FUN exam 4 pt 6

A nurse is concerned that a client receiving peritoneal dialysis may be receiving peritoneal dialysis may be experiencing peritonitis. Which finding noted on the nursing assessment supported this concern

- Cloudy dialysis output

It is most important for the nurse to understand the various ways in which pain is classified so they can:

- Develop an effective pain management plan

Mr. Zenobia's chronic cancer pain has recently increased, and he asks the home health nurse what can be done. In relation to his long-acting opioid, which is an appropriate response by the nurse?

- I'll call the primary care provider and ask for an increased dose."

The nurse is teaching a client with an ileal conduit how to prevent a urinary tract infection. Which measures are most effective

- Maintain a daily fluid intake of 2,000-3,000 mL

The nurse is assessing the confused client. In trying to determine the client's level of pain, the nurse should:

- Observe the client carefully for changes in behavior or vital signs.

The nurse is conducting a focused assessment for the client with suspected bladder cancer. What information should the nurse obtain when assessing this client

- Painless hematuria

The client who has had a stroke states to the nurse, "You know I can't even tell where my left leg IS." This reflects lack of response to stimuli by the:

- Proprioceptors

Do pt's have the right to fall

- Yes, you cannot restrain them with all side rails

Pain management for newborns

Effective in newborns sugar water

exercise of contraction without motion

isometric

osteoporosis

porous bones

What are some defining characteristics of deficient fluid volume?

- Change in mental status; decreased blood pressure, pulse pressure, pulse volume, skin turgor, decreased urine output, dry mucous membranes, dry skin, elevated hematocrit, increased body temp, pulse rate, and urine concentration, sudden weight loss, thirst, weakness

common immobility of skin

sores and ulcers

A 76 yo client lives alone at home. Which of the following is the highest priority question for the home health nurse to ask regarding safety?

- . Do any of your medications cause you to be physically unsteady?

Mr. Arbor complains to the nurse that he is feeling anxious. He states, "I'm just so tired of all these tests they are doing, and it's so noisy here at night." Mr. Arbor's pulse is 110 beats/min and his blood pressure is 140/70 mm Hg. Nursing actions should include which of the following?

- Ask the client if he would like to discuss his anxiety further. 1st - Close the blinds, dim the lights, and ask the patient what other measures would help him rest. 2nd - Call the physician and obtain an order for an anti-anxiety medication for prn use. 3rd

A nurse is planning care for a client with a catheter. What actions should the nurse take to prevent cath ass uti

- Provide perineal care at least one per day - Maintain a closed drainage system - Encourage the client to drink 3000 mL fluids daily

What are some ways that the aging process makes the older adult more prone to injury?

- The aging process can result in physiological changes that can create changes in strength and gait stability. - Some adults experience sensory losses, particularly hearing and vision.

When the oxygen level of the blood falls, what is the effect on the central nervous system?

- When inadequate oxygen enters the pulmonary blood circulation, hypoxemia results - Acid in blood

You are caring for a patient with poorly controlled type 2 diabetes mellitus. What physical complications would you expect them to also experience as a result of impaired sensation to their feet and lower legs?

Experiencing pins and needles - Fall risk - Pressure ulcers

Antagonist analgesics (Tx for opioid analgesic overdose)

Naloxone/Narcan is treatment for opioid OD and turn on their side

Physical fitness is

ability to perform adls

function of autonomic nervous system is to

control involuntary muscles

Fibromyalgia

relatively recent diagnosis and don't know cause. Can be specific place or all over

goal of Ra

relieve pain

Many never events can be reduced by good nursing care. By preventing complications and maximizing reimbursement, nurses can prove their value to and organization and make the case for better staffing. - Which of the never events do you think nurses have the most control over?

hai's

risk of high impact exercises

musclskeletal injury

what controls muscoskeletal system movement

nervous system

if pt had nerve block in their arm can you use it?

no bc it is in sensory deprivation

benefit of flexibility training

prevents injury

t/f proper posture maintains natural curvature of the spine

true

Sympathectomy

used to treat main from vascular disorders such as Raynaud's

does resistance training increase muscular strength

yes