NUR2090 Fundamentals Final Review QUESTIONS AND ANSWERS VERIFIED WITH
COMPLETE SOLUTIONS
sites to assess pulses
temporal
carotid
apical
brachial
radial
femoral
popliteal
pedal
posterior tibia
location of apical pulse
locate fifth intercostal space at the left midclavicular line.
What is tachypnea?
rapid breathing (>20 breaths/ min)
bradypnea
slow breathing (<12 breaths/min)
what is apnea?
absence of breathing (> or = 10 secs)
normal breathing
eupnea
difficulty breathing
dyspnea
,what is Biot?
cyclic breathing pattern characterized by shallow breathing alternating with periods of
apnea
Cheyne-Stokes respirations
cyclic breathing pattern characterized by periods of respirations of increased rate and depth
alternating with periods of apnea
Kussmaul respirations
increased rate (above 20 beats/min) and depth of respirations
atelectasis (alveoli collapse) and pneumonia prevention
deep breathing and incentive spirometer are beneficial in maximizing air exchange
manifestations of altered mobility
-decreased muscle strength and tone
-lack of coordination
-altered gait
-falls
-decreased joint flexibility
-pain on movement
functions of the musculoskeletal
alignment and posture
balance
coordinated movement
nursing interventions for musculoskeletal impairment
1. positioning: prone, side-lying, supine, sims, fowlers, dorsal recumbent, Trendelenburg's
2. turning schedules (every 2hr)
,3. logrolling
4. ROM exercises
important measure for patient safety with a musculoskeletal deficit
- physical therapy
- using proper body mechanics when lifting
- providing a safe environment
- using assistive devices
t physiologic impact does immobility have
1. muscle atrophy and weakness
2. contractures and joint pain
3. increased cardiac workload
4. orthostatic Hypotension
5. thrombus formation and embolism
6. decreased lung expansion
psychological impact immobility have on a patient
sensory deprivation
confusion
hallucinations
pain
anxiety
anger
depression
powerlessness
care for a patient who just had hip replacement surgery
, 1. Prevent adduction of the affected hip and leg
2. Use abductor pillows
3. Avoid hip flexion <90 degrees
how can nurses prevent musculoskeletal injury
1. Use the large muscle groups of the legs.
2. Work at the appropriate height for body position.
3. Use mechanical lifts or assistance when possible.
what are national patient safety goals?
-identify patients correctly
-improve staff communication
-use medicine safely
-use alarms safely
-prevent infection
-identify patient safety risks
-prevent mistakes in surgery
common manifestations of altered safety
- motor vehicle incidents
- falls
- poisoning
- suffocation and drowning
- fires
Mini-Mental State Examination
- Brief screening test for cognitive dysfunction
Includes screening items for orientation, registration, attention and calculation, recall and
COMPLETE SOLUTIONS
sites to assess pulses
temporal
carotid
apical
brachial
radial
femoral
popliteal
pedal
posterior tibia
location of apical pulse
locate fifth intercostal space at the left midclavicular line.
What is tachypnea?
rapid breathing (>20 breaths/ min)
bradypnea
slow breathing (<12 breaths/min)
what is apnea?
absence of breathing (> or = 10 secs)
normal breathing
eupnea
difficulty breathing
dyspnea
,what is Biot?
cyclic breathing pattern characterized by shallow breathing alternating with periods of
apnea
Cheyne-Stokes respirations
cyclic breathing pattern characterized by periods of respirations of increased rate and depth
alternating with periods of apnea
Kussmaul respirations
increased rate (above 20 beats/min) and depth of respirations
atelectasis (alveoli collapse) and pneumonia prevention
deep breathing and incentive spirometer are beneficial in maximizing air exchange
manifestations of altered mobility
-decreased muscle strength and tone
-lack of coordination
-altered gait
-falls
-decreased joint flexibility
-pain on movement
functions of the musculoskeletal
alignment and posture
balance
coordinated movement
nursing interventions for musculoskeletal impairment
1. positioning: prone, side-lying, supine, sims, fowlers, dorsal recumbent, Trendelenburg's
2. turning schedules (every 2hr)
,3. logrolling
4. ROM exercises
important measure for patient safety with a musculoskeletal deficit
- physical therapy
- using proper body mechanics when lifting
- providing a safe environment
- using assistive devices
t physiologic impact does immobility have
1. muscle atrophy and weakness
2. contractures and joint pain
3. increased cardiac workload
4. orthostatic Hypotension
5. thrombus formation and embolism
6. decreased lung expansion
psychological impact immobility have on a patient
sensory deprivation
confusion
hallucinations
pain
anxiety
anger
depression
powerlessness
care for a patient who just had hip replacement surgery
, 1. Prevent adduction of the affected hip and leg
2. Use abductor pillows
3. Avoid hip flexion <90 degrees
how can nurses prevent musculoskeletal injury
1. Use the large muscle groups of the legs.
2. Work at the appropriate height for body position.
3. Use mechanical lifts or assistance when possible.
what are national patient safety goals?
-identify patients correctly
-improve staff communication
-use medicine safely
-use alarms safely
-prevent infection
-identify patient safety risks
-prevent mistakes in surgery
common manifestations of altered safety
- motor vehicle incidents
- falls
- poisoning
- suffocation and drowning
- fires
Mini-Mental State Examination
- Brief screening test for cognitive dysfunction
Includes screening items for orientation, registration, attention and calculation, recall and
