthus to the outer canthus measuring BP in an obese patient - use leg cuff if a BP cuff is applied too loosely - false lower reading drooping of the eyelid - ptosis this type of table is useful for a patient with a spinal cord injury, orthostatic hypotension, or brain damage because it can move the patient gradually from a horizontal to a vertical (upright) position - tilt table how to perform a venipuncture with the least injury to the vessel - turn the bevel upward when the vessel's lumen is larger than the needle, turn it downward when the lumen is only slightly larger than the needle patient should wear _______ when being measured for crutches - shoes never attach a restraint to this portion of the bed - mattress, side rails (always the bed frame) position for a sigmoidoscopy - knee-chest or Sims order of Maslow's hierarchy of needs - physiologic, safety and security, love and belonging, self-esteem and recognition, self-actualization this should be applied to the nostril to prevent soreness when caring for a patient with a nasogastric tube - water-soluble lubricant gastric lavage procedure (stomach pump) - nasogastric tube inserted, stomach is flushed, ingested substances removed through tube documenting drainage of a surgical dressing - size, color, consistency of drainage to elicit this reflex, the nurse strokes the sole of the patient's foot with a moderately sharp object - Babinski's reflex positive Babinski's reflex - fanning toes assessing for bladder distension - check the contour of the lower abdomen for a rounded mass above the symphysis pubis best way to prevent pressure ulcers - turn and reposition patient at least every 2 hours this decompresses the superficial blood vessels, reducing the risk of thrombus formation - antiembolism stockings (TED hose) most convenient veins for venipuncture for adults - basilic, median cubital what must be done 2-3 hours before beginning a tube feeding - aspirate the patient's stomach to verify that gastric emptying is adequate universal blood donors - type O universal blood recipients - type AB unit of measurement of sound frequency - Hz (Hertz) sound intensity level when hearing protection is required - exceeds 84 db sound intensity level when double hearing protection is required - exceeds 104 db where prothombin, a clotting factor, is produced - liver what should be done if a patient is menstruating when a urine sample is collected - note on lab request what must be noted during a lumbar puncture - initial intracranial pressure, color of cerebrospinal fluid this type of treatment can be used to help obtain a sample if a patient can't cough to provide a sputum sample for culture - heated aerosal treatment What must be instilled first in eye ointment and eyedrops must be instilled in the same eye? - eyedrops first to be removed for PPE - gloves before mask (because fewer pathogens are on mask) the most effective means of traction, applying to a bone with wire pins or tongs - skeletal traction preparation of TPN - stored in a refrigerator, removed 30-60 minutes before use symptoms of delivering a chilled solution - pain, hypothermia, venous spasm, venous constriction where drugs aren't routinely injected intramuscularly because they may not be absorbed - edematous tissue explaining actions when caring for a comatose patient - explain in a normal voice cleaning dentures - in a sink that's lined with a washcloth patient should void within ____ hours after surgery - 8 hours an _____ identifies normal and abnormal brain waves - EEG these types of lab tests should be delivered to the lab without delay and without refrigeration - feces (for ova) samples, parasite tests this nervous system regulates the cardiovascular and respiratory systems - autonomic nervous system intermittent suction should be applied no more than ___ seconds using a slight twisting motion when providing tracheostomy care - 15 seconds low-residue diet foods - roasted chicken, rice, pasta why a rectal tube shouldn't be inserted no longer than 20 minutes - irritation of the rectal mucosa, can cause loss of sphincter control order of bed bath - face, neck, arms, hands, chest, abdomen, back, legs, perineum muscles the nurse uses to prevent injury when lifting and moving a patient - upper leg muscles patient prep for cholecystography - ingestion of a contrast medium and a low-fat evening meal what to do while an occupied bed is being changed - cover patient with a bath blanket to promote warmth and prevent exposure mourning that occurs for an extended time when the patient realizes death is inevitable - anticipatory grief foods that can alter the color of feces - beets (red), cocoa (dark red/brown), licorice (black), spinach (green), meat protein (dark brown) patient should remove all jewelry and dentures when preparing for a ______ x-ray - skull x-ray the flight-or-flight response comes a response from this nervous system - sympathetic nervous system if bronchovesicular sounds are heard in peripheral lung fields - abnormal what bronchovesicular lung sounds suggest if heard in peripheral lung fields - pneumonia an abnormal, high-pitched breath sound that's acccentuated on expiration - wheezing this in the ear should be flushed out gently by irrigation with warn saline solution - wax or a foreign body what should be done if a patient complains that their hearing aid is "not working" - check the switch to see if it's turned on, check batteries grading hyperactive biceps and triceps reflexes - 4+ if two eye medications are prescribed for twice-daily instillation - should be administered 5 minutes apart forcing fluids in a post-op patient - helps prevent constipation Who establishes the standards of care? - American Nurses association, state regulations, facility policy a unit of energy measurement that represents the amount of heat needed to raise the temperature 1 kilogram of water 1 degree C - kilocalorie (kcal) What do nutrients undergo as they move through the body? - ingestion, digestion, absorption, transport, cell metabolism, excretion how the body metabolizes alcohol - fixed rate, regardless of serum concentration this reflects the percentage of alcohol multiplied 2 in an alcohol beverage (a 100-proof beverage contains 50% alcohol) - proof a witnessed document that states a patient's desire for certain types of care and treatment - living will what decisions in a living will are based on - patient's wishes and views on quality of life how often nurse should flush a peripheral heparin lock - every 8 hours (if it wasn't used during the previous 8 hours) and as needed with normal saline solution