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Questions and Answers
What is the MOST important risk factor for skin cancer?
What is the MOST important risk factor for skin cancer?
What is the FIRST action to take in the event of a needlestick injury?
What is the FIRST action to take in the event of a needlestick injury?
How often should a patient at risk for skin breakdown be repositioned?
How often should a patient at risk for skin breakdown be repositioned?
Every 2 hours
Recapping a needle is a safe practice.
Recapping a needle is a safe practice.
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What is the normal response to touching a patient's cornea with a wisp of cotton?
What is the normal response to touching a patient's cornea with a wisp of cotton?
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Which of the following is a sign of cyanosis?
Which of the following is a sign of cyanosis?
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Which of the following is NOT a common cause of cyanosis?
Which of the following is NOT a common cause of cyanosis?
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Match the following cranial nerves with their primary function:
Match the following cranial nerves with their primary function:
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Which of the following is a sign of a pressure ulcer?
Which of the following is a sign of a pressure ulcer?
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A stage 4 pressure ulcer involves full-thickness skin and tissue loss.
A stage 4 pressure ulcer involves full-thickness skin and tissue loss.
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What is the recommended angle for intramuscular injections?
What is the recommended angle for intramuscular injections?
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Which of the following conditions is characterized by a sudden loss of strength and consciousness?
Which of the following conditions is characterized by a sudden loss of strength and consciousness?
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What is the term for the abnormal posture where the arms are folded in tight against the chest?
What is the term for the abnormal posture where the arms are folded in tight against the chest?
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Decerbrate posturing is a more severe sign than decorticate posturing.
Decerbrate posturing is a more severe sign than decorticate posturing.
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What is the purpose of the Glasgow Coma Scale?
What is the purpose of the Glasgow Coma Scale?
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A patient who scores a 6 on the Glasgow Coma Scale would be independent.
A patient who scores a 6 on the Glasgow Coma Scale would be independent.
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What is the difference between air conduction and bone conduction?
What is the difference between air conduction and bone conduction?
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What is the Romberg test used for?
What is the Romberg test used for?
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What is the maximum score that can be achieved on the muscle strength scale?
What is the maximum score that can be achieved on the muscle strength scale?
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Dehiscence is a partial or total separation of wound layers.
Dehiscence is a partial or total separation of wound layers.
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What is evisceration?
What is evisceration?
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The Braden Scale is used to predict the risk of pressure ulcers.
The Braden Scale is used to predict the risk of pressure ulcers.
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What is the primary goal of the Braden Scale?
What is the primary goal of the Braden Scale?
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Sterile objects remain sterile only when touched by another sterile object.
Sterile objects remain sterile only when touched by another sterile object.
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A sterile field becomes contaminated if it is exposed to the air for too long.
A sterile field becomes contaminated if it is exposed to the air for too long.
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A sterile surface becomes contaminated if it is exposed to moisture.
A sterile surface becomes contaminated if it is exposed to moisture.
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What is the direction of fluid flow in a sterile field?
What is the direction of fluid flow in a sterile field?
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The edges of a sterile field are considered contaminated.
The edges of a sterile field are considered contaminated.
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Which of the following is a nursing intervention for transferring a patient?
Which of the following is a nursing intervention for transferring a patient?
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What is a common complication of immobility?
What is a common complication of immobility?
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Lordosis is an exaggerated inward curvature of the spine.
Lordosis is an exaggerated inward curvature of the spine.
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Kyphosis is an exaggerated outward curvature of the spine.
Kyphosis is an exaggerated outward curvature of the spine.
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Scoliosis is a lateral curvature of the spine.
Scoliosis is a lateral curvature of the spine.
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It is important to assess a patient's weight-bearing ability before transferring them.
It is important to assess a patient's weight-bearing ability before transferring them.
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It is safe to twist your body when lifting a patient.
It is safe to twist your body when lifting a patient.
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What is the primary reason for using a wheelchair to transfer a patient?
What is the primary reason for using a wheelchair to transfer a patient?
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It is important to clear the area before transferring a patient to prevent falls.
It is important to clear the area before transferring a patient to prevent falls.
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Motivating a patient to move is not as important as providing them with the necessary equipment for mobility.
Motivating a patient to move is not as important as providing them with the necessary equipment for mobility.
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What is a common intervention to prevent falls in a patient?
What is a common intervention to prevent falls in a patient?
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Which of the following is a post-fall intervention?
Which of the following is a post-fall intervention?
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Slipper socks can increase the risk of falls.
Slipper socks can increase the risk of falls.
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A bed alarm can be used to alert staff when a patient gets out of bed.
A bed alarm can be used to alert staff when a patient gets out of bed.
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Physiological changes with age can make it difficult to fall asleep.
Physiological changes with age can make it difficult to fall asleep.
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The term 'atonia' refers to a lack of muscle activity during REM sleep.
The term 'atonia' refers to a lack of muscle activity during REM sleep.
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Which of the following accurately describes insomnia?
Which of the following accurately describes insomnia?
