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NURS 332 Fundamental Nursing Concepts
EXAM 2 2025 LATEST COMPLETE FULL
LEGTH EXAM WITH ANSWERS GRADED A+
A patient suffers from sleep pattern disturbance. To promote adequate sleep, the most important nursing intervention is: A. administering a sleep aid. B. synchronizing the medication, treatment, and vital signs schedule. C. encouraging the patient to exercise immediately before sleep. D. discussing with the patient the benefits of beginning a long-term nighttime medication regimen. CORRECT ANSWER >B The nursing assistant asks you the difference between a wound that heals by primary or secondary intention. You will reply that a wound heals by primary intention when the skin edges: A. Are approximated. B. Migrate across the incision.
C. Appear slightly pink. D. Slightly overlap each other. CORRECT ANSWER >A •A postoperative patient arrives at an ambulatory care center and states, "I am not feeling good." Upon assessment, you note an elevated temperature. An indication that the wound is infected would be: •A. It has no odor. •B. A culture is negative. •C. The edges reveal the presence of fluid. •D. It shows purulent drainage coming from the incision site. CORRECT ANSWER >D The body's fluid and electrolyte balance is maintained partially by hormonal regulation. Which of the following statements shows an understanding of this mechanism? A. "The pituitary secretes aldosterone." B. "The kidneys secrete antidiuretic hormone." C. "The adrenal cortex secretes antidiuretic hormone."
- Central nervous system controls the sequence of physiological states
- Reticular Activating system control allergic and wakefulness Sleep Cycle: Stage 1 NREM
- last a few min
- lightest level of sleep
- gradual fall in vital signs and metabolic signs
- easily aroused by noise
- if awakened, feel as you've been daydreaming Sleep Cycle: Stage 2 NREM
- lasts 10-20 min
- sound sleep and relaxation progresses
- body functions continue to slow
- easily aroused
Sleep Cycle: Stage 3/ NREM
- lasts 15-30 min
- deep sleep, muscles completely relaxed
- Difficult to arouse
- Decreased vitals, but normal sleepwalking or enuresis may occur Sleep Cycle: REM
- Begins around 90 minutes after sleep has occurred
- Duration increases with each cycle
- vivid dreams
- very difficult to arouse sleepers A 4-year-old pediatric patient resists going to sleep. To assist this patient, the best action to take would be: A. adding a daytime nap. B. allowing the child to sleep longer in the morning. C. maintaining the child's home sleep routine. D. offering the child a bedtime snack.
Hypersomnias Sleep disturbance that result in excessive sleepiness not cause by alterations in Circadian Rhythms Parasomnias Undesirable behaviors that occur during sleep, more common in children (E.g. sleepwalking, night tremors, bed-wetting, body rocking, tooth grinding etc. ) Insomnia Difficulty falling asleep, most common Sleep Apnea The lack of airflow Through the nose and mouth for 10 seconds or longer
- obstructive sleep apnea (OSA) more common
- central sleep apnea (CSA)
- mixed Obstructive sleep apnea (OSA) Upper airway becomes partially or completely blocked, diminishing airflow for 30 seconds Central Sleep Apnea Breathing fails temporarily; nasal airflow and chest wall movement cease might report insomnia due to waking up often Narcolepsy/Sleepiness When a wave of sleepiness hits you during the day Sleep Deprivation can be cause by... Emotional stress, medications, environmental disturbances
Tissue Tolerance What factors contributing to pressure ulcer formation?
- impaired sensory perception
- impaired mobility
- alteration in LOC
- shear & friction
- moisture
- poor nutrition Pressure Ulcer Stage 1
- intact skin
- nonblanchable redness Pressure Ulcers Stage 2
- partial thickness skin loss (involving epidermis and dermis)
- without slough
Pressure Ulcers Stage 3
- full thickness tissue lost with visible fat
- slough may be present Pressure Ulcers Stage 4
- full thickness tissue loss with exposed bone, muscle, or tendon
- slough or eschar may be present Partial thickness wounds heal by... Regeneration (epidermis regenerates) Full thickness wounds heal by... Forming new tissue and takes longer to heal (Ex: Pressure Ulcer) Primary Intention Wounds
- Edges are approximated or closed (sutures)
- 12 or less high risk Assessing Wounds
- Assess bony prominences for signs of breakdown and/or ulcer development
- Assess any risk factors for pressure ulcers
- Nutritional status, body fluids exposure, mobility, and pain
- Assess appearance, any drainage (COCA), or any drains
- Assess wound closures, palpate wound, wound cultures
- Continually assess the skin for signs of skin breakdown and/or ulcer development Drainage Assessment (COCA) C-color O-odor C-consistency A-amount Drainage color types
- Serous: clear, watery plasma
- Sanguineous: brights red indicating active bleeding
- Serosanguineous: pale, pink watery; a mix of clear and red fluid
- Purulent: yellow, green, tan or brown Planning Interventions according to..... (Wound Care)
- Risk for pressure ulcers
- Type and severity of the wound
- Presence of compl;citations (infection, nutrition, etc.)
- Set priorities to prevent pressure ulcers and promote wound healing
- Teamwork and collaboration Nursing Interventions for Health Promotion on Wounds
- Prevention of pressure ulcers
- Topical skin care
- Incontinence management
- Positioning
- Support Devices
- Hydrocolloid: facilitate autolytic debridement (removal of necrotic tissue)
- Hydrogel: gauze impregnated with water or glycerin-based gel to hold moisture
- Foam: wounds with large amount of exudate that needs packing
- Composite: combination of two dressing types in one Packing a wound
- Negative-pressure wound therapy (vacuum) facilitates healing and collects wound fluid
- over packing causes pressure Debridement The removal of no viable, necrotic tissue, enables healing and gets rid of source of infection. Three types:
- Autolytic Debridement
- Chemical Debridement
- Surgical Debridement
Autolytic Debridement use of synthetic dressings to allow self-digestion of eschar Chemicals Debridement topical enzymes that breakdown necrotic tissue E.g. Dakins Solution Surgical Debridement removal by a scalpel, scissors, etc How does a moist environment contribute to wound healing? A moisture environment supports the movement of epithelial cells and facilitates wound closure Ex: The use of a Transparent Film and Hydrogel Heat and Cold Therapy
- effects of heat application improve blood flow
Hypotonic Solution Osmolality is less than body fluids, thus diluting body fluids; water is brought into the cells Hypertonic Solution Osmolality is greater than body fluids; water gets pulled out of cell causing them to shrivel Intravenous Therapy
- Giving fluids through a needle or catheter inserted into a vein
- It corrects/prevents fluid & electrolyte disturbances Vascular Access Devices (VAD) catheters or infusion ports designed for repeated access to the vascular system When to discontinue IV access?
- after prescribed amount of fluid has been given
- when infiltration occurs
- when phlebitis occurs
- when an infection occurs
- If IV catheter develops a thrombus at its tip Hormonal Influences on fluids
- antidiuretic hormone
- renin-angiotensin-aldosterone mechanism
- atrial natriuretic peptides When administering blood transfusions...
- prime tubing with 0.9% NaCl and use a filter to remove clots and discard tubing after use
- check blood product against prescribers order
- check blood product against patient identifiers
- monitors for any adverse reactions Extracellular Volume (ECV) Defecit means... Insufficient Isotonic Fluid