to maintain patency a method of determining whether nursing actions and practices meet established standards - quality assurance Six rights of medication administration - right drug, right dose, right documentation, right route, right time, right patient this phase of the nursing process is to determine whether nursing interventions have enabled the patient to meet the desired goals - evaluation only these forms of nitroglycerine should be used to relieve acute anginal attacks outside the hospital setting - sublingual, translingual this phase of the nursing process involves recording the patient's response to the nursing plan, putting the nursing plan into action, delegating specific nursing interventions, and coordinating patient's activities - implementation this offers patients guidance and protection by stating the responsibilities of the hospital and its staff toward and their families during hospitalization - Patient's Bill of Rights the nurse should record this as soon as it's gathered to minimize omission and distortion of fats - information the nurse should record current illness this way when assessing a patient's health history - chronologically, beginning with the onset of the problem and continuing to the present never give ____ ________ to a patient - false assurance after receiving preoperative medication, a patient isn't competent to do this - sign an informed consent form a nurse uses this instead of the strength in her arms when lifting a patient - weight of her body What must be done if a patient has questions about informed consent? - refer to the physician a nurse can do this about an operation or a procedure to a patient - clarify a physician's explanation the nurse should limit questions to those that provide necessary information when obtaining a health history from these patients - acutely ill or agitated patient what to do if a chest drainage system line is broken or interrupted - clamp tube immediately why should you never use the thumb to take a patient's pulse rate - thumb has a pulse that can be confused with the patient's pulse; index and middle finger should be used instead these 2 things count as one respiration - inspiration, expiration term for normal respiration - eupnea positioning of a patient's arm during blood pressure measurement - rest arm against a surface if a patient uses muscle strength to hold up the arm when taking blood pressure - may raise BP major, unalterable risk factors for coronary artery disease - heredity, sex, race, age the most frequently used assessment technique - inspection What should family members of an elderly person in a long-term care facility do to provide a comfortable atmosphere? - transfer some personal items to the person's room (such as photographs, a favorite chair, knickknacks, etc.) a regular pulse rhythm with alternating weak and strong beats that occurs in ventricular enlargement because the stroke volume varies with each heartbeat - pulsus alternans What does the upper respiratory tract do to inspired air? - warms and humidifies What does the upper respiratory tract play a part in? - taste, smell, mastication What are shoulder elevation, intercostal muscle retraction, and scalene and sternocleidomastoid muscle use signs of during respiration? - accessory muscle use What should bear the brunt of the weight with patients using axillary crutches? - palms What are eating, bathing, dressing, grooming, toileting, and interacting socially examples of? - activities of daily living (ADLs) 2 phases of a normal gait - stance phase (patient's foot rests on the ground), swing phase (patient's foot moves forward) 4 phases of mitosis - prophase, metaphase, anaphase, telophase What should the nurse follow when providing routine care for all patients? - standard precautions part of the stethoscope used to listen for venous hums and cardiac murmurs - bell example of a question to assess a patient's general knowledge - "Who is the president of the United States?" What is applied for the first 20-48 hours after an injury? - cold packs What is applied after a cold pack after an injury? - heat how a cold application is applied after an injury - 20 minutes, removed 10-15 minutes (to prevent reflex dilation, a rebound phenomenon, and frostbite injury) this is located above the medulla and consists of white and gray amtter - pons this nervous system controls the smooth muscles - autonomic nervous system Who collaborates with the nurse to develop a patient goal? - patient 5 basic notes of percussion - tympany (loud intensity, as heard over a gastric air bubble or puffed out cheek), hyperresonance (very loud, as heard over an emphysematous lung), resonance (loud, as heard over a normal lung), dullness (medium intensity, as heard over the liver or other solid organ), flatness (soft, as heard over the thigh) description of the optic disk - yellowish pink and circular, with a distinct border What is a primary disability caused by? - pathologic process What is a secondary disability caused by? - inactivity this person is commonly held liable for failing to keep an accurate count of sponges and other devices during surgery - nurse best dietary sources of vitamin B6 - liver, kidney, pork soybeans, corn, whole-grain cereals iron-rich foods that commonly have a low water content - organ meats, nuts, legumes, dried fruit, green leafy vegetables, eggs, whole grains this is a joint communication and decision making between nurses and physicians - collaboration this is designed to meet patients' need by integrating the care regimens of both professions into one comprehensive approach - collaboration a heart rate of fewer than 60 beats/minute - bradycardia a statement of a patient's actual or potential health problem that can be resolved, diminished, or otherwise changed by nursing interventions - nursing diganosis analysis of 3 types of data collected during the assessment phase - health history, physical exam, lab and diagnostic test data this consists primarily of subjective data, information that's supplied by the patient - health history this includes objective data obtained by inspection, palpation, percussion, and ausculatation - physical exam factors that can affect body temperature - time of day, age, physical activity, phase of menstrual cycle, pregnancy the most commonly used artery for measuring a patient's pulse rate - radial artery the normal pulse rate is slightly faster in this gender - women the normal pulse rate is slightly faster in this age - children laboratory test results are an _______ form of assessment data - objective 3 most commonly used