Exam 3

Normal urine output in a day

1500 mL

normal urine output

30 mL/hr

atheist

A person who denies the existence of God

wound

A wound is a break or disruption in the normal integrity of the skin and tissues

The nurse is caring for a very active, athletic adolescent recently diagnosed with multiple sclerosis. The client appears to be withdrawn and depressed when the nurse asks how the client is doing today. Using the health belief model, what step(s) will the nurse take to create a plan of care for this client? Select all that apply.

Encourage the client to participate in as many activities as they can tolerate and provide information for health counseling. Review possible outcomes of the diagnosis with the client, allowing the client to express concerns while providing support. Conduct an in-depth interview of the client's previous health issues, how the client reacted to the illness, and what support system the client has.

ISBARQ

Introduction Situation Background Assessment Recommendation Question and answer

A nurse is caring for a 17-year-old pregnant client who is unable to afford health care. Which resources will the nurse access to obtain assistance for this client?

Make a referral to the social services department.

Benefits of complementary alternative medicine

REDUCES A PATIENTS PAIN PERCEPTION

REEDA

Redness, edema, ecchymosis, drainage and approximation

SALTT

Size, appearance, location, treatment, and tolerance

Mourning:

actions and expressions of grief, including the symbols and ceremonies that make up outward expression of grief

factors influencing bowel elimination

age and developmental stages, food, active or inactive lifestyle, control over where to go to the bathroom, hormonal changes in pregnancy, and medications

immediately after an intravenous pyelogram (IVP) the nurse should observe the patient for which of the following?

an allergic reaction to the contrast dye

A durable power of attorney

appoints an agent, trusted by the person who is ill, to make decisions in the event of subsequent incapacity.

Wounds healed by tertiary intention, or delayed primary closure,

are those wounds left open for several days to allow edema or infection to resolve or fluid to drain, and then are closed (Hess, 2013).

Tertiary:

begins after an illness is diagnosed and treated,with the goal of reducing disability and helpingrehabilitate clients to a maximum level of functioning

actual loss

can be recognized by others

The nurse is teaching an older adult female who must provide a urine specimen. Which is the proper method to instruct the client to use to obtain a clean-catch urine specimen?

catch the urine while holding the labia apart, after following the first urine flow into the toilet.

A 16-year-old client has been injured in an accident and is receiving home care due to fractures and multiple trauma-related injuries. The client states, "I don't know why I survived and not my best friend." It is most important for the home care nurse to encourage the client to:

communicate these feelings to family and friends.

serous drainage

composed primarily of the clear, serous portion of the blood and from serous membranes. Serous drainage is clear and watery.

passive euthanasia

the withholding of available treatments, such as life-sustaining devices, allowing the person to die

Primary intention healing

tissue surfaces are approximated (closed) and there is minimal or no tissue loss, formation of minimal granulation tissue and scarring

a team is composed of

two or more people who interact interdependently and adaptively. have complementary skills. have effective leadership. work toward a common goal, and have clear roles and responsibilities

which vitamins are essential to wound healing (in addition to proteins)

vitamins E and C

(1) partial thickness

where all or a portion of the dermis is intact;

Secondary intention healing

wound in which the tissue surfaces are not approximated and there is extensive tissue loss; formation of excessive granulation tissue and scarring

Among the many factors that can influence a person's spirituality, the most important are

developmental considerations, family, ethnic background, formal religion, and life events

Primary:

directed toward promoting health and preventing the development of disease processes or injury.

Situational loss:

experienced as a result of an unpredictable event

maturational loss

experienced as a result of natural developmental process

Flacc pain scale

face, legs, activity, cry, consolability

Secondary:

focus on screening for early detection of disease with prompt diagnosis and treatment of any found

the nurse provides teaching to a client experiencing constipation. Which food choice on the clients breakfast tray indications effective teaching

grapefruit

(2) full thickness

here the entire dermis and sweat glands and hair follicles are severed, which can expose bone, tendon, or muscle

remember that

hourly output of less than 30 ml for 2 hours is cause for concern

Morbidity

incidence of a specific notifiable disease

grief

internal emotional reaction to loss

urge incontinence

involuntary leakage of urine with a sudden, strong desire to urinate

overflow incontinence

involuntary loss of urine associated with overdistention and overflow of the bladder

reflex incontinence

involuntary, cannot sense when bladder is full

Stage 4 pressure injury

involve full-thickness tissue loss with exposed or palpable bone, cartilage, ligament, tendon, fascia, or muscle. Slough or eschar may be present on some part of the wound bed; epibole, undermining, and/or tunneling often occur

