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Nursing exam three


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What is documentation of what has been taught and what needs to be taught for self- care?
discharge plans
This is represented by a change in behavior. desire or requirement to know something that is presently unknown and knowledge or skill, physical ability, or behavior must occur for this to take place?
What three people had learning theories based on behavior?
These included positive reinforcement, modeling, and imitation. Utilization: identification of what is being taught, immediate practice and role models
Pavlov, Skinner, and Bandura
What three people had learning theories based on cognitivism?
These include thinking process, teacher/learner relationship, must look at cognitive stage, Domains: psychomotor, affective, cognitive. Utilization: Learner's developmental stage, multise
Piaget, Lewin, and Bloom
What two people had a Humanism learning theory: cognitive and affective qualities of learner, relevant to learner. Utilization: focus on feelings and attitudes, self- motivation, resource person, mentor, nurse/patient relationship.
Maslow, Rogers
Always involve the patient in the planning of how they are going to be taught and prioritize what needs to be taught first.
No answer
Learning outcomes are _____ or measurable.
What is the ability to move freely, easily, rhythmically, and purposefully in the environment?
Enery plus mobility are vital for _______.
What kind of ROM are initiated by the person?
What kind of ROM are initiated by a person other than the patient?
In this type of exercise the muscles shorten to produce muscle contraction and active movement; like with running, walking, swimming, cycling, and ADL's. Active ROM. This exercise increases muscle tone, mass, and strength, maintains joint flexibility and
This exercise is change in muscle tension, no change in muscle length, no muscle movement or joint movement.
examples: Quadriceps
leg extensions from sitting position, tensing thigh muscle, and pressing knee against bed
This type of exercise involves muscle contraction or tension against resistence; person moves (isotonic) or tenses (isometric) against resistence. Example would be weight lifting.
This is an activity during which the amount of oxygen taken in the body is greather than that used to perform the activity. Uses large muscle groups in a rhythmic nature, and improves cardiovascular conditioning.
Aerobic exercise
This is an activity in which the muscle cannot draw out enough oxygen from the bloodstream, additional energy for a short time, such as endurance training for atheletes.
Anaerobic exercise
Complete bed rest is essential in the healing process why?
Reduces the need for oxygen and the oxygen goes toward the healing process
_____ is the lack of movement or the state of not being able to move. It affects multi- systems.
_____ of altered mobility. Decreased muscle strength and tone, lack of coordination, altered gait (ataxic staggering undsteady, waddle duck like, hemiplegic- one leg paralyzed, festinating walking on toes); falls; decreased joint flexibility; and pain on
What is anklosed?
It is when the joint is permanently immobile.
Three factors contribute to ____: Impaired venous return of blood to heart (positioning, edema); injury to vessel wall (blood gets caught and clots); and hypercoagulability (dehydration-blood viscosity to increase and elevated serum calcium levels- seen
Respiratory related to immobility
-Decreased lung span
Decreased vital capacity
Decreased inflation of lungs
restricted movement
pooling of secretions
hypostatic _______
atelectasis (collapsed lung)
Nutrition/metabolic rate with immobility
Decreased metabolic rate- basal metabolic rate decreases
Alters drug metabolism
Weight loss R/t loss of muscle mass and diuresis
Negative Nitrogen Balance- Depletion of ______ stored and elevat
What is the loss of appetite R/T decreased metabolic rate=decreased caloric needs which results in decreased energy and malnutrion.
Disuse ______- Bone demineralization secondary to immobility
Immobility leads to ____ sores (decubitus), which are pressure induced sores because of decreased blood supply to tissue resulting in decreased nutrients, O2, waste removal decreased, cells die=necrotic.
Pressure is greater in teh supin position- Ba
Immobility leads to urinary ____
Decreased urge to void in supin position, inconvenient for the staff/bother, cannot void lying down, delayed micturition (urine pools in the bladder, overstretching of the bladder muscle which results in permanent ch
Urinary retention from immobility
_____ r/t stagnant urine
Renal Caliculi (kidney stones)
Urinary stasis increases serum calcium levels from the loss of calcium from the bones
Urinary calcium can precipitate to for crystals that may
___________ from immobility
Abdominal and perineal muscles weaken causing decreased ability to bear down and exert pressure to pass stool.
Decreased peristalsis causing hardening of stool, dehydration
Impaction because of decreased activit
Immobility interfers with normal sleep patterns
Lack of fatigue
Increase _____
Awaken by frequent turning
Unfamiliar noisy environment
_____ decreases freedom to socialize
Preoccupation with somatic complaints
Decreased ability to recognize and respond to pain r/t prolonged pressure.
Feelings of powerlessness
Dependence on others
Embarrassment r/t devices such as crutches, walker, cane, and wheelchair
no answer
Roles/relationships with immobility
Disruption of school and social activities
Inability to work
Disruption of parental or spousal activities, care of children/parents
no answer
coping/stress with immobility
not a desired function ability
trauma- permanent
many hours alone
bored and lonely
depression, anxiety, anger- withdrawl and demanding
no answer
Sexuality with immobility
Limited mobility
lack of privacy
impede grooming- sexual identity
What is a fiberoptic examination of abnormalities in the knees, hips, joints, and elbows?

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