measurement systems in clinical practice - metric system, apothecaries' system, household system what the patient must know before signing an informed consent form - other treatment options are available, understand what will occur, the risks involved, the possible complications, time required for surgery to recovery a patient must sign one of these for each procedure - informed consent form this procedure is done to determine the size, shape, position, and density of underlying organs and tissues, elicit tenderness, or assess reflexes - percussion a form of light palpation involving gentle, repetitive bouncing of tissues against the hand and feeling their rebound - ballottement this keeps bed linen off the patient's feet to prevent skin irritation and breakdown, especially in a patient who has peripheral vascular disease or neuropathy - foot cradle a flushing of the stomach and removal of ingested substances through a nasogastric tube, used to treat poisoning or drug overdose - gastric lavage the nurse asses the patient's response to therapy during this step of the nursing process - evaluation this is commonly indicates a life- or limb- threatening vascular disease - bruits O.U. means... - each eye O.D. means... - right eye O.S. means... - left eye to remove a patient's artificial eye - depress the lower lid cleaning an artificial eye - use a warm saline solution this type of pulse is fine and scarcely palpable - thready this temp site is usually 1 degree F lower than oral temperature - axillary temperature what the nurse must document after suctioning a tracheostomy tube - color, amount, consistency, odor of secretions what does "pc" mean on a prescription? - after meals what should be documented after a bladder irrigation - amount, color, and clarity of urine, presence of clots or sediment the inside diameter of a needle (the smaller this is, the larger the diameter) - gauge normal number of permanent adult teeth - 32 the purpose of therapeutic interaction - to allow the client to autonomy to make choices when appropriate. keep statements value-free, advice free, and reassurance-free what action should the nurse take in a psychiatric situation when the client describes a physical problem? - assess. example: if a client has schizophrenia complains of chest pain take their blood pressure basic communication principles - establish trust, nonjudgemental attitude,active listening, offer self, accept client's feelings, validate client's statements, matter of fact approach nausea is a common complaint after ECT - vomiting by an unconscious can lead to aspiration. maintain a paten airway common physiological responses to anxiety - increased heart rate, and blood pressure, rapid shallow respirations, dry mouth, tight feeling in throat, tremors, muscle twitching, anorexia, urinary frequency, palmar sweating nurse-client anxiety - anxiety is contagious, nurse needs to asses on anxiety level and remain calm. it helps gain control, decrease anxiety, and increase feelings of security desensitization - is the nursing intervention for phobia disorders. --assess client to recognize the factors associated with feared stimuli. -teach and practice with client alternative coping strategies -expose client to feared stimuli -provide positive reinforcement the nurse should place an anxious client where there are reduced environmental stimuli - quiet area of the unit away from the nurse's station the best time for interaction with a client is at the completion of the performed ritual - the client's anxiety is lowest at this time and its an optimal time for learning compulsive acts are used in response to anxiety, which may or may not be related to the obsession. its the nurse's responsibility help alleviate anxiety - its the nurse's responsibility help alleviate anxiety, interfering will increase the anxiety as long as the client's acts are free of violence: nurse should.... - -actively listen to the clients obsessive themes -acknowledge the effects that ritualistic acts have on the client -demonstrate empathy -avoid being judgmental ford clients with PTSD, the nurse should.... - -actively listen to client's stories of experiences surrounding the traumatic event -assess suicide risk -assist client to develop objectivity about the event and problem solve regarding possible means of controlling anxiety related to the event -encourage group therapy with other clients who have experienced the same traumatic event be aware of your own feelings when dealing with this somatoform clients. - the pain is real to the person experiencing it theses disorders cannot be explained medically, it results from internal conflict. the nurse should... - -acknowledge the symptom or complaint -reaffirm that diagnostic test results reveal no organic pathology -determine the secondary gains acquired by the client avoid giving clients with dissociative disorders too much information about past events at one time - the various types of amnestic that accompany dissociative disorders provide protection from pain and too much to soon can cause decompensation personality disorders are long standing behavioral traits that are maladaptive responses to anxiety and that cause difficulty in relating to and working with other individuals - persons with personality disorders are usually comfortable with their disorders and believe that they are right and the world is wrong and have little motivation people with anorexia gain pleasure from providing others with food and watching them eat - these behaviors reinforce their perception of self-control. don not allow these clients to plan or prepare food for unit-based activities individuals with Bulimia often use syrup of ipecac to induce vomiting. if ipecac is not vomited and is absorbed, cardiotoxicity may occur and cause conduction disturbances, cardiac dysrhythmias, fatal myocarditis, and circulatory failure - because heart failure is not usually seen in this age group, it is often overlooked. assess for edema and listen to breath sounds physical assessment and nutritional support are a priority, the physiological implication are great. nursing interventions should increase self-esteem and develop a positive body image. - family therapy is most effective because issues of control are common in these (eating disorders.) therapy is usually long term the most important s/s of depression are a depressed mood with a loss of interest in the pleasures in life - the client has a sustained loss s/s of depression - -significant change in appetite -insomnia -fatigue or lack of energy -feelings of hopelessness -loss of ability to