Fundamentals Of Nursing III- Www.Rnpedia.Com

The given chart entries provide information about a patient's vital signs, symptoms, and behavior. The entries mention that the patient has complained of chest pain, is able to ambulate without assistance, and has a blood pressure of 120/80. However, the entry "Seems agitated" is not a vital sign or symptom and does not provide any concrete information about the patient's condition. Therefore, this entry is not correct.

The coronary vessels, which supply blood to the heart muscle, respond to sympathetic stimulation by vasodilatation. This means that when the sympathetic nervous system is activated, the coronary vessels widen or relax, allowing more blood to flow through them. This increased blood flow helps to meet the increased oxygen demand of the heart during times of stress or exercise. Vasodilatation of the coronary vessels ensures that the heart receives an adequate supply of oxygen and nutrients to function properly.

Nurse Aida's belief that Roger is worthwhile simply because he is a human being demonstrates her positive regard for him. Positive regard is a major ingredient in therapeutic communication, as it involves showing respect, acceptance, and non-judgment towards the patient. Despite the incident that may have occurred, Nurse Aida's positive regard allows her to maintain a compassionate and non-discriminatory approach towards Roger, which can enhance the therapeutic relationship and promote effective communication.

Anxiety is a psychological condition that is characterized by feelings of fear, unease, and worry. It is often accompanied by physical symptoms such as increased heart rate, sweating, and trembling. The statement "The source of dread or uneasiness is from a recognized entity" is not true with regards to anxiety. In many cases, individuals with anxiety may experience feelings of dread or uneasiness without being able to identify a specific cause or trigger. This can make it difficult to address and manage their anxiety effectively.

Kenneth is experiencing both spiritual anxiety and spiritual guilt. He feels that he has not met God's expectations and fears punishment from God due to his illness, which indicates spiritual guilt. Additionally, his fear of God not being supportive during his illness demonstrates spiritual anxiety.

The term "Od" is an abbreviation for "Once a day." In this context, it indicates the frequency at which the physician has prescribed Maxitrol, which is to be taken once a day.

The last expected process in the stages of inflammation is the loss of normal function in the affected part. This occurs as a result of the inflammation process, which includes the release of inflammatory mediators and the recruitment of immune cells to the site of injury or infection. The loss of normal function can be due to pain, swelling, or impaired movement in the affected area.

Milieu Therapy is the best intervention when the client has just experienced a crisis and is still in the first phase. Milieu Therapy focuses on creating a therapeutic environment that promotes healing and recovery. It involves providing a safe and supportive space for the client, with structured activities and routines that help them regain a sense of stability and control. This intervention can help the client feel secure, reduce anxiety, and prevent further escalation of the crisis.

After tissue injury, the initial response is immediate vasoconstriction. This is a protective mechanism that helps to reduce blood flow to the injured area, preventing excessive bleeding and the spread of toxins. Vasoconstriction also helps to limit tissue damage and inflammation. This response is followed by vasodilation, which increases blood flow to the injured area, facilitating the delivery of oxygen and nutrients for tissue repair. However, the immediate vasoconstriction is the first response that occurs after tissue injury.

Eosinophils are a type of white blood cell that is involved in the immune response against parasitic infections and allergic reactions. In cases of anaphylaxis, which is a severe allergic reaction, there is a release of histamine and other chemicals that trigger an immune response. Eosinophils are known to increase in number during allergic reactions, including anaphylaxis, as they play a role in combating the allergic response. Therefore, eosinophils proliferate in cases of anaphylaxis.

Third intention healing, also known as delayed primary closure, occurs when there is a delayed surgical closure of an infected wound. In this type of healing, the wound is initially left open to allow for drainage and removal of infected material. Once the infection has been controlled, the wound is then surgically closed. This method is typically used when the wound is contaminated or infected and cannot be immediately closed without an increased risk of complications. It allows for the wound to heal from the inside out, reducing the risk of infection and promoting better healing.

Inflammation can cause pain due to the compression of local nerve endings by the edema fluids. Edema refers to the accumulation of fluid in the affected area, which can lead to swelling and increased pressure on the surrounding tissues, including the nerve endings. This compression stimulates the nerves and triggers pain signals to be sent to the brain, resulting in the sensation of pain.

Putting the vital information about the client's allergy to Iodine based dye at the front metal plate of the chart ensures that it is easily visible and accessible to all healthcare providers. This placement allows for quick identification of the allergy and helps prevent any potential administration of Iodine based dye, which could lead to an allergic reaction in the client.

Increased awareness of environmental details is an indication of mild anxiety because when a person is anxious, they tend to become hyper-vigilant and overly focused on their surroundings. This heightened awareness can be a result of the individual's attempt to control their anxiety by seeking out potential threats or dangers in their environment. It is a common manifestation of mild anxiety and can be seen as a coping mechanism in response to the upcoming surgery.

Non verbal communication is considered as the most accurate expression of a person's thoughts and feelings because it includes body language, facial expressions, gestures, and tone of voice. These nonverbal cues often convey emotions and attitudes more effectively than words alone. Unlike verbal communication, which can be influenced by factors such as language barriers or misinterpretation, nonverbal communication is often seen as a more reliable indicator of a person's true thoughts and feelings. It can provide valuable insights into someone's emotions, intentions, and overall communication style.

Second intention healing, also known as secondary intention healing, occurs when a wound is left open to heal naturally without surgical closure. In this case, since Miss Imelda suffered massive tissue loss and laceration, it is likely that her wounds will heal through second intention. This type of healing involves the formation of granulation tissue, contraction of the wound edges, and reepithelialization, resulting in the gradual closure of the wound over time.

Restating is the correct answer because Budek is repeating Myra's statement back to her in order to clarify and confirm his understanding of what she said. Restating is a therapeutic communication technique that helps the speaker feel heard and understood, and it also allows the listener to check for accuracy and ensure effective communication.

Luvox is not an anxiolytic because it is primarily used as an antidepressant and is classified as a selective serotonin reuptake inhibitor (SSRI). Anxiolytics are drugs that are specifically designed to reduce anxiety and promote relaxation, whereas Luvox is primarily used to treat obsessive-compulsive disorder (OCD) and other mood disorders. Valium, Ativan, and Milltown, on the other hand, are all benzodiazepines which are commonly prescribed as anxiolytics due to their sedative and calming effects.

The response "Why are you so anxious? Please tell me more about your feelings Erik" is non-therapeutic because it dismisses Erik's concerns and fails to address his fear and pain. It does not show empathy or understanding towards Erik's emotions and does not provide any reassurance or support. It may make Erik feel invalidated and unheard, which is not conducive to a therapeutic relationship.

The best way to communicate the client's penicillin allergy is to notify the attending physician. This is important because the physician needs to be aware of the allergy in order to make informed decisions about the client's treatment plan. Placing an allergy alert in the Kardex, writing it on the patient's chart, and taking note when giving medications are also important steps, but notifying the attending physician should be the first priority to ensure the client's safety.

Lyza uses biofeedback as a relaxation technique. Biofeedback involves using electronic sensors to monitor and provide feedback on physiological functions such as pulse rate, temperature, and muscle tension. By visualizing and assessing this feedback, individuals like Lyza can learn to control and regulate these bodily functions, leading to relaxation and stress reduction. Massage, autogenic training, and visualization and imagery are other relaxation techniques, but they do not involve the use of electronic sensors for feedback like biofeedback does.

POMR stands for Problem-Oriented Medical Record. It is a type of recording that integrates all data about the problem, gathered by members of the health team. In this approach, the patient's medical record is organized around specific problems or issues, and each problem is addressed individually. This allows for a more comprehensive and organized approach to patient care, as all relevant information is grouped together based on the specific problems being addressed.

The correct answer indicates that learning has been achieved because Matuts is taking action and implementing the knowledge that was taught to her. She is actively engaging in behavior change by exercising every morning and eating a balanced diet, which shows that she has understood and internalized the lessons from the mag HL tayo program.

Validation is the most effective communication skill in dealing with covert communication. Covert communication refers to hidden or indirect messages that are not openly expressed. Validation involves acknowledging and accepting the feelings, thoughts, and experiences of the other person without judgment. By validating their covert communication, you create a safe and supportive environment, encouraging them to express themselves openly and honestly. This helps to build trust and improve understanding, leading to effective communication and resolution of any underlying issues.

