2024 NUR155 Comprehensive Practice Exam With Answers (646 Solved Questions)

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NUR 155 Exam 1 - 4 2024 Full and Revised Study Guide WithSatisfied SolutionsPsychological - The internal variable dimension that includes mind-body interactions likeemotional responses to stress that affect body function. Self- Concept is another one.Cognitive - The internal variable that includes lifestyle, which refers to general way of livingfor a person like their living conditions and patterns of behavior, which can be positive ornegative.Spiritual and religious beliefs like that Jehovah Witnesses oppose blood transfusions.External variables - Variables Influencing Health Status, Beliefs, and Practices:The type of variable that includes physical environment, standards of living, family andCultural Beliefs, and social support networks.Physical environment - External Variables/health Status, Beliefs, and Practices:Radiation, chemicals used to control weeds and plant diseases, the greenhouse effect, x-ray,acid rain, ect...Standards of living - External Variables/health Status, Beliefs, and Practices:Occupation, income, and education, hygiene, food habits, and ability to seek healthcareadvice.Family and cultural beliefs - External Variables/health Status, Beliefs, and Practices:Family passes on patterns of daily living and lifestyle to offspring. Once abused as a childman might grow up and abuse his own children.Social support networks - External Variables/health Status, Beliefs, and Practices:

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Having support from family, friends, or confidant along with job satisfaction helps peopleavoid illness.Acute Illness - Characterized by severe symptoms of relatively short duration.Symptoms appear abruptly and subside quicklyMay or may not require health care intervention- ex. appendicitis requires surgicalintervention, but colds subside without medical intervention or with help of over the countermeds.Chronic Illness - Lasts for extended periods of time 6 months or longer and often forpersons entire life.Has slow onsetPeriods of "remission" and "exacerbation"Ex: heart and lung disease, diabetes mellitus.Effects of illness - Privacy, Autonomy, Financial Burden, Changes in lifestyles.Impact on the client - Effects of Illness: Who is impacted based on the information below?Behavioral and emotional changesSelf concept and body image changesLifestyle changesImpact on the Family - Effects of Illness: Who is impacted based on the information below?Depends On: Member of the family who is illSeriousness and length of the illnessCultural and social customs the family followsUsing silence - Therapeutic Communication Techniques:

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Accepting pauses or sliences that may extend for several seconds or minutes withoutinterjecting any verbal responseProviding general leads - Therapeutic Communication Techniques:Using statements or questions that...* encourage the client to verbalize* choose a topic of conversation* and facilitate continued verbalizationBeing specific and tentative - Therapeutic Communication Techniques:Making statements that are specific rather than general, and tentative rather than absoluteusing open-ended questions - Therapeutic Communication Techniques:Asking broad questions that lead or invite the client to explore (elaborate, clarify, describe,compare or illustrate) thoughts or feelings; invite answers that are longer than one or twowordsusing touch - Therapeutic Communication Techniques:Providing appropriate forms of touch to reinforce caring feelings; be sensitive todifferences in attitudes and practices of clients and selfrestating or paraphrasing - Therapeutic Communication Techniques:Actively listening for the client's basic message then repeating those thoughts and/orfeelings in similar wordsseeing clarification - Therapeutic Communication Techniques:A method of making the client's broad overall meaning of the message more understandable;to clarify the message or confess confusionperception checking or seeking consensual validation - Therapeutic CommunicationTechniques:A method similar to clarifying that verifies the meaning of specific words rather than theoverall meaning of a message