concentrate -preoccupation with death or suicide depressed clients have difficulty hearing and accepting compliments because of their lowered self-concept - comment on signs of improvement by noting behavior the nurse knows depressed clients are improving when they - begin to take an interest in their appearance or begin to perform self-care activities the nurse should suspect an imminent suicide attempt if a depressed client becomes "better" - be aware a happy affect may signify the the client feels relieved that a plan has been made and is prepared for the suicide attempt when dealing with a depressed client the nurse should assist with personal hygiene tasks and encourage the client to initiate grooming activities even when they dont feel like doing so - this helps to promote self-esteem and a sense of control nursing intervention for depressed client - sit quietly with the client, offering your support with your presence side effects of antianxiety drugs - sedation, drowsiness s/e of antidepressants drugs - anticholinergic effects, postural hypotension s/e MAO inhibitors - hypertensive crisis lithium requires renal function assessment and monitoring - phenothiazines cause EPS (tardic dyskinesia can be permanent) phenothiazines cause photosensitivity so client must wear protective clothing and sunglasses - MAO inhibitors require dietary restrictions to prevent hypertensive crisis atypical antipsychotics drugs are also indication for mania - monitor serum lithium levels carefully. 0.-1.5 is therapeutic level, blood should be drawn every 12 hours after last dose manic clients can be very caustic toward authority figures - avoid arguing or becoming defensive what activities are appropriate for a manic client? - noncompetitive physical activities that require the use of large muscle groups where should a manic client be place on the unit? - make every attempt to reduce stimuli in the environment, place client in quiet part of the unit what intervention should the nurse use if the client becomes abusive - -redirect negative behavior -suggest a walk -set limits on intrusive behavior -seclude or administer medication Bleuler's 4 A's for schizophrenia - autism (preoccupied with self) affect (flat) associations (loose) ambivalence (difficulty making decisions) observe for increased motor activity and erratic response to staff and other clients - client may experiencing an increase in command in hallucinations, when this occurs there is an increased potential for aggressive behavior don't argue with a client about the delusions. - logic only increases a client's anxiety, so be matter of fact and divert delusional thought to reality what medication can the nurse expect to administer to chemically dependent clients? - librium or ativan, antabuse for alcohol abuse what type of therapy is used with chemically dependent clients? - group therapy harm reduction is a community health strategy designed to reduce the harm of substance abuse to families, individuals, community, and society - denial and rationalization are the two most common coping styles used for substance abuse what basic needs take priority when working with chemically dependent clients? - nutrition is a priority, alcohol and drug intake has superseded the intake of food for these clients what behaviors are expected during withdrawal? - in the alcoholic DT's occur 12-36 hours after the last intake of alcohol select only one nurse to care for an abused child - abused children have difficulty establishing trust, and the child will be less anxious with one consistent caregiver women who are abused may rationalize the spouse's behavior and unnecessarily accept blame for his actions. - the woman may or may not choose to press charges. be sure to give her the number of a shelter or help line it is difficult for an elderly person to admit abuse for fear of being placed in a nursing home or being abandoned - it is imperative to establish a trusting relationship with elderly client rape victims are at high risk for PTSD. immediate intervention to diminish distress is vital. - the nurse should also assess for and intervene for sequelae such as unwanted pregnancy, STD's, and HIV in child abuse, the nurse is responsible for reporting all suspected cases of abuse - in intimate abuse, its the adult's decision and the nurse should be supportive the basic difference between delirium and dementia is ... - delirium is acute and reversible but dementia is gradual and permanent confusion in the elderly is often accepted as being part of growing old. - however, the confusion may be caused from dehydration and is usually due to a specific stressor confabulation is not lying - it is used by the client to decrease anxiety and protect the ego Alzheimer medication - you can use atypical antipsychotics. Clozaril is not a front line agent because of side effects. one may also give mood stabilizers, and antianxiety medications nursing interventions for confused elderly - -maintain client's health and safety -encourage self care -reinforce reality orientation -provide safe, consistent environment provide a consistent caregiver is priority in planning nursing care for the confused older client - change increases anxiety and confusion children experience depression, which presents as headaches, stomachaches, and other somatic complaints - assess suicide risks, especially in the adolescent the child/adolescent's lack of remorse about antisocial behavior represents a malfunction of the superego - the id functions on the basic instinct level and strives to meet immediate needs. the ego is in touch with external reality and is the part of personality that makes decisions provide consistent interventions for children - this helps to prevent manipulation because inconsistency does not help the client develop self control What type of procedures should be assigned to professional nurses? - Inform the health care provider or physician; record that the health care provider or physician was informed and the health care provider's or physician's response to such information; inform the nursing supervisor; refuse to carry out the prescription Describe the nurse's legal responsibility when asked to perform a task for which he or she is unprepared. - Inform the health care provider or physician or person asking the nurse to perform the task that he or she is unprepared to carry out the task; refuse to perform the task Describe nursing care for a restrained client. - Apply restraints properly; check restraints frequently to see that they are not causing injury and record such monitoring; remove restraints