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The larger the needle gauge, the smaller the needle diameter.
The larger the needle gauge, the smaller the needle diameter.
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Study Notes
Pressure Ulcer Management/Prevention
- Reposition patients every 2 hours if at risk for skin breakdown
- Elevate the head of the bed (HOB) 30 degrees or less
- Use a "chuck" to assist patients in bed
- Implement good incontinence care to prevent moisture
- Clean incontinence areas with a no-rinse perineal cleaner and protect skin with a moisture barrier ointment
- Keep skin dry
- Avoid hot water and soap to prevent dryness
- Ensure skin is completely dry and apply moisturizer
Pressure Ulcer Identification
- Stage 1: Non-blanchable erythema of intact skin
- Stage 2: Partial-thickness skin loss with exposed dermis
- Stage 3: Full-thickness skin loss
- Stage 4: Full-thickness skin and tissue loss
- Unstageable pressure injury: Full-thickness skin and tissue loss obscured by slough or eschar
- Deep-tissue pressure injury: Localized area of non-blanchable dark discoloration, or epidermal separation with dark wound bed or blood-filled blister
Skin Cancer Prevention
- Main risk factor: exposure to UV radiation from sun and tanning sources
- Increased risk of melanoma due to multiple sunburns
- Family history is a factor
- Certain medications can increase risk
- Fair skin that burns easily (lack of melanin) is a risk factor
- To prevent, reduce midday sun exposure
- Use protective clothing, sunglasses and high SPF sunscreen
- Avoid indoor tanning
- Perform regular self-skin checks and annual screenings
Assessing Cyanosis
- Cyanosis: Bluish mottling due to decreased perfusion, increased deoxygenated blood
- Non-specific; assess other clinical signs
- Associated with shock, cardiac arrest, heart failure, chronic bronchitis, congenital heart disease
- Lighter skin: generalized dusky blue color centrally and dusky nail beds peripherally
- Darker skin: skin may appear dull, lifeless; hard to detect severe cyanosis; check conjunctivae, oral mucosa, nail beds
Skin Assessment
- Color: Assessment of skin tone
- Temperature: Palpate using back of hand
- Turgor: Assess skin elasticity
- Lesions: Note any marks or sores on skin
- Bruising: Look for any contusions
- Moisture: Observe skin for dryness or wetness
Needlestick Injuries
- Immediate action for needlestick injuries: wash puncture sites with soap and water for 15 minutes
- Know wash station locations for your shift
- Apply direct pressure to lacerations, control bleeding and seek medical attention
Needle Safety
- Pre-injection: wash hands, gather supplies (syringe, needle, alcohol), draw up medication, and follow 5 rights
- Always use smallest syringe for the volume and measurement of medication dose
- Swab the skin with alcohol prep pad for 15 seconds for every injection
- Use safety needles when available.
- Never recap needles!
Assessing Pallor, Cyanosis, Erythema, Jaundice
- Pallor: Loss of red-pink tones from oxygenated hemoglobin (anemia, shock, arterial insufficiency)
- Cyanosis: Bluish mottling due to decreased perfusion, elevated deoxygenated blood (shock, cardiac arrest)
- Erythema: Intense red color due to excess blood in dilated superficial capillaries (fever, inflammation)
- Jaundice: Yellowish tone due to increased bilirubin in blood (hepatitis)
Cranial Nerves
- I (Olfactory): Smell
- II (Optic): Visual acuity
- III (Oculomotor): Eye movement, pupil dilation
- IV (Trochlear): Eye movement
- V (Trigeminal): Facial sensation, jaw movement
- VI (Abducens): Eye movement
- VII (Facial): Facial expression, taste
- VIII (Acoustic): Hearing, balance
- IX (Glossopharyngeal): Taste, swallowing
- X (Vagus): Swallowing, vocalization
- XI (Accessory): Shoulder, head movement
- XII (Hypoglossal): Tongue movement
Corneal Reflexes
- Assess corneal reflex if patient has abnormal facial sensations or facial movement abnormalities
- Use a wisp of cotton to touch the cornea
- Normal response is blinking
Neurological Assessment
- Screen well persons and complete exam on persons with neurologic concerns
- Perform neurologic recheck on persons with demonstrated neurologic deficits
Identifying a Client's Level of Consciousness
- Easily arousable: Arousal to voice, touch, or sternal rub
- Lethargic: Easily aroused by name but the patient remains drowsy
- Obtunded: Needs more stimulation for arousal
- Stuporous: Needs intense and repeated stimulation for arousal, falls back to sleep easily
- Semi-coma: Moves when stimulated, no response to other stimuli
- Coma: No response to any stimulus
Glasgow Coma Scale
- The Glasgow Coma Scale (GCS) is tool used to assess level of consciousness
- It is standardized, objective and defines the level of consciousness
- Three categories include eye responses, motor responses and verbal responses
Assessing Hearing Abnormalities
- Perform Weber's test with vibrating tuning fork
- Perform Rinne test: assessing air and bone conduction
- Perform Romberg test (see neuro lecture)
Assessing Muscle Strength
- Test muscle strength of major muscle groups for each joint
- Ask the patient to flex and hold while you apply opposing force
- Rate muscle strength on a scale: 0-no contraction to 5-full resistance
Complications of Wounds
- Hemorrhage: Bleeding from the wound site
- Infection: Invasion of microorganisms (signs include erythema, green/yellow drainage)
- Dehiscence: Partial or complete separation of wound layers
- Evisceration: Protrusion of visceral organs through an open wound
Braden Scale
- Predicts pressure sore risk
- Assesses sensory perception, moisture, activity, mobility, nutrition and friction/shear
Preparing a Sterile Field
- Sterile objects remain sterile only when touched by another sterile object
- Ensure objects remain within the field's visual range & below the waist are contaminated
- Avoid prolonged air exposure (masks, minimize movement in the area & talk)
- Contaminated field when surface is wet
- Edges of sterile field are considered contaminated
Disposal of Contaminated Dressing
- Nonsterile gloves: remove soiled dressing, dispose in biohazard
Insomnia
- Difficulty falling asleep, staying asleep, or achieving high-quality sleep
All about Sleep
- REM (Rapid Eye Movement): 25% of sleep; rapid eye movement, muscle atonia; important for memory and learning
- NREM (Non-Rapid Eye Movement): 75% of sleep; important for tissue repair and growth
IM Injections
- The larger the needle gauge, the smaller the needle
- Typical needle geometry varies based on injection route (intradermal, subcutaneous, intramuscular)
Vertigo vs. Syncope
- Vertigo: Rotational spinning caused by neurological disease in brainstem or ear
- Objective: Does the room spin? Subjective: Do you feel you are spinning?
- Syncope: Sudden loss of strength and temporary loss of consciousness due to lack of blood flow
Abnormal Posturing
- Decorticate: Arms folded tight against chest
- Decerebrate: Arms out to the side and wrists outward, back is arched
Cranial Nerve Function & Assessment
- Assess each cranial nerve for function and abnormalities
- Use specific methods to evaluate each nerve's various components (smells, vision, movements, taste, etc.)
Dressings by Pressure Injury Stage
- Describe different dressings for pressure injuries, stages and expected time frames for healing
Range of Motion
- Abduction: Moving a limb away from the midline of the body
- Adduction: Moving a limb toward the midline of the body
- Circumduction: Moving a limb in a circle
- Inversion: Moving the sole of the foot inward
- Eversion: Moving the sole of the foot outward
- Extension: Straightening a limb at a joint
- Flexion: Bending a limb at a joint
- Pronation: Turning the forearm so the palm faces down
- Supination: Turning the forearm so the palm faces up
- Retraction: Moving a body part backward
- Rotation: Moving a body part around a central axis
- External rotation: Rotating a body part away from the central axis
- Internal rotation: Rotating a body part toward the central axis
- Dorsiflexion: Lifting the front of the foot, pointing the toes upward.
- Plantar flexion: Pointing the toes downward.
Complications of Immobility
- Respiratory complications (pneumonia, atelectasis, pulmonary embolus)
- Cardiovascular complications (postural hypotension, cardiac muscle atrophy)
- Neurological complications (depression, anxiety)
- Musculoskeletal complications (osteoporosis, muscle atrophy, weakness)
- Metabolic complications (glucose intolerance, negative nitrogen balance)
- Renal complications (calculi, nephritis)
- Skin complications (pressure ulcers)
- Gastrointestinal complications (constipation, fecal impaction)
Musculoskeletal Abnormalities
- Normal spine: Normal curvature of the spine
- Lordosis of the spine: Exaggerated inward curvature of the lumbar spine
- Kyphosis: Exaggerated outward curvature of the thoracic spine
- Scoliosis: Lateral curvature of the spine
Transferring Patient
- Assess weight-bearing ability
- Keep back, neck, pelvis, and feet aligned when transferring
- Avoid twisting
- Bend at knees and keep feet wide apart
- Use arms and legs, not the back, to lift
Transferring Nursing Interventions
- Plan how to do the transfer
- Obtain necessary equipment
- Remove obstacles
- Explain the procedure to the patient
Physiological Changes with Age
- Decrease in muscle mass and strength
- Decrease in bone density (increase in osteoporosis)
- Tendon and joint breakdown
- Postural changes
- Gait and mobility changes
- Increased risk of falls
Mobility Considerations for Patients
- Medicate for pain
- Ensure proper bracing or slings are worn
- Use assistive devices (walkers, wheelchairs)
- Clear the patient's surroundings of any obstacles
- Use appropriate footwear
- Encourage mobility and set goals
Interventions to Prevent Falls/During Falls/Post-Fall
- Teach the client to use the call light.
- Keep the bed in the lowest position and locked.
- Identify the patient as high fall risk
- Regularly assess the patient's needs.
- Place necessary items within reach
- Have assistive devices available
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