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offering self - Therapeutic Communication Techniques:Suggesting one's presence, interest, or wish to understand the client without making anydemands or attaching conditionsgiving information - Therapeutic Communication Techniques:Providing in simple terms and direct manner, specific, factual information the client may ormay not requestacknowledging - Therapeutic Communication Techniques:Giving recognition, in a nonjudgmental way, of a change in behavior, an effort the client hasmade, or a contribution to a communicationclarifying time or sequence - Therapeutic Communication Techniques:Helping the client clarify an event, situation, or happening in relationship to timepresenting reality - Therapeutic Communication Techniques:Helping the client to differentiate the real from the unrealfocusing - Therapeutic Communication Techniques:Helping the client expand on and develop a topic of importancereflecting - Therapeutic Communication Techniques:Directing ideas, feelings, questions, or content back to clients to enable them to exploretheir own ideas and feelings about a situationsummarizing and planning - Therapeutic Communication Techniques:Stating the main points of a discussion to clarify the relevant points discussedstereotyping - Barriers to Communication:Offering generalized and oversimplified beliefs about groups of people that are based onexperiences too limited to be validagreeing and disagreeing - Barriers to Communication:Implies that the client is either right or wrong and that the nurse is in a position to judge this

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being defensive - Barriers to Communication:Attempting to protect a person or health care services from negative commentschallenging - Barriers to Communication:Giving a response that makes clients prove their statement or point of viewprobing - Barriers to Communication:Asking for more information chiefly out of curiosity rather than with the intent to assist theclienttesting - Barriers to Communication:Asking questions that make the client admit to somethingrejecting - Barriers to Communication:Refusing to discuss certain topics with the clientchanging topics and subjects - Barriers to Communication:Directing the communication into areas of self interest rather than considering the client'sconcerns is often a self-protective response to a topic that causes anxietyunwarranted reassurance - Barriers to Communication:Using cliches or comforting statements of advice as a means to reassure the clientpassing judgment - Barriers to Communication:Giving opinions and approving or disapproving responses, moralizing, or implying one's ownvaluesgiving common advice - Barriers to Communication:Telling the client what to doSBAR - S - situationB - backgroundA - assessment

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R - recommendationCommunication - -Any means of exchanging information or feelings-Consists of verbal and nonverbal messagesPace and intonation - Verbal Communication:The manner of speech, as in the rate or rhythm and tone.Simplicity - Verbal Communication:The use of commonly understood wordsClarity and brevity - Verbal Communication:A message that is direct and simple, saying precisely what is meant, and using the fewestwords necessaryTiming & relevance - Verbal Communication:Needs to be appropriate to ensure that words are heard and needs to relate to the personor the person's interest or concernsAdaptability - Verbal Communication:What is said and how it is said needs to be individualized and carefully consideredCredibility - Verbal Communication:Worthiness of belief, trustworthiness, and reliabilityHumor - Verbal Communication:Can be a positive and powerful tool but must be used with careBody Language - Another name for nonverbal communication; includes gestures, bodymovements, use of touch, and physical appearance (including adornment).Personal appearance - Factors of nonverbal communication:Clothing and adornments can be sources of information about a person.

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Posture and gait - Factors of nonverbal communicationThe way people walk and carry themselves is often a reliable indicator of self-concept,current mood, and health.Facial expression - Factors of nonverbal communication:How the face expresses emotion.Gestures - Factors of nonverbal communication:Hand and body movements may emphasize and clarify the spoken word, may also occurwithout words.Therapeutic communication - Communication that promotes understanding and can helpestablish a constructive relationship between the nurse and the clientattentive listening - Therapeutic communication:Listening actively with all the senses as apposed to listening with just the ear; requiresenergy and concentration5 actions of physical attending - Therapeutic communication:1. face the person squarely2. adopt an open posture3. lean toward the person4. maintain good eye contact5. try to be relatively relaxedSituationBackgroundAssessmentRecommendation - Often used in a Telephone Report.SBAR stands for?120/80 - What is a normal Blood pressure (BP) reading in a healthy adult?60-100 - What is a normal Pulse range for a healthy adult?

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12-20 - What is a normal range in a healthy adult for respiration?96.8-98.6 - What is a normal range in a healthy adult for temperature?Oralrectalaxillaryearforehead - What are the 5 locations that temperature can be measured in an adult?Axillary (Armpit) & Tympanic (Ear) - What are 2 preferred methods/locations for taking aninfant's temperature?Tympanic (Ear), Temporal (Forehead/temporal artery), Oral (mouth), & Rectal. - What are 4preferred methods/locations for taking a Child's (>3 years) temperature?Rectal - What is the least desirable methods/locations for taking an infant's temperature?ApicalBrachialRadialFemoralPoplitealPosterior TibialDorsal Pedis - Visualizing the body in the anatomical position, starting at the head and endingat the feet, list all 9 of the pulse locations. (Arms start after the "chest" pulse and feet startposterior)TemporalCarotid - What are the pulse sites on the head and neck?Apical - What is the pulse site on the torso?