as soon as possible; use restraints only as a last resort. Describe six patient rights guaranteed under HIPAA regulations that nurses must be aware of in practice. - a. A patient must give written consent before health care providers can use or disclose personal health information b. Health care providers and physicians must give patients notice about providers' responsibilities regarding patient confidentiality c. Patient's must have access to their medication records; Providers who restrict access must explain why and must offer patients a description of the complaint process d. Patients have the right to request that changes be made in their medical records to correct inaccuracies e. Health care providers must follow specific tracking procedures for any disclosures made that ensure accountability for maintenance of patient confidentiality f. Patients have the right to request that health care providers and physicians restrict the use and disclosure of their personal health information, though the provider may decline to do so. A UAP may perform care that falls within which component of the nursing process? - Implementation What are the five rights of delegation? - A. Right task B. Right circumstance C. Right person D. Right direction or communication E. Right supervision Common causes of fluid volume deficit: - a. Gastrointestinal causes b. Vomiting c. Diarrhea d. GI suctioning e. Decrease in fluid intake f. Increase in fluid output such as sweating g. Massive edema h. Ascites Common causes of fluid volume overload: - a. Heart failure b. Renal failure c. Cirrhosis d. Excess ingestion of table salt e. Overhydration with sodium containing fluids Identify two examples of isotonic IV fluids. - a. Ringers lactate b. Normal saline List three systems that maintain acid base balance. - a. Lungs b. Kidneys c. Chemical buffers normal ABGs - a. pH: 7.35-7.45 b. PaCO2: 35-45 c. HCO3: 22-26 Variables that increase surgical risk. - a. Age: very young and very old b. Obesity c. Malnutrition d. Preoperative dehydration/hypovolemia e. Preoperative infection f. Use of anticoagulants (aspirin) preoperatively Why is a client with liver disease at increased risk of operative complications? - a. Impairs ability to detoxify medications used during surgery b. Impairs ability to produce prothrombin to reduce hemorrhage Preoperative teaching should include demonstration and explanation of expected postoperative client activities. What activities should be included? - a. Respiratory activities: coughing, breathing, use of spirometer b. Exercises: range of motion, leg exercises, turning c. Pain Management: medications and splinting d. Dietary restrictions: NPO evolving to progressive diet e. Dressings and drains: orientation to recovery room environment What items should the nurse assist the client in removing before surgery? - Contact lenses; Glasses; Dentures; Partial plates; Wigs; Jewelry; Prosthesis; Makeup; Nail polish. Nursing actions that prevent postoperative wound dehiscence and evisceration: - a. Teaching client to splint incision when coughing b. Encouraging coughing and deep breathing in early postoperative period when sutures are strong. c. Monitoring for signs of infection d. Malnutrition e. Dehydration f. Encouraging high-protein diet Identify three nursing interventions that prevent postoperative urinary tract infections. - a. Avoiding postoperative catheterization b. Increasing oral fluid intake c. Emptying bladder every 4 to 6 hours d. Early ambulation Identify nursing/medical interventions that prevent postoperative paralytic ileus. - a. Early ambulation b. Limiting use of narcotic analgesics c. NG tube decompression List four interventions that prevent postoperative thrombophlebitis. - a. Teaching performance of in bed leg exercises b. Encouraging early ambulation c. Applying antiembolus stockings d. Teaching avoidance of positions and pressures that obstruct venous flow What six factors should the nurse include when assessing the pain experience? - a. Location b. Intensity c. Comfort measures d. Quality e. Chronology f. Subjective view of pain List the six modalities that are considered noninvasive, nonpharmacological pain relief measures. - a. Heat and cold application b. TENS c. Massage d. Distraction e. Relaxation techniques f. Biofeedback techniques Identify the five stages of death and dying. - a. Denial b. Anger c. Bargaining d. Depression e. Acceptance List five nursing interventions to promote adequate bowel functioning for older persons. - a. Determine what is "normal" GI functioning for each individual b. Increase fiber and bulk in the diet c. Provide adequate hydration d. Encourage eating small meals frequently What areas of care are important for end-of-life care? - a. Pain b. Dyspnea c. Anxiety d. GI symptoms e. Psychiatric symptoms f. Spirituality g. Support for family caregivers h. Family support during bereavement period Vegetables High in Sodium: - Canned vegetables Carrots, particularly canned Tomatoes, particularly canned Tomato, catsup Tomato juice Condiments High in Sodium: - Bouillon cubes Mustard Olives, pickled, canned or bottled Pickles, cucumber, dill Salad dressings, commercially prepared Soy Sauce Other Foods High in Sodium - Bacon Cheeses Ready-to-eat breakfast cereals Peanut butter Soups, commercially prepared, canned Corned beef Calcium - Milk, cheese, dark green vegetables, dried figs, soy, and legumes Phosphorus - Milk, liver, legumes, fish, and soy Magnesium - Whole grains, green leafy vegetables, tea, nuts, and fruit Iron - Meats, eggs, legumes, whole grains, green leafy vegetables , and dried fruits Iodine - Marine fish, shellfish, dairy products, iodized salt, and some breads Potassium - Citrus fruits, and dried fruit , bananas, watermelon, potatoes, legumes, tea, and peanut butter Zinc - Meats, seafood and whole grains apical pulse - pulse normally heard at the heart's apex, usuallly gives the most accurate assessment of pulse rate apical-radial pulse - reading done by measuring both the apical and radial pulse simultaneously, used when it is suspected that the heart is not effectively pumping blood. apnea - cessatation of breathing ausculation - externally listening to sounds from within the body to determine abnormal conditions, as in blood pressure axillary - under the armpit bradycardia - abnormally slow breathing/respiration carotid pulse - pulse felt on either side of the neck over the carotid artery bradypenia - condition where the breathes are abnormally slow and fall below 10 breathes/ minute. celsius - temperature scale which water boils @ 100 degrees and freezes @ zero degrees. Cheyne-stokes respirations - breathing characterized by deep breathing alternating with very slow breathing or apnea, indicative of brain damage, often precedes death. crisis - the turning point of a disease with intensification of symptoms cyanosis - blueness or duskiness of the skin due to lack of oxygen and excess carbon dioxide diastolic - atrial and ventricular relaxation of which allows the chambers of the heart to fill with blood dyspnea - difficulty breathing euphea - normal breathing farenheit - temperature scale at which water boils at 212 degrees and freezes at 32 degrees. femoral pulse - pulse felt in the groin over the femoral artery fever - abnormally high body temperature hand sanitization - cleansing the hands using a chemical agent or thorough hand washing. hypertension - elevated blood pressure hypotension - abnormally low blood pressure Korotkoff's sounds - sound heard when measuring the heartbeat with a stethoscope kussmaul's respirations - severe paroxysmal dyspnea as in diabetic acidosis and coma lysis - destruction due to a specific agent; gradual recovery from disease or an elevated temperature that gradually returns to normal oral - of or perrtaining to the mouth orthopnea - sitting or leaning forward to facilitate breathing palpatation - the act of feeling with the hand, placing two fingers on the body to determing the condition of the underlying part pedal pulse - pulse in the foot. popliteal pulse - pulse located in the posterior of the knee pulse - the heartbeat as felt through the walls of the srteries and the skin or as heard at the apex of the heart with a stethoscope pulse pressure - difference of systolic minus diastolic pressure radial pulse - pulsed measured on the wrist over the radial artery rectal - distal portion of the large intestines between the sigmoid colon and the anal canal sphygmomanometer - device used is conjuction with a stethoscope to measure blood pressure, consisting of a cuff and bulb stertorous breathing - breathing that occurs when air travels through secretions in the air passage; snoring stethoscope - instrument used to hear internal sounds systole - contraction of the heartbeat systolic blood pressure; pressure of the blood against the walls of the artery tachycardia - abnormally high heart beat tachypnea - abnormally fast breathing temporal - pertaining to the temple tempanic - ear/eardrum AP - apical pulse A-R - apical-radial pulse Ax - under the arm ; axillary BPM - Beats per minute C - celsius DBP - diastolic blood pressure F - farenheit HR - heart rate I & O - Intake and output MAP - mean arterial pressure O - oral/mouth PMI - point of maximal impulse PO - per os R - rectal SBP - systolic blood pressure TA - forehead TM - ear canal TPR - temperature, pulse, respiration Evidence-based practice - Use of current best evidence from nursing research, clinical expertise, practice trends and patient preferences to guide nursing decisions about care provided to patients Certification - Beyond NCLEX-RN; exam in nursing specialty; minimum practice requirements are set depending in the certification; include years required working in specialty area Standards of practice - A list of standards to assist the professional in making good decisions while conducting day to day responsibilities within his or her scope of practice. Licensure - A mandatory credentialing process established by law, usually at the state level, that grants the right to practice certain skills and endeavors Accountability - Taking responsibility for ones actions Advanced roles of the RN - caregiver, communicator, teacher, client advocate, counselor, change agent, leader, manager and case manager Career options for the RN - Clinical specialist, nurse practitioner, midwife, anesthetist, educator, entrepreneur, administrator ANA - American Nurses Association; concerned with legal aspects of nursing NLN - National League for Nursing; sets standards for excellence and innovation in nursing education State boards of nursing - Reason for existance is public protection; regulation of nursing care Nurse practice act - Nurses are required to be familiar with the laws that regulate their practice; used to measure appropriateness of nurses actions and behavior Autonomy - Persons right to choose and the ability to act on that choice Beneficence - Duty to do or promote good; taking positive actions to help others Fidelity - Faithfulness; obligation to keep promises Justice - Obligation to be fair; equal treatment to all clients Nonmaleficience - Obligation to "do no harm"; prevent harm Verocity - Duty to tell the truth Confidentiality - Protection of personal health information HIPAA - Protection of personal health information Responsibility - Willingness to respect obligations; foloow through on promises Values - Strongly held personal beliefs about the worth and importance of an idea, attitude, custom or object that sets standards that influence behavior Value clarification - Process of becoming conscious of and identifying ones values Deontology - Defines actions as right or wrong; looks to the presence of principle regardless of outcome Utilitarianism - Act must result in the greatest good for the greatest number of people Feminine ethics - Looks at social issues; looks to the nature of relationships for guidance of processing ethical demands Ethic of care - Caring, promoting dignity Code of ethics - Philosophical ideals of right and wrong that define the principles you will use to provide care to your patients Patient advocate - Protect patients human and legal rights and provide assistance in asserting these rights if the need arises Caregiver - Help patient maintain and regain health, manage disease and symptoms, and attain a maximal level function and independence through the healing process Educator - Explain concepts and facts about health, describe the reason for routine care activities, demonstrate self-care activities and reinforce learning Advanced Practice Registered Nurse (APRN) - Most independently functioning nurse; has masters degree in nursing Clinical Nurse Specialist (CNS) - An APRN who is an expert clinician in a specialized area of practice Nurse Practitioner (NP) - An APRN who provides health care to a group of patients, usually in an outpatient, ambulatory care or community-based setting Certified Nurse-Midwife (CNM) - An APRN who is also educated in midwifery and is certified by the American College of Nurse-Midwifes Certified Registered Nurse Anesthetist (CRNA) - An APRN with advanced education in a nurse anesthetia accredited program do not - Incident