NUR 352 Exam 2 study guide

• To prepare for the NUR 352 Exam 2, ensure you have a fully charged laptop with an updated Respondus lockdown browser
• Remember to maintain academic integrity
• Refer to the ASU Pre Licensure Student Testing Information for details on testing procedures
• Exam 2 consists of 50 questions, each worth 0.5 points, totaling 25 points
• The time limit to complete the exam is 75 minutes
• Question formats include multiple-choice, fill-in-the-blank, multiple-answer, and alternate-style Next Generation NCLEX questions

Terms to Know

• Ambulate: to move or walk around
• Dermatitis: inflammation of the skin, often causing redness, itching, and irritation
• Supine: lying on the back with face and chest facing upward
• Lateral: relating to the side; away from the midline of the body
• Anterior: front of the body/structure
• Posterior: back of the body/structure
• Medial: closer to the midline of the body
• Midline: imaginary vertical line dividing the body into equal left and right halves
• Bedside commode: portable toilet placed next to a patient's bed for convenience
• Auricle: external, visible part of the ear that helps capture sound waves
• Morphine: powerful opioid pain medication used to treat severe pain; CAUSES
• Bite block: device placed between teeth to prevent biting down during medical procedures or seizures
• Accommodation: necessary modifications/adjustments to ensure people with disabilities can fully participate in healthcare services
• Convergence/converge: integration/collaboration of different disciplines, technologies, and stakeholders to improve patient care/outcomes, focusing on holistic and personalized approaches
• Ecchymosis: bruise, discoloration of the skin due to bleeding under the skin from a ruptured blood vessel
• Petechiae: small, pinpoint red/purple spots on the skin caused by minor bleeding under the skin
• Clubbing: a condition in which fingers become thickened/rounded, often due to chronic low O2 levels associated with lung OR heart disease

Health Assessment (Hair/Skin/Nails)

• Physical assessment techniques/screening tools include skin assessment
• Skin Assessment:
  • Inspection focuses on color, texture, moisture, and integrity
  • Palpation assesses texture, moisture, temperature, mobility, and turgor
• Expected findings include variation in color (even and consistent with patient genetic background), variations due to environment
• Variations can be general, localized (scar tissue, freckling), genetic, age-related (thinner, sun spots), or sun damage/pregnancy (hyperpigmentation)
• Temperature variations can be due to environment or chronic perfusion issues
• Unexpected findings include pallor, cyanosis, jaundice, erythema, ecchymosis (bruising), hematoma (raised ecchymosis), petechiae (pinpoint hemorrhage), hypo/hyperthermia
• Palpating for moisture, texture, and turgor
• Expected findings include dry, intact, smooth skin, variations due to age, genetics, weight loss/gain (wrinkling, acne, stretch marks), trauma, procedures (scars)
• Turgor: skin should rise easily when pinched and rapidly return to a flat position when released
• Unexpected findings include profound dryness, rough, flaking skin, velvet, thickening texture(thyroid disease), diaphoresis, tenting(severe weight loss/dehydration), edema, prolonged response times
• Hair/Nails Assessment involves assessing hair distribution, quantity, hygiene, nail symmetry, smoothness, and color
• Expected: Hair evenly distributed, good hygiene, nails symmetrical and smooth, color normal, brisk capillary refill (less than 2 seconds), and variations with aging (thinning, balding, brittle)
• Unexpected: hair loss (alopecia), abnormal nails (broken or missing, clubbing, delayed cap refill, loosely attached), abnormal nail color (brown with linear streaks, melanoma, bluish, whitish), brittle, thick
• Age-related considerations: sun exposure (skin cancers), less elasticity (skin tears), collagen fibers stiffen, less fatty acids in epidermis, decrease sebum (dryness), uneven pigmentation, slower hair/nail growth, nail discoloration/thicker, less SubQ tissue, wrinkling (UV exposure)
• Ethnic considerations: "MIND THE GAP". When assessing for pallor, look at mucous membranes (e.g., conjunctival pallor) or palms
• Health promotion strategies include hygiene practices (bathing, skin care), wound care and balanced care
• Strategies to address skin conditions include acne and other skin conditions: keep skin clean, avoid oily cosmetics and creams
• Strategies to address excessive dryness: use alcohol-free lotion, bath less frequently or don't use soap, hydrate, cotton clothing
• Encourage decreased sun exposure, self/provider wellness exams, and knowledge of skin cancer risk factors
• Pressure Wound RISK: immobility, poor nutrition, presence of moisture (incontinence, seeping wounds, perspiration), thin skin (aging), edema, caused by client being pulled up or across bed linens causing shearing
• Pressure Wound Stage 1: red, doesn't blanch with pressure, texture/temperature difference
• Pressure Wound Stage 2: partial loss of dermis, shiny or dry with pink wound bed, may be intact or ruptured blister
• Pressure Wound Stage 3: full thickness with damage/necrosis to SUBQ tissue, SUBQ fat may be visible, dead tissue
• Pressure Wound Stage 4: full thickness loss, exposed bones/tendons/muscle, dead tissue may be present in wound bed
• Prevention strategies involve inspecting at-risk patient’s skin frequently and repositioning every 2 hours
• Additional prevention also includes elevating HOB no more than 30º, removing excess moisture, dietary supplements, provide wound care, and never rub reddened area
• Documentation should include location, size, depth, appearance, drainage presence, and characteristics
• Braden Scale assesses sensory perception, moisture, activity, mobility, nutrition, and friction/shear but not body temperature

