NURS 208 Exam 3

physical changes neuromuscular development in aging adults

- Loss of height (stature) → atrophy of intervertebral discs -Slower reaction time → diminished conduction speed of nerve fibers and decreased muscle tone -Loss of bone mass → bone resorption outpaces bone formation -Joint stiffness → drying and loss of elasticity in joint cartilage -Impaired balance → decreased muscle strength, reaction time, and coordination, change in center of gravity -Greater difficulty in complex learning and abstraction → fewer cells in cerebral cortex

how do you triage a client suspected of the ebola infection?

- has the client traveled internationally? - has the client had contact with an individual with EVD within the previous 21 days? -has the client met exposure criteria? if so, further questioning regarding presence of signs and symptoms capable with EVD - assess for clients that have fever or headache, fatigue, weakness, muscle pain, vomiting, diarrhea, abdominal pain, or hemorrhage (bleeding gums, blood in using, nose bleeds, coffee grounds emesis or melena)

what are the S&S of inhalation anthrax?

- initial symptoms are fever, headache, and muscle aches

how does learning change in an elderly person?

- need additional time for learning because it takes longer to retrieve info -nurse must figure out what is meaningful to the patient b/c they might have more difficulty learning something they don't value as meaningful

how do we decontaminate and dispose of hazardous materials?

- protect yourself w/ gloves, gown, mask, and shoe covers -if the material is liquid, wash skin w/ copious amounts of water. for dry material, brush off the skin and clothing before using water -carefully remove contaminated clothing and place all contaminated material into large plastic bags and seal them

how does perception change in an elderly person?

-If the aging person's senses are impaired, the ability to perceive the environment and act appropriately is diminished -The brain loses mass with aging and the blood flow to the brain decreases, the meninges thicken, and the brain metabolism slows

what are the indications of death?

-Total lack of response to external stimuli -No muscular movement, especially breathing -No reflexes -Flat encephalogram (brain waves) for at least 24 hours

what criteria is used to determine when clients can be safely discharged? (3 things)

-ambulatory clients requiring minimal care are discharged/relocated first -clients requiring assistance are next and arrangements are made for continuation of their care -clients who are unstable and/or require nursing care are not discharged or relocated unless they are in imminent danger

what biologic agents have been identified by the CDC as being of highest concern?

-anthrax - botulism -plague -biral hemorrhagic fevers (ebola, yellow fever) -smallpox -tularemia

how do we approach and handle hazardous materials if they're present?

-avoid contact -approach with caution - use safety data sheets manual to identify material -try to contain material in one place prior to the arrival of the hazardous material team

category A of bioterrorism

-can be easily spread or transmitted from person to person -result in high death rates and have potential for major public health impact -might cause public panic and social disruption -require special action for public health preparedness

What are CDCs 3 categories of bioterrorism?

-category A -category B -category c

what are the 4 types of human anthrax infection?

-cutaneous anthrax -gastrointestinal anthrax -inhalational anthrax -injection related anthrax

what measures should you take during a severe thunderstorm/tornado?

-draw shades and close drapes to protect against shattering glass -lower beds to the lowest position and move away from the windows -place blanket over all clients who are confined to bed -close all doors -relocate as many ambulatory clients as possible into hallways -do not use elevators -monitor for severe weather warnings

What measures should you take in a fire?

-evacuation: horizontal first, then lateral evacuation if client safety cannot be maintained -RACE Rescue Alarm Contain Extinguish

how should you react if you answer the phone and a bomb threat is made?

-extend the conversation as long as possible -listen for distinguishing background noises (music, traffic, airplanes) -ask where and when the bomb is set to explode -note whether the caller is familiar with he physical arrangement of the facility -if a bomb-like device is located, do not touch it. clear the area and isolated device (close door) -notify appropriate authorities and personnel (administrator, director of nursing) -cooperate with police and others. assist to conduct search if needed -keep elevators available for authorities -remain calm and alert and try not to alarm clients

what is FEMA?

-federal emergency management agency

physical changes of the integument development in aging adults

-increased skin dryness --> increase in sebaceous gland activity and tissue fluid -increased skin pallor --> reduced vascularity -Increased skin fragility → reduced thickness and vascularity of the dermis; loss of subcutaneous fat -Progressive wrinkling and sagging of the skin → loss of skin elasticity, increased dryness and decreased subcutaneous fat -Decreased perspiration → reduced number and function of sweat glands -Slower nail growth and increased thickening with ridges → increased calcium deposition

Category B bioterrorism

-moderately easy to spread -result in moderate illness rates and low death rates -require specific enhancements of CDCs laboratory capacity and enhanced disease monitoring

what are the CDCs categories of disaster? (5)

-natural disaster or severe weather -bioterrorism -chemical emergencies -mass casualties -radiation emergencies

what are the S&S of gastrointestinal anthrax?

-oropharyngeal: fever, ulcers in the back of the mouth and throat, severe sore throat, difficulty swallowing, and lymph node and neck swelling -intestinal: nausea and vomiting. the disease may progress rapidly to bloody diarrhea, abdominal pain, and shock

what are the 3 changes that occur with cognition in the elderly?

-perception -memory -learning

what can the nurse expect to occur with cold therapy?

-vasoconstriction -decreases capillary permeability -decreases cellular metabolism -slows bacterial growth -local anesthetic effect

what can the nurse expect to occur with heat therapy?

-vasodilation -increased capillary permeability -increases cellular metabolism -increases inflammation -sedative effect

In working with a dying client, the nurse demonstrates assisting the client to die with dignity when performing which action? 1. Allows the client to make as many decisions about care as is possible. 2. Shares with the client the nurse's own views about life after death. 3. Avoids talking about dying and focuses on the present. 4. Relieves the client of as much responsibility for self-care as is possible.

1. Allows the client to make as many decisions about care as is possible.

A A nurse is consoling the partner of a client who just expired after a long battle with liver cancer. The partner is displaying grief and states "I hate him for leaving me". Which of the following statements by the nurse successfully facilitate mourning for The Grieving partner? (select all that apply) A. Would you like me to contact the chaplain to come speak with you? B. You will feel better soon. You have been expecting this for awhile now C. Let's talk about your children and how they are going to react D. You know, it is quite normal to feel anger toward your husband at this time E. tell me more about how you are feeling

A. Would you like me to contact the chaplain to come speak with you? D. You know, it is quite normal to feel anger toward your husband at this time E. tell me more about how you are feeling

A nurse educator is discussing the facility protocol in the event of a tornado with the staff. which of the following should the nurse include in the instructions? select all that apply A. open doors to clients rooms B. place blankets over clients who are confined to beds C. move beds away from windows D. draw shades and close drapes E instruct ambulatory clients in hallways to return to their rooms

B. place blankets over clients who are confined to beds C. move beds away from windows D. draw shades and close drapes

A nurse is assisting a newly licensed nurse with post-mortem care of a client. The family wishes to view the body which of the following statements by the newly licensed nurse indicates an understanding of the procedure? A. "I will remove the dentures from the body." B. "I will make sure the body is lying completely flat." C. "I will apply fresh linens and place clean gown on the body." D. "I will remove all equipment from the bedside." E. "I will dim the lights in the room."

C. "I will apply fresh linens and place clean gown on the body." D. "I will remove all equipment from the bedside." E. "I will dim the lights in the room."

An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care? A. Irrigate the affected area with running water B. Wash the affected area with antibacterial soap C. Brush the chemical off the skin and clothing D. leave the clothing in the place until emergency personnel arrive

C. Brush the chemical off the skin and clothing

A nurse is caring for a client who has terminal lung cancer. the nurse observes the client's family assisting with all ADLs. which of the following rationales for self-care should the nurse communicate to the family? A. Allowing the client to function independently will strengthen her muscles and promote healing B. the client needs to be given privacy at times for self-reflecting and organizing her life C. The client's sense of loss can be lessened through retaining control of certain areas of her life D. performing ADLs is required prior to discharge from an acute care facility

C. The client's sense of loss can be lessened through retaining control of certain areas of her life Allowing the client as much control as possible maintains dignity and send esteem

A nurse is caring for multiple clients during a mass casualty event. which of the following clients is the priority? A. a client who received crush injuries to the abdomen and is expected to die B. A client who has a 4 inch laceration to the head C. a client who has partial-thickness burns to his face, neck, and chest D. A client who has a fractured fibula and tibia

C. a client who has partial-thickness burns to his face, neck, and chest

a nurse on the medical-surgical unit is informed that a mass casualty event in the community and that it is necessary to discharge stable clients to make beds available for injury victims. which of the following clients should the nurse recommend for discharge? select all that apply A. a client who is dehydrated and receiving IV fluid and electrolytes B. a client who has a nasogastric tube to treat a small bowel obstruction C. a client who is schedules for elective surgery D. a client who has chronic hypertension and blood pressure 135/85 mm Hg E. a client who has acute appendicitis and is scheduled for an appendectomy

C. a client who is schedules for elective surgery D. a client who has chronic hypertension and blood pressure 135/85 mm Hg

A nurse is caring for a client who has stage IV lung cancer and is 3 days postoperative following a wedge resection. The client states, "I told myself that I would go through with the surgery and quit smoking, if I could just live long enough to attend my daughter's wedding." Based on Kugler-Ross' model, which stage of grief is the client experiencing? A. anger B. denial C. bargaining D. acceptance

C. bargaining The client is displaying bargaining by attempting to negotiate more time to live to see his daughter get married

A nurse is caring for a client who has a terminal illness. Death is expected within 24 hours. The client's family is at the bedside and asks the nurse about anticipated findings at this time. Which of the following findings should the nurse include in the discussion? A. regular breathing patterns B. warm extremities C. increased urine output D. decreased muscle tone

D. decreased muscle tone

wound going through the body (gunshot wound) that goes posterior to anterior. penetrates the skin and the underlying tissue

penetrating wound

example of dirty or infected wound

perforated bowel, wound debridement, and positive cultures

How do changes in cognitive development impact perception?

If the aging person's senses are impaired, the ability to perceive the environment and act appropriately is diminished

-Intact skin with an area of persistent redness which is typically over a bony providence -Tissue is swollen and has congestion, with possible discomfort at the site -Ulcer can appear blue or purple with darker skin tones

Stage 1. Nonblanchable erythema

-Involves the epidermis and dermis -Ulcer is visible with reddish-pinkish bed without bruising and is superficial -Can appear as an abrasion, blister, or shallow crater -Can become infected, possibly with pain and scant drainage

Stage 2. Partial Thickness

-Damage to the subcutaneous tissue -Ulcer appears as a deep crater with or without undermining or tunneling of adjacent tissue and without exposed muscle or bone -Drainage and infection are common

Stage 3: full thickness skin loss

-Destruction, tissue necrosis, or damage to muscle, bone, or supporting structures -Can be sinus tracts, deep pockets of infection, tunneling, undermining, eschar (black scab like material), or slough (yellow/ green scab like material)

Stage 4: Full thickness tissue loss

A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? (Select all that apply) a) Keep the head of the bed elevated at 30 degrees. b) Massage the client's bony prominences frequently. c) Apply cornstarch liberally to the skin after bathing. d) Have the client sit on a gel cushion when in a chair. e) Reposition the client at least every 3 hours while in bed

a) The nurse should slightly elevate the client head of bed reduce shearing forces that could tear sensitive skin on the sacrum, buttocks, and heals. d) The nurse should have the client sit on a gel, air, or foam cushion to redistribute weight away from ischial areas

when asked to sign the permission form for surgical removal of a large, but noncancerous lesion on her face, the client begins to cry. which of the following is the most appropriate response? a. "tell me what it means to you to have this surgery." b. "you must be very glad to be having this lesion removed." c. "i cry when I am happy or relieved sometimes, too." d. "isn't it wonderful that the lesion is not cancer?"

a. "tell me what it means to you to have this surgery."

surface scrape and scraped knee

abrasion

What is delirium?

abrupt onset of confusion that has a reversible cause

what is injected related anthrax?

a newly recognizes entity. several cases have occurred recently in Europe in intravenous drug users. this is believed to be caused by injecting heroin that is contaminated with material containing B anthraces spores

what is the first symptom of cutaneous anthrax?

a small sore at the point of infection that develops into a blister and later into a pressure ulcer covered by a black scab. often there is marked swelling around the ulcer

A nurse educator is reviewing the wound healing process with a group of nurses. the nurse educator should include the information which of the following alterations for wound healing by secondary intention? (select all that apply) a. stage 3 pressure ulcer b. sutured surgical incision c. casted bone fracture d. laceration sealed with adhesive e. open burn area

a) Open pressure ulcers heal by secondary intention, which is the process for wounds that have tissue loss and widely separated edges. e) Open burn areas heal by secondary intention, which is the process for wounds that have tissue loss and widely separated edges

A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in his surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? (select all that apply) a) Cover the area with saline-soaked sterile dressings. b) Apply an abdominal binder snugly around the abdomen. c) Use sterile gauze to apply gentle pressure to the exposed tissues. d) Position the client supine with his hips and knees bent. e) Offer the client a warm beverage, such as herbal tea

a) The nurse should cover the wound with a sterile dressing soaked with sterile normal saline solution to keep the exposed organs and tissues moist until the surgeon can assess and intervene. d) This position minimizes pressure on the abdominal area

A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? (select all that apply) a) Increase in incisional pain b) Fever and chills c) reddened wound edges d) Increase in serosanguinous drainage e) decrease in thirst

a) The nurse should expect the client to have pain and tenderness at the wound site of an incisional infection. b) The nurse should expect the client to have fever and chills with an incisional infection c) The nurse should expect the client to have reddened or inflamed wound edges with an incisional infection.

what age group is the fastest growing?

adults 65 and older

sterile objects become unsterile by prolonged exposure to _______

air

A nurse is caring for an adolescent client who is 2 days postoperative following an appendectomy and has type 1 diabetes mellitus. The client is tolerating a regular diet. He has ambulated successfully around the unit with assistance. He requests pain medication every 6 to 8 hours while reporting pain at a 2 on scale of 0 to 10 after receiving medication. His incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? (select all that apply) a) Extremes in age b) Impaired circulation c) Impaired/suppressed immune system d) Malnutrition e) Poor wound care

b) The client who has type I diabetes mellitus is at risk for impaired circulation. c) The client who has type I diabetes mellitus is at risk for impaired immune system function.

which of the following may be considered normal or "healthy" types of grief? select all that apply a. complicated grief b. anticipatory grief c. abbreviated grief d. inhibited grief e. disenfranchised grief f. unresolved grief

b, c, and e

A client's family tells the nurse that their culture does not permit a dead person to be left along before burial. hospital policy stated that after 6pm when the mortuaries are closed, bodies are to be stored in the hospital morgue refrigerator until the next day. how would the nurse best manage this situation? a. gently explain the policy to the family and then implement it b. inquire of the nursing supervisor how an exception to the policy could be made c. call the client's primary care provider for advice d. move the deceased to an empty room and assign an aid to stay with the body

b. inquire of the nursing supervisor how an exception to the policy could be made

the client has been close to death for some time and the family asks how the nurse will know when the client has actually died. which of the following would be most accurate response from the nurse? a. when BP can no longer be measured b. when there is no apical pulse c. when the gag reflex is no longer present d. when the extremities are cool and dark in color

b. when there is no apical pulse

dirty or infected wounds

wounds containing dead tissue and wounds with evidence of a clinical infection, such as purulent drainage. also has a foul smell

At which age does a child begin to accept that he or she will someday die: a. less than 5 years old b. 5-9 years old c) 9-12 years old d) 12-18 years old

c) 9-12 years old

the shift changes while the nursing staff was waiting for the adult children of a deceased client to arrive. the oncoming nurse has never met the family. which of the following initial greetings is most appropriate? a. "I'll take you in to view the body." b. " I didn't know your father but I am sure he was a wonderful person." c. "I'm very sorry for your loss." d. "how long will you want to stay with your father?"

c. "I'm very sorry for your loss."

An 82 year old patient has been told by his primary care provider that it is no longer safe for him to drive a car. which statement by the client would indicate beginning positive adaptation to this loss? a. "i told the doctor I would stop driving, but I am not going to yet." b. "I always knew this day would come, but I hoped it wouldn't be now." c. "well, at least I have friends and family who can take me places." d. "what does he know? I'm a better driver than he will ever be."

c. "well, at least I have friends and family who can take me places."

the nurse is caring for a family in a shelter 2 days after the loss of their home due to a fire. the fire caused minor burns to several members of the family but no life-threatening conditions. which of the following is the most important assessment data for the nurse to gather at this time? a. availability of insurance coverage for rebuilding the house b. family members' understanding of the event of their physical injuries c. family members' grief responses and coping behaviors d. psychological support resources available from friends or other sources

c. family members' grief responses and coping behaviors

example of clean wounds

clear dressings after a procedure

A nursing care plan includes the desired outcome of "quality of life" for a client with a chronic degenerative disease who is likely to live for many more years. which of the following is one example that would indicate the outcome has been met? a. the client demonstrates having adequate financial resources to pay for health care for many more years b. the client spends the majority of his or her time in spiritual reflection c. the client as no signs or symptoms or preventative complications of the illness d. the client verbalizes satisfaction with current relationships with other people

d. the client verbalizes satisfaction with current relationships with other people

example of contaminated wound

diverticulitis, rectal surgery, or penetrating wounds. these are surgical wounds in the GI tract that have a high risk of becoming infected

what is isolate, identify, and inform?

emergency department evaluation and management of patients with possible ebola virus disease (EVD)

partial thickness

confined to the skin, that is, the dermis and epidermis and heal by regeneration

blow from an instrument and the skin around it appears ecchymotic (bruised)

contusion

how does CDC define bioterrorism?

deliberate release of viruses, bacteria, or other germs (agents) used to cause illness or death in people, animals, or plants

Moisture or fluid that passes on or through the sterile field causes ___________.

field to become contaminated

example of clean contaminated wound

gastric surgery or colon surgery

fluids flow in the direction of _________

gravity

external disaster

hurricanes, floods, volcano eruptions, earthquakes, disease epidemics, industrial accidents, chemical plant explosions, major transportation accidents, building collapse, and terrorist attacks

sharp instrument (knife or scapel) and is a clean cut and heals/seals well

incision

contaminated wound

include open, fresh, accidental wounds, and surgical wounds involving a major break in sterile technique or a large amount of spillage from the GI tract. Contaminated wounds show evidence of inflammation. MAJOR BREAK IN STERILE TECHNIQUE

what are the S&S of injected related anthrax?

inflammation or abscess at the injection site sometimes progressing to cellulitis or recognizing fasciitis (plantar).

full thickness

involving the dermis, epidermis, subcutaneous tissue, and possibly muscle and bone; require connective tissue repair

why might agiesm be assigned to the age group that is the fastest growing?

it's used to describe negative attitudes toward aging or older adults and prefer younger people

tissues torn apart, often from accidents. they have jagged edges , typically from a serrated knife or machinery

laceration

internal disaster

loss of electric power or portable water, and severe damage or casualties within the facility related to fire, weather, explosion, or a terrorist attack

what can injected related anthrax progress to?

progress to sepsis without extensive local infection

what is dementia?

progressive loss of cognitive function

penetration of the skin and often the underlying tissues by a sharp instrument

puncture

what can happen if heat and cold therapy is applied for more than 20 minutes?

rebound therapy

what is inhalation anthrax?

result of breathing B anthracis spores into the lungs

what does chest imaging reveal in inhalation anthrax?

reveals widening of the mediastinum, enlargement of and bleeding into lymph nodes, and bloody fluid collectors around the lungs

how does memory change in an elderly person?

short term memory loss decreases and they tend to have better long term memory

all objects in the sterile field must be ______

sterile

Conscientiousness, alertness and honesty are essential qualities in maintaining ________________________

surgical asepsis

clean contaminated wound

surgical wounds in which the respiratory, GI, genital, or urinary tracts has been ENTERED. such wounds show no evidence of infection

What is perception?

the ability to interpret the environment and depends on the acuteness of the senses

what can inhalation anthrax lead to if it goes untreated?

the disease can progress to SOB, cough, sore throat, chest discomfort, respiratory failure, shock, and death

what is cutaneous anthrax?