reports do/do not belong in patient's chart facility - Incident reports help identify ?? issues needing attention/correction slander - ?? is when one makes false VERBAL statements libel - Written slander malice - Hurting someone on purpose, or with reckless disregard for the truth assault - ?? may be actual or threatened, such as giving an injection or threatening to restrain a client who has refused a procedure battery - ?? is intentional touching without consent false imprisonment - ?? ?? is restraining a client without justification (w/o physicians written order) negligence - ?? is conduct that falls below the standard of care malpractice - ?? is professional negligence airborne - ?? precautions are for droplet nuclei smaller than 5 mcg - measles, chickenpox droplet - ?? precautions are for droplets larger than 5 mcg being within 3 feet of client - pneumonias, plague, pertussis, mumps contact - ?? precaution is direct client or contact - MRDO such as VRE or MRSA, RSV, scabies protective equipment - ?? ?? alllogenic hymatopoietic stem cell transplants; private room 2 hours - You must remove restraints every ?? ?? 15 minutes - You must check patient in a restraint every ?? ?? least restrictive - You must use the ?? ?? method for a restraint physicians written order - You must have a ?? ?? ?? to use a restraint ALL - ?? other appropriate methods must have been exhausted before using a restraint informed consent - To put a restraint on a patient, you have their ?? ?? nausea dizziness headache fatigue - Low O2 can cause ??, ??, ?? and ?? 1 3 - High O2 can cause death within ? to ? minutes CO2 - ??? is a colorless, ordorless gas that is emitted from improperly set furnaces, heaters, and stoves food water shelter clothing - The lowest level of the Maslow's pyramid is ??, ??, ??, and ?? storage refrigeration preparation - The proper ??, ??, and ?? of food is essential to be of value to the human body 64 75 - Normal room temperature is between ??F and ??F hyperthermia - ?? is when the body's core temp is too high hypothermia - ?? is when the body's core temp is below 95F lifestyle - Risks such as drug and alcohol abuse are considered ?? risk factors heart disease cancer cerebrovascular disease - The top three causes of death are ?? ??, ??, and ?? ?? deficit - Sensory ?? is reduced perception of sensory reception and perception primary intention - Healing process: ?? ?? is a wound that is closed secondary intention - Healing process: ?? ?? is where the wound edges are not approximated tertiary intention - Healing process: ?? ?? is where the wound is open for several days tertiary intention - Wound that is left open to monitor for infection is considered ?? ?? (healing process) secondary intention - Wound resulting from surgery causing tissue loss is considered ?? ?? (healing process) stage 1 - Pressure ulcer showing intact skin with nonblanchable redness of a localized area stage 2 - Pressure ulcer showing partial-thickness skin loss involving epidermis, dermis, or both stage 3 - Pressure ulcer where full-thickness skin loss; subcutaneous fat may be visible, but bone, tendon, or muscles are not stage 4 - Pressure ulcer where full-thickness tissue loss with exposed bone, tendon, or muscle unstageable - Pressure ulcer where wound cannot be visualized; ulcer is full-thickness tissue loss in which base of the ulcer is covered by slough, typically has eschar subjective findings - S of SOAP ?? ?? objective findings - O of SOAP ?? ?? assessment - A of SOAP interventions - I of SOAPIE evaluations - E of SOAPIE planning - P of SOAP sit facing the client - S of SOLER (listening skills) ?? ?? ?? ?? observe an open posture - O of SOLER (listening skills) ?? ?? ?? ?? lean toward the client - L of SOLER (listening skills) ?? ?? ?? ?? establish and maintain intermittent eye contact - E of SOLER (listening skills) ?? ?? ?? ?? ?? ?? relax - R of SOLER (listening skills) ?? assessment diagnose plan implement evaluate - The 5 phases of the nursing process - ??, ??, ??, ??, and ?? NANDA - Nursing diagnoses must come from the ?? approved list diagnostic label - ?? ?? is another term for the nursing diagnosis (from NANDA) related factor - The condition identified in the client's assessment data is called the ?? ?? (R/T) etiology - ?? is what which is within the nursing domain of practice definition - ?? helps describe the characteristics of the condition risk factors - ?? ?? are cues or clues which indicate diagnosis is applicable to the clients condition support - ?? the diagnostic statement with specific assessment data which has defining characteristics proving the accurate nursing diagnosis as evidenced by - AEB means as manifested by - AMB means Acute pain - -temporary -occurs after an injury to the body -includes postoperative pain, labor pain, renal calculus pain Chronic pain - -nonmalignant (low back pain, rheumatoid arthritis etc.) -intermittent (migraine headaches etc.) -malignant, associated w/ neoplastic diseases Gate control theory - pain impulses travel from the periphery to the gray matter in the dorsal horn of the spinal cord along small nerve fibers acupuncture - the insertion of needles at various points on the body to relieve pain -invasive -associated with the gate control theory -thought to increase the production of endogenous opiates preparation for death - -Denial: coping style used to protect self/ego; non compliance, refusal to seek treatment, ignoring symptoms; changing the subject when speaking about illness; stating, "not me, it must be a mistake." -Anger: often directing it a t family or health care team members; stating, "why me? it's not fair." -Bargaining: making a deal with God to prolong life; usually not sharing this with anyone, keeping it a very private experience -Depression: results from the losses experienced because of health status & hospitalization; anticipating the loss of life -Acceptance: accepting the inevitable; beginning to separate emotionally dealing with delayed grief - -unresolved grief (determine level of dysfunction) -physical symptoms similar to those of the deceased -clinical depression -social isolation -failure to acknowledge loss Temperature range for adults - 36-38 C (96.8-100.4 F) Average oral temp - 37 (98.6) Average rectal temp - 37.5 (99.5) Average axillary temp - 36.5 (97.7) Pulse range - 60-100 bpm Respiration range - 12-20 bpm Prehypertension range - 120-139/80-89 Stage 1 Hypertension - 140-159/90-99 Stage 2 Hypertension - Over 160/ over 100 Where should a blood pressure cuff NOT be placed? - Not on site of IV, fistula, mastectomy What should a patient do before