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BrachialRadial - What are the pulse sites on the arm?FemoralPoplitealPosterior TibialDorsal Pedis - What are the pulse sites of the leg?Femoral - Pulse sites:Used in cases of cardiac arrest/shockUsed to determine circulation of the legPopliteal - Pulse sites:Used to determine circulation of the lower legPosterior Tibial - Pulse sites:Used to determine circulation of the foot (Back)Dorsal Pedis - Pulse sites:Used to determine circulation of the foot (Top of foot)Brachial - Pulse sites:Used to measure BPUsed during cardiac arrest for infantsRadial - Pulse sites:Readily accessibleApical - Pulse sites:Routinely used for infants and children up to 3 years of ageUsed to determine discrepancies with radial pulseTemporal - Pulse sites:Used when radial pulse is not accessible

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Carotid - Pulse sites:Used during cardiac arrest / shock in adultsUsed to determine circulation in the brainDecreases(In contrast when blood volume increases (for example, as a result of a rapid IV infusion),the BP increases.) - When blood volume decreases (For example, as a result of dehydration),what happens to blood pressure?Upper arm (using the brachial artery) - In what location is the BP usually assessed?Thigh (femoral Artery) - If the BP cannot be assessed in either arm, what is the next locationis indicated to use?Tachypnea - Breathing Patterns: RateQuick, Shallow breathsBradypnea - Breathing Patterns: RateAbnormally slow breathsApnea - Breathing Patterns: RateCessation of breathingHyperventilation - Breathing Patterns: VolumeOverexpansion of the lungs characterized by rapid deep breaths.Hypoventilation - Breathing Patterns: VolumeUnderexpansion of the lungs, characterized by shallow respiration.Cheyne-stokes-breathing - Breathing Patterns: RythmRhythmic waxing and waning of respirations, from very deep to very shallow breathing andtemporary apnea.

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Dyspnea - Breathing Patterns: Ease or effortDifficult and labored breathing during which the individual has persistent, unsatisfied needfor air and feels distressed.Orthopnea - Breathing Patterns: Ease or effortAbility to breathe only in upright sitting or standing positions.Crackles - Breath Sounds:Rales, fine, short, interrupted crackling sounds, air passing through fluid or mucus.Gurgles - Breath Sounds:Rhonchi, continuous, low pitched, coarse, gurgling, harsh, louder sounds, with moaning orsnoring quality, air passing through narrowed air passages as a result of secretions,swelling.Wheeze - Breath Sounds:Continuous, high pitched, squeaky, best heard on expiration, air passing through constrictedbronchus.Stridor - Breath Sounds:Life threatening, typically caused by an obstructionOrientation - Neurologic check:This aspect of the assessment determines the client's ability to recognize other persons(Person), awareness of when and where they presently are (time and Place), and who they,themselves are (self).Neurologic check - Performed at regular intervals on patients whohave had a head injury or brain surgeryPupils equally round and react to light and accommodation - Neurologic check:PERRLA

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LOC (Level of consciousness) - Neurologic check:The Glasgow comma scale is used to asses this.Glasgow comma scale - Neurologic check:Tests 3 major areas: Eye response, Motor response, and verbal response.2 - Restraints must be taken off every __ hours and ROM should be tested and documented.C (Droplet)(Rationale: Droplet precautions involve use of mask to prevent passing to others.)(A. AIRBORNE precautions require an isolation room, and the client is not allowed outside theroom.)(B. CONTACT precautions involve gown and glove for direct client contact. This client wouldnot be out of the room.)(D. STANDARD precaution is the global term for all types of precautions.) - A hospitalizedclient is in a private room. When outside the room, the client must wear a surgical mask.What type of isolation precaution is in use?A. AirborneB. ContactC. DropletD. StandardA (Vascular and cellular response)(Rationale: Hyperemia indicates a marked increase in blood supply, and is the first stage ofthe inflammatory response. The vascular and cellular response is the first stage.)(B. EXUDATE PRODUCTION is the second stage.)(C. REPARITIVE PHASE is the third stage.)