Health Assessment (Musculoskeletal)

• Assessing range of motion/strength (know proper terminology):
• Flexion: bending a joint
• Extension: straightening of a joint
• Hyperextension: extension beyond anatomical position
• Pronation: turning the palm downward
• Supination: movement that turns the palm up
• Dorsiflexion: bending of the foot or toes upward
• Plantar flexion: bending of the sole of the foot by curling the toes toward the ground
• Abduction: movement away from the midline
• Adduction: movement toward the midline
• Eversion: turning the sole of the foot outward
• Inversion: turning the sole of the foot inward
• External (lateral) rotation: turning the joint outward
• Internal (medial) rotation: turning the joint inward
• Decorticate: flexion and internal rotation of the upper-extremity joints & legs
• Decerebrate: extension of all limbs with upper limbs maintaining a stiffly flexed position
• Strength grading uses a scale from 0-5
  • 0: no movement
  • 1: flicker of contraction
  • 2: movement without gravity
  • 3: movement against gravity
  • 4: movement against some resistance
  • 5: full strength
• Expected findings for the Head & Neck: equal movement of head, jaw, and face, full ROM without pain, neck muscle symmetry, no masses/deformities; may have SOME jaw clicking (TMJ
• Unexpected findings for the Head & Neck: any muscle asymmetry, pain, muscle spasms with palpation, atrophic/hypertrophic tone
• Expected findings for the Spine: equal movement, extremity length, steady gait, alignment, full ROM w/out pain, curve of spine (lateral view), full, firm equal tone & strength, no pain, symmetrical muscles
• Unexpected findings for the Spine: masses, deformities, asymmetry, pain, unsteady gait, joint warmth (inflammation), abnormal spinal curvature (kyphosis, lordosis, scoliosis)
• Expected findings for Shoulders/Upper Extremities: symmetry in control and height, equal firmness, fullness; dominant arm may be larger/stronger
• Unexpected findings for Shoulders/Upper Extremities: erythema, atrophy, deformities, swelling, heat, tenderness
• Expected findings for Hips/Lower Extremities: steady gait, smooth, even, stable & symmetrical without pain
• Unexpected findings for Hips/Lower Extremities: asymmetry, erythema, swelling, deformities, pain, tenderness, crepitus
• Expected findings for ROM: jaw, cervical, spine, upper & lower extremities; Crepitus WITHOUT pain or limitations can be normal (knees), Full ROM, Active v. Passive ROM
  • Active ROM: client moves unassisted
  • Passive ROM: nurse moves muscles for client
• Unexpected findings for ROM: PAINFUL crepitus, limited movement, joint deformity, unsymmetrical ROM, hesitancy resistance to movement of joint
• Age-related changes with musculoskeletal: decline in speed/strength/resistance to fatigue/reaction and coordination, increased risk for falls, decreased bone density/muscle mass/flexibility/ROM, and increased risk for osteoarthritis/osteoporosis
• Health promotion strategies related MS: ergonomics, injury prevention, exercise (helps endurance, ROM, balance), good nutrition, supplementations, sunlight
• Abnormal musculoskeletal findings: kyphosis (excessive forward curvature of thoracic spine - hunchback), lordosis (inward curvature of lumbar spine - sway back), scoliosis (lateral curvature of the spine), and crepitus (audible/palpable crunching produced by air in SUBQ tissue)

Safety (Topics for Questions)

• Nurse responsibilities for patient safety include ensuring a safe environment, administering medications properly, following facility protocols, practicing proper hand hygiene, and communicating with other healthcare professionals
• Delegation procedures: transfer of task performance to another health team member while retaining accountability
  • Delegation Steps:
    • Assess & Plan
    • Communicate
    • Ensure Surveillance and Supervision
    • Evaluate and Give Feedback
  • Five Rights of Delegation:
    • Right Task
    • Right Situation
    • Right Worker
    • Right Direction & Communication
    • Right Teaching, Supervision, and Evaluation
• Factors to Consider: - Education/training - Facility policies - Level of critical thinking required - Demonstration of competence - Scope of practice
  • Error Types:
    • Near miss: potential error, event, or circumstance that could have caused harm but was caught and avoided
    • Patient safety event: unexpected event or circumstance that occurred with/without injury to the patient
    • Sentinel event: critical, unexpected adverse event that caused severe physical or psychological harm to a patient
    • SRE's (serious reportable events) AKA never events: errors in medical care that are clearly identifiable, preventable
• Fall risk require screenings to identify
  • Variables include fall history, medical diagnosis, use of assistive devices, and mental status
  • Morse Fall Scale is reliable and valid, yields predictive scores (low, moderate, or high) for client's risk of falling
  • Risk factors include: age, infants and toddlers, impaired mobility, medications, and medical history such as stroke
• Restraints use types of physical, mechanical, chemical, barrier, and seclusion
  • A provider must renew restraint prescription every 24 hours, and the order must include different points
  • Restraints are a last resort
  • The nurse should remove the restraints and check the client's skin & circulation with each vital sign & at least every 2 hours to monitor client injury
  • With restraints 2 fingers should fit under restraints, use a quick release knot, and tie to bed frame
  • Use restraints if client is exhibiting unnecessary/unwanted movements considered unsafe, attempting to remove medical items, and can provide safety & security for a client undergoing a procedure
  • Nurse Interventions: frequent circulatory, respiratory, and skin checks to ensure device is not too tight & decreases the blood & airflow around the area, must be removed during assessments
  • Must document behavior before, after and during restraint, alternative measures taken to avoid restraints! must include all related nursing care

Age-Related Safety Concerns

• Age-related safety concerns (home and clinical setting)
  • Safety risks: missing smoke detectors, throw rugs
  • Do not secure extension cords under rug, leave appliances plugged in when not in use, set water heaters to above 120°
  • Infants & Preschoolers (0-4 years): prone to burn injuries, accidental poisoning & choking, drowning, and car safety
  • School-Age Children (5-12 years): vehicle safety, participation in sports, water/firearm safety, and internet use
  • Adolescents (13-19 years): water/fire/sports/firearms & vehicles, bullying, intimate-partner violence, suicide risk, risk-taking behavior
  • Adults (19 & Older): risks from stress, poor coping, alcohol, smoking, mental disorders, obesity, occupational hazards
  • Joint Commission Patient Safety Goals:
    • Hospital: two patient identifiers, improve staff communication, medication safety, alarm safety, infection prevention, patient safety risk (reduce suicide)
      • Home: medication safety, infection prevention, fall prevention, and identify safety risk
  • Fire safety (RACE and PASS)
    • RACE: rescue & remove clients, activate the alarm, confine the fire, extinguish the fire
      • PASS: pull, aim, squeeze, sweep
  • Seizure safety:
    • Move objects away from the client
      • Place client on their side (laterally) to prevent aspiration

Functional Ability

• ADL's (Basic): personal care & mobility, eating, dressing, bathing, brushing teeth
• Instrumental: complex skills essential to living in a community: paying electric bill, cooking, grocery shopping, laundry, accessing transportation

Scope of Functional Ability

• Factors: psychological, social, cultural, economical, physical
  • Ask questions related to: relationships/support, values/beliefs/spirituality, self-esteem, impairments, personal habits, environment/occupational hazards, mental health
• Tools:
  • MOCA: assess patients for MILD cognitive dysfunction
  • MMSE: assess cognitive impairment within older adults, hospitalized, institutionalized, & community
  • TUG: assess MOBILITY, balance & fall risk Katz: Assess patient's ability to perform ADLS

Morse Fall Risk Assessment

• A patient's likelihood of falling
  • History of falling, ambulatory aid used, gait, mental status, use of IV/heparin lock
  • Fall risk is no risk: 0-24, risk: 25-50 and high risk: >51
  • Risk recognition: essential for early ID of functional deficits, linked to health outcomes
  • Conditions that increase risk for functional impairment include: abnormalities and trauma

Assessment approaches

• Comprehensive functional assessment is time sensitive; is interprofessional effort -Indications - Children with delayed developmental milestones - Adults with loss of functional ability
  • Approaches
    • Self reporting tools
    • Theory

Health Assessment (Neurologic/HEENT)

• Techniques/tools:
  • Inspect head, noting the position, size, shape, contour
  • Palpate the temporomandibular joint space bilaterally and neck

Expected vs unexpected findings

• Head: symmetry/slight asymmetry
• Symmetry/slight asymmetry, aging (thinning, drying hair)
• Significant asymmetry (paralysis of cranial nerve, stroke), lumps
• Eyes: external structure position, brows - Protrusions, sunken appearance, exophthalmos

Functional Ability

Teachings

• Meaningful Measurement
  • EHR documentation: Communication tool for the interprofessional healthcare team
    • Meaningul Nursing Intervention; Reduce risk and screen frequently.