having their blood pressure taken? - Avoid caffeine/smoking, rest 5 minutes before taking BP What sounds represent blood pressure noises? - Korotkoff's sounds (1st-systolic, 4th-diastolic) What is the most BP can vary between arms and still be considered normal? - 10 Normal respirations in newborns - 35-40 Normal respirations for infants - 30-50 Normal respirations for toddlers - 25-32 Normal respirations for children - 20-30 Normal respirations for adolescents - 16-20 Normal respirations for adults - 12-20 Intervention for insomnia - Sleep and exercise; encourage client to begin walking routinely during the day, but not 2-3 hours before bedtime Who can perform catheter insertions? - RNs. UAP can only position patient, report discomfort, report characterization of urine How far should a catheter be inserted? - 2-3 inches for female; 7-9 inches for male Chain of infection - Infectious agent/pathogen -- reservoir/source for growth -- portal of exit from reservoir -- mode of transmission -- portal of entry to host -- susceptible host Showering with an IV - Adjust IV flow rate to KVO and remove IV tubing from pump. Reset after shower is over. Logrolling - Obtain assistance; place pillow between client's knees (prevents tension on the spinal column). Cross client's arms (prevents injury). Measuring intake and output - I-O= Total; when you flush a GI tube, have an IV running, or wash the perineum, yo have subtract this from your output. Check I&O every 8 hours. Weight can tell if fluid retention Two types of contact transmission - Direct and indirect Direct contact transmission - Applied to care and handling of contaminated body fluids Indirect contact transmission - Involves transfer of an infectious agent through a contaminated intermediate object Droplet precautions - Used for diseases that are transmitted by large droplets that are expelled into the air 3-6 feet. Mask, hand hygiene, dedicated care equipment. Ex. influenza Airborne precautions - Used for diseases that are transmitted by smaller droplets that remain in the hair for long periods of time. Requires negative air flow; air filtered through HEPA filter Protective environment - Focuses on clients w/ transplants or gene therapy; positive airflow (12 exchanges/hour). Basic contact precautions for protective environments - Hand hygiene before and after entering room; dispose of contaminated supplies in a way that prevents the spread of germs; use protective barriers; protect all persons who might be exposed during transport Heat application guidelines - Must have health care provider's orders Do's for applying heat/cold therapy - Explain sensations to be felt; report changes immediately; provide timer and call light; look up safe temps Don'ts for applying heat/cold therapy - Don't let client adjust temp; don't allow client to move application or place hands on wound; make sure client can move away from temp source; don't leave client who can't feel temp changes How long can a restraint order be good for? - 4 hours for adults, 2 hours for children (9-17) and 1 hour for under 9 IM site/ ventrogluteal - Deep site situated away from major nerves and blood vessels; less chance of contamination; easily ID by bony landmarks; total IM volume is 3mL 6 Rights of Medication Administration - Right dose, right time, right patient, right route, right documentation, right medication Syringe sizes used for IM and subQ injections - 1-3ml When are syringes larger than 5 mL used? - Administer IV meds, add meds to IV solutions, irrigate wounds Insulin syringes - .3-1 mL (calibrated in units). Most are 100 U Tuberculin syringe - 16ths of minim and 100ths of a mL. (capacity of 1mL). intradermal or subQ Incident pain - Pain that is predictable and elicited by a specific behaviors such as physical therapy or wound dressing changes End-of-dose failure pain - Pain that occurs toward the end of the usual dosing interval of a regularly scheduled analgesic Spontaneous pain - Pain that is unpredictable and not associated with any activity or event Pulse Ox site - Finger (remove nailpolish) or earlobe Oxygen flow meter - Meter that controls the amount of oxygen when using a nasal cannula or mask What level should O2 stats remain above? - 90% What is prune juice used for? - Bowel stimulation Diarrhea nursing diagnosis - Diarrhea related to... NG tubes - Cannot be delegated; have patient sip water; can go into lungs; clients w; impaired LOC are at risk for aspiration Intermittent tube feedings - Done periodically Bolus tube feeding - Large feeding done over 20-30 minutes Continuous tube feeding - Done continuously Elimination in bedside chair - Can be delegated; remind assistant to report any abnormal findings C. diff - Can't use hand sanitizer; must wash with soap and water SBAR - Situation, background, assessment, recommendation Noctural emissions - Normal Cultural/spiritual nursing process - You must know yourself/your values before you can help the patient. Always. Penrose drain - Lies under dressing; pin placed in drain to prevent it from slipping into the wound Skin break down - Related to shear, friction, altered LOC, impaired mobility/sensory perception and moisture; lead to ulcers How should darker skinned individuals be assessed for skin breakdown? - Use natural/halogen light; will appear darker than surrounding tissue with purplish/bluish hue; have initial warmth with coolness as tissue devitalizes; may appear taut, shiny, scaly Wound dressings - Protect, aid in homeostasis, promotes healing, supports, promotes thermal insulation, protects client from seeing it; provides moist environment Hypokalemia - Low K; normally 3.6 to 5.2 mmol/L; lower than 2.5 mmol/L can be life-threateningin the purpose of therapeutic interaction - to allow the client to autonomy to make choices when appropriate. keep statements value-free, advice free, and reassurance-free what action should the nurse take in a psychiatric situation when the client describes a physical problem? - assess. example: if a client has schizophrenia complains of chest pain take their blood pressure basic communication principles - establish trust, nonjudgemental attitude,active listening, offer self, accept client's feelings, validate client's statements, matter of fact approach nausea is a common complaint after ECT - vomiting by an unconscious can lead to aspiration. maintain a paten airway common physiological responses to anxiety - increased heart rate, and blood pressure, rapid shallow respirations, dry mouth, tight feeling in throat, tremors, muscle twitching, anorexia, urinary frequency, palmar sweating nurse-client an