MDC 1 Exam 1 Questions with Correctly Solved
Solutions.
Maslow - Nursing Interventions to achieve different levels
Air
Food - Nutrition
Water
Temperature Regulation
Elimination
Rest - Sleep Effects
Sex
Physical Activity - Mobility Assessment
Blood Flow (perfusion) - Necessary to meet other needs
Safety and Security
Protection from physical harm
Adequate shelter
Freedom from fear and anxiety
Temperature Definition and Normal Value
Regulation or thermoregulation determined using client's temperature
Normal: 96.4-99.5
Hypothermia definition and Interventions
Temperature below 96.4 - Move person out of the cold, remove wet clothing, cover with blankets,
insulate person's body, monitor breathing, provide warm beverages, use warm/dry compresses
Hyperthermia definition and interventions
Temperature above 99.5 - Remove excessive clothing/blankets, administer antibiotics/anti-pyretic
medications, elevate head of bed, encourage oral fluid intake, start IV therapy as prescribed
Pulse : Normal values, what are the pulse points, what do you assess
Normal: 60-100 bpm
Pulse points: Carotid, radial, femoral, popliteal, posterior tibial, dorsalis pedis
Assessment: Rate, Rhythm, quality
Blood Pressure: Normal values, what is the appropriate cuff size
Normal 120/80
Bladder of cuff needs to be 80% of arm circumference, width of cuff should be 40% of arm
circumference.
Respirations: Normal Values, Assessment, Effort
Normal values: 12-20
Assessment: Normal, Deep, Shallow, etc.
Effort: Nasal flaring, use of accessory muscles, body positioning
, Interventions to treat hypoxia:
Oxygen administration, Oral suctioning, position changes, deep breathing, coughing exercises
Pharmacological Interventions for pain
Use of medications to manage illness
Non-pharmacological interventions for pain
Distraction, relaxation, repositioning, heat/cold application, massages
Assessment before and after treatment of pain
Level of pain, pain type, and location
Assessment of Pain history:
· P: Provocation and Palliative: What causes it, what makes it better, what makes it worse
· Q: Quality and Quantity: Describe the pain
· R: Region and Radiation: Where is it?
· S: Severity and Scale: 0-10 pain scale, does it interfere with activities?
· T: Timing: When did it start, consistent/intermittent, how long does it last
Cutaneous pain
Arises from burning of skin like on a hot iron or hot pain on the stove
Visceral pain
Caused from deep internal disorders: Menstrual cramps, labor pains, of GI infections
Deep Somatic Pain
Originates from ligaments, tendons, bones, blood vessels, and nerves (Fractures or sprains)
Radiating Pain
Starts at the origin but extends to other locations.
Ex: the pain of a severe sore throat may extend to the ears and head.
Referred Pain
occurs in an area that is distant from the original site
Ex: pain from heart attack might be felt in left arms or jaw
Phantom Pain
Pain that is perceived to originate from an area that has been surgically removed (Amputated limb)
Neuropathic pain
Results from nerve injury; the pain continues even after the painful stimuli are gone.
Acute Pain
Short duration, rapid onset, associated with some king of injury
Solutions.
Maslow - Nursing Interventions to achieve different levels
Air
Food - Nutrition
Water
Temperature Regulation
Elimination
Rest - Sleep Effects
Sex
Physical Activity - Mobility Assessment
Blood Flow (perfusion) - Necessary to meet other needs
Safety and Security
Protection from physical harm
Adequate shelter
Freedom from fear and anxiety
Temperature Definition and Normal Value
Regulation or thermoregulation determined using client's temperature
Normal: 96.4-99.5
Hypothermia definition and Interventions
Temperature below 96.4 - Move person out of the cold, remove wet clothing, cover with blankets,
insulate person's body, monitor breathing, provide warm beverages, use warm/dry compresses
Hyperthermia definition and interventions
Temperature above 99.5 - Remove excessive clothing/blankets, administer antibiotics/anti-pyretic
medications, elevate head of bed, encourage oral fluid intake, start IV therapy as prescribed
Pulse : Normal values, what are the pulse points, what do you assess
Normal: 60-100 bpm
Pulse points: Carotid, radial, femoral, popliteal, posterior tibial, dorsalis pedis
Assessment: Rate, Rhythm, quality
Blood Pressure: Normal values, what is the appropriate cuff size
Normal 120/80
Bladder of cuff needs to be 80% of arm circumference, width of cuff should be 40% of arm
circumference.
Respirations: Normal Values, Assessment, Effort
Normal values: 12-20
Assessment: Normal, Deep, Shallow, etc.
Effort: Nasal flaring, use of accessory muscles, body positioning
, Interventions to treat hypoxia:
Oxygen administration, Oral suctioning, position changes, deep breathing, coughing exercises
Pharmacological Interventions for pain
Use of medications to manage illness
Non-pharmacological interventions for pain
Distraction, relaxation, repositioning, heat/cold application, massages
Assessment before and after treatment of pain
Level of pain, pain type, and location
Assessment of Pain history:
· P: Provocation and Palliative: What causes it, what makes it better, what makes it worse
· Q: Quality and Quantity: Describe the pain
· R: Region and Radiation: Where is it?
· S: Severity and Scale: 0-10 pain scale, does it interfere with activities?
· T: Timing: When did it start, consistent/intermittent, how long does it last
Cutaneous pain
Arises from burning of skin like on a hot iron or hot pain on the stove
Visceral pain
Caused from deep internal disorders: Menstrual cramps, labor pains, of GI infections
Deep Somatic Pain
Originates from ligaments, tendons, bones, blood vessels, and nerves (Fractures or sprains)
Radiating Pain
Starts at the origin but extends to other locations.
Ex: the pain of a severe sore throat may extend to the ears and head.
Referred Pain
occurs in an area that is distant from the original site
Ex: pain from heart attack might be felt in left arms or jaw
Phantom Pain
Pain that is perceived to originate from an area that has been surgically removed (Amputated limb)
Neuropathic pain
Results from nerve injury; the pain continues even after the painful stimuli are gone.
Acute Pain
Short duration, rapid onset, associated with some king of injury