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(D. MARGINATION is part of the first stage.) - The nurse notes hyperemia when evaluating theincision of a client. The nurse knows that this indicates what stage in the inflammatoryresponse?A. Vascular and cellular responseB. Exudate productionC. Reparative phaseD. MarginationA, B, C (Escherichia coli, Entercocci, Staphylcoccus aureus) - What are the most commoninfecting microorganisms in nosocomial infections? (Select all that apply.)A. Escherichia coliB. EnterococciC. Staphylcoccus aureusD. SerratiaAsepsis - The freedom from disease-causing microorganisms.Medical Asepsis (Clean Technique) - All practices intended to confine a specificmicroorganism to a specific area, limiting the number, growth, and spread ofmicroorganisms.Surgical Asepsis (Sterile Technique) - All practices the keep an area or object free of ALLmicroorganisms.Sepsis - The presence of pathogenic organisms or their toxins in the body or body tissues.HAI's (Healthcare Associated Infections) - Infections that originate in any health caresetting.Nosocomial Infections - Infections that originate in the hospital.(A subgroup of HAI's)

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Endogenous - The term used to describe the SOURCE of microorganisms that causenosocomial infections thst originate from the CLIENT themselves.Exogenous - The term used to describe the SOURCE of microorganisms that causenosocomial infections can originate from the hospital environment or hospital personnel.A (Through hand hygiene)(Rationale: Since the hands are frequently in contact with clients and equipment, they arethe most obvious source of transmission. Regular and routine hand hygiene is the mosteffective way to prevent movement of potentially infective materials.)(B. PPE (gloves and masks) is indicated for situations requiring standard precautions.)(C. ISOLATION PRECAUTIONS are used for clients with known communicable diseases.)(D. Routine use of antibiotics is not effective and can be harmful due to the incidence ofsuperinfection and development of resistant organisms.) - Which is the most effectivenursing action for controlling the spread of infection?A. Through hand hygieneB. Wearing gloves and masks when providing direct client careC. Implementing appropriate isolation precautionsD. Administering broad-spectrum prophylactic antibioticsC (Follow standard precautions in all interactions with the client.)(Rationale: Standard precautions include all aspects of contact precautions with theexception of placing the client in a private room.)(A .A mask is indicated when working over a sterile wound rather than an infected one.)(B. Disposable food trays are not necessary for clients with infected wounds unlikely tocontaminate the client's hands.)(D. Sterile technique (surgical asepsis) is not indicated for all contact with the client.)

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(The nurse would utilize clean technique when dressing the wound to prevent introduction ofadditional microbes.) - In caring for a client on contact precautions for a draining infectedfoot ulcer, which action should the nurse perform?A. Wear a mask during dressing changes.B. Provide disposable meal trays and silverware.C. Follow standard precautions in all interactions with the client.D. Use surgical aseptic technique for all direct contact with the client.A (Goggles)(Rationale: Unless overly contaminated by material that has splashed in the nurse's face andcannot be effectively rinsed off, goggles may be worn repeatedly)(B. Since gowns are at high risk for contamination, they should be used only once and thendiscarded or washed.)(C. Surgical masks and Option D gloves are never washed or reused.) - When caring for asingle client during one shift, it is appropriate for the nurse to reuse only which of thefollowing personal protective equipment?A. GogglesB. GownC. Surgical maskD. Clean glovesEtiologic Agent - The extent to which any microorganism is capable of producing aninfectious process depends on the number of microorganisms present, the virulence andpotency of the microorganisms (pathogenicity), the ability to enter the body, and thesusceptibility of the host.Reservoir - Where the microorganism lives, common sources are other humans.Carrier - A person or animal reservoir of a specific infectious agent that usually does notmanifest any clinical signs of disease.

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