Nurse Aida should intervene and correct Nurse Irma because her statement shows that she is lacking positive regard. Positive regard refers to the ability to maintain a non-judgmental and accepting attitude towards others, regardless of their mental health condition. Nurse Irma's statement demonstrates a lack of empathy and understanding towards the patient, which goes against the principle of positive regard. By intervening and correcting Nurse Irma, Nurse Aida can promote a more compassionate and respectful approach towards the patient.

The most important characteristic of a nurse-patient relationship is that it is growth facilitating. This means that the relationship between the nurse and the patient is focused on promoting the patient's personal development, well-being, and progress towards their health goals. The nurse supports and encourages the patient's growth by providing education, guidance, and emotional support. This characteristic emphasizes the nurse's role in empowering the patient to take control of their own health and make positive changes in their life.

Monocytes are responsible for phagocytosis in chronic tissue injury. Monocytes are a type of white blood cell that can differentiate into macrophages, which are specialized cells that engulf and digest cellular debris, pathogens, and other foreign substances. In chronic tissue injury, the immune response involves the recruitment of monocytes to the site of injury, where they can phagocytize and remove damaged tissue and pathogens, promoting the healing process. Neutrophils, basophils, and eosinophils are also types of white blood cells, but they have different functions and are not primarily involved in phagocytosis in chronic tissue injury.

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The defense mechanism of restitution refers to the act of making amends or compensating for a perceived wrongdoing or guilt. In this scenario, Legrande is buying his son ice cream and food, which can be seen as a way of making up for any negative feelings or guilt he may have experienced earlier in the day. This behavior is an unconscious defense mechanism aimed at restoring a sense of balance or rectifying a perceived imbalance.

The effects of the sympatho-adreno-medullary response by the client include constipation, hyperglycemia, and increased blood pressure.

Levito Devin is experiencing a maturational crisis. This type of crisis occurs when an individual goes through a significant life transition or change, such as retirement. In this case, Devin is feeling depressed because he is facing the loss of influence, power, fame, and fortune that he had as the Italian prime minister. This loss of identity and purpose can lead to feelings of sadness and uncertainty, which are characteristic of a maturational crisis.

The features described in the question, such as disorganized and unintelligible speech, indicate a high level of anxiety. Panic is characterized by extreme and overwhelming feelings of fear and anxiety, which can lead to physical and cognitive symptoms such as difficulty speaking coherently. Therefore, the correct answer in this case is Panic.

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The answer is "The client has a blood pressure of 120/80, Temperature of 36.6 C Pulse rate of 120 and Respiratory rate of 22". This violates the characteristic of good recording because it lacks the time and date of when these vital signs were taken. Good recording should include the specific time and date to provide an accurate and complete picture of the client's condition.

The given explanation suggests that the correct answer is "Resource oriented" because it is a type of record where each person or department makes notations in separate records, such as nursing notes for nurses and physician's order sheet for doctors. The data in resource-oriented records is arranged according to the information source.

The most appropriate response by Budek is "What is that you said?" because it shows active listening and encourages the patient to further express their feelings or concerns. This response indicates that Budek is attentive and interested in understanding the patient's statement, which can help establish trust and open communication between them.

In patients with anxiety, it is common to observe dilated pupils. This physiological response occurs due to the activation of the sympathetic nervous system, which is responsible for the body's "fight or flight" response. When a person is anxious, their body releases stress hormones, such as adrenaline, which can cause the pupils to dilate. This allows more light to enter the eyes, enhancing visual perception and alertness. Therefore, dilated pupils are an expected physical manifestation in a client with anxiety.

Active listening on what the patient says is the best way to assess the client's pain because pain is a subjective experience and can vary greatly from person to person. By actively listening to what the patient says about their pain, healthcare providers can gain valuable insights into the nature, intensity, and location of the pain. This information can help guide appropriate interventions and treatment plans to effectively manage the client's pain. Additionally, active listening can help establish trust and rapport between the healthcare provider and the client, creating a supportive and empathetic environment for pain assessment and management.

Budek's response of "Do you think your crazy?" is an example of reflecting in therapeutic communication. Reflecting involves repeating or rephrasing the client's statement to show understanding and encourage further exploration of their thoughts and feelings. In this case, Budek reflects Rommel's question back to him, allowing Rommel to reflect on his own thoughts and feelings about his mental state.

In establishing a therapeutic nurse-patient relationship, it is important for the nurse to understand that patients might test her before trust is established. Patients may exhibit behaviors such as resistance, skepticism, or challenging the nurse's authority as a way to assess the nurse's reliability and trustworthiness. By being aware of this possibility and responding with empathy and understanding, the nurse can effectively build trust and rapport with the patient, which is crucial for the success of the therapeutic relationship.

Providing opportunities to express feelings would least likely be effective when dealing with a client with aggressive behavior. Aggressive behavior often stems from frustration, anger, or other strong emotions, and allowing the client to express these feelings may escalate their aggression. It is important to first ensure the safety of the client and others, and then use calming techniques such as approaching in a calm manner, maintaining eye contact, and providing a calm environment. Isolating the client from others may also be necessary to prevent harm, but it should be done in a safe and controlled manner.

Thorndike is the correct answer because he is associated with the theory of learning known as behaviorism. In this theory, Thorndike proposed that learning occurs through the transfer of knowledge from old situations to new ones, specifically when the new situation closely resembles the old one. This theory emphasizes the importance of reinforcement and rewards in shaping behavior.

Pavementation is the correct answer because it is the first process that occurs in the inflammatory response after injury. During pavementation, the endothelial cells lining the blood vessels become sticky and adhere to leukocytes, which helps to slow down their movement and allows them to migrate out of the blood vessels and into the injured tissue. This process is crucial for the recruitment of immune cells to the site of injury and the initiation of the inflammatory response.

When a patient has a blood sugar level of 50 mg/dl, it indicates hypoglycemia, which is a low blood sugar level. In response to this, the body activates the stress response known as the "fight-or-flight" response. This response triggers the release of stress hormones, such as adrenaline, which can cause an increase in blood pressure. This increase in blood pressure is a result of the body's attempt to restore glucose levels to normal by increasing the delivery of glucose to the brain and other vital organs.

Inflammation serves several purposes in the body, including localized tissue injury by increasing capillary permeability, protecting the tissue from injury by producing pain, and preparing for tissue repair. However, increasing heat does not contribute to the abatement of phagocytosis. Phagocytosis is a process by which cells engulf and destroy pathogens or debris, and increasing heat would not hinder this process.

Autogenic training refers to a relaxation technique that involves self-suggestion and self-hypnosis. It focuses on achieving a state of deep relaxation by repeating a series of specific phrases or visualizations that promote relaxation and reduce stress. This technique allows individuals to tap into their own innate ability to influence their physical and mental state, leading to improved well-being and self-regulation. Therefore, autogenic training aligns with the given description of being known as self-suggestion or self-hypnosis.

Grace is experiencing spiritual alienation. This is evident from the fact that she believes her relationship with God is broken and she is trying to go to church every day to ask for forgiveness in order to remedy her feelings. Spiritual alienation refers to a sense of separation or disconnection from one's spiritual beliefs or higher power.

The correct answer is social because the tsunami in Thailand and Indonesia affected not only individuals but also entire communities and societies. The impact of the disaster was widespread and had significant social implications, including the loss of lives, displacement of people, and the need for collective efforts to rebuild and recover. The affected individuals are not only dealing with personal challenges but also facing the social consequences of the disaster, such as changes in their social structures and relationships.

The statement "What makes you feel anxious?" is considered not therapeutic because it can be seen as intrusive and judgmental. It puts the responsibility on the patient to identify and justify the reasons behind their anxiety, which may make them feel defensive or uncomfortable. It is important for the nurse to create a safe and non-judgmental environment, allowing the patient to express their feelings without feeling pressured to provide explanations.

Restating is the therapeutic technique used in this situation. Restating involves repeating the client's words back to them in order to confirm understanding and to encourage further exploration of their thoughts and feelings. In this case, Nurse Budek restated Myra's statement about thinking a lot about her ex-boyfriend, which allows Myra to reflect on the connection between her thoughts and her difficulty sleeping.