A stage 2 pressure injury

involves partial-thickness loss of dermis and presents as a shallow, open ulcer or a ruptured/intact serum-filled blister

A stage 1 pressure injury

is a defined, localized area of intact skin with nonblanchable erythema (redness). Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding skin. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue

perceived loss

is felt by person but intangible to others

The goal of palliative care

is to give patients with life-threatening illnesses the best quality of life they can have by the aggressive treatment of symptom

why are patients counseled to consume cranberry juice, plums, or vitamin c if they are prone to urinary tract infections?

lowers the pH of urine

the nurse may suspect that a patient is experiencing urinary retention when the patient has:

small amounts of urine voided 2-3 times per hour

the nurse is working with a patient with a urinary diversion, included in the plan of care are:

special skin care is a priority

Bereavement:

state of grieving from loss of a loved one

active euthanasia

taking specific steps to cause a patient's death

a therapeutic nursing intervention for the nursing diagnosis of stress incontinence related to decreased pelvic muscle tone is

teach Kegel exercises

urge incontinence

the involuntary loss of urine that occurs soon after feeling an urgent need to void

to decrease falls, give a diuretic in

the morning

functional incontinence

the person has bladder control but cannot use the toilet in time : involuntary voiding with normal bladder and sphincter control

symptoms of cellulitis

Dull pain or tenderness Swelling warmth Fever and chills Swollen glands and lymph nodes Rash with blisters and scabs

The nurse has received an order to apply a saline-moistened dressing to a client's wound. Which action should the nurse perform?

Apply dry gauze pads over the wet gauze and place the abdominal pad over the gauzes.

which of the following should be of concern to the nurse? An ostomy stoma that is

Dark red to brown in color, dry and dull in appearance

stress incontinence

Occurs when there is an involuntary loss of urine related to an increase in intra-abdominal pressure. This commonly occurs during coughing, sneezing, laughing, or other physical activities.

Which nursing action helps to maintain a sense of self for clients?

Offering a simple explanation before initiating any procedure

shear results when

One layer of tissue slides over another layer.

health

Physical, mental, and social well-being

stages of illness behavior

Stage 1: Experiencing symptoms Stage 2: Assuming the sick role Stage 3: Assuming a dependent role Stage 4: Achieving recovery and rehabilitation SSDR

What have the models of health promotion and illness prevention been used for?

To help health care providers understand health-related behaviors.

Dehiscence

separation of the layers of a surgical wound; may be partial, superficial, or a complete disruption of the surgical wound

symptoms of a UTI

Urinary urgency, burning sensation during urination, low grade fever, fatigue, incontinence, and suprapubic pain.

unstageable pressure ulcer

When the clinician is unable to visualize the extent of tissue damage due to slough or eschar

secondary intention

Wound healing where edges can't be easily approximated and wound fills with granulation

Primary intention healing

Wounds healed by primary intention are well approximated (skin edges tightly together). Intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges, usually heal by primary intention.

Rifampin poop color

Yellow orange color

(3) unstageable

a full-thickness loss where the true depth cannot be determined; may also involve deep tissue injury

sanguinous drainage

consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding.

The result of liver disease

dark Amber urine that has bilirubin

Dessication

dehydration

Kubler Ross stages of grief

denial, anger, bargaining, depression, acceptance

which of the following is a normal change in bowel elimination as a person ages?

mastication processes are less efficient

Which is the largest single source of reimbursement for home health care services?

medicare

perform kegel exercises that do not involve

muscles in the inner thighs, abdomen, and buttocks

Somatic pain

non-localized and most often originates from muscles, tendons, and ligaments

the client is being discharged to the home setting following a stroke. The client requires assistance in relearning how to cook safely. To which home health care team member should the nurse refer the client?

occupational therapist

agnostic

one who holds that nothing can be known about the existence of a higher power

a patient who recently underwent surgery and now has a colostomy is correctly instructed by the nurse that for the next few weeks the diet will include foods such as:

poached eggs and rice

Stage 3 pressure injury

presents with full-thickness tissue loss. Subcutaneous fat may be visible and epibole (rolled wound edges) may occur, but bone, tendon, or muscle is not exposed. Slough and/or eschar that may be present do not obscure the depth of tissue loss. Ulcers at this stage may include undermining and tunneling

Evisceration

protrusion of viscera through an incision

a client with severe heart failure has been referred to a long term care facility. The nurse is transferring care from the hospital setting to a long term care facility. Which action is a priority to ensure continuity of care for the client?

providing accurate and complete communication to the new facility

The nurse understands that planning for discharge actually begins upon admission to the facility. The purpose of discharge planning is best described as:

providing continuity of care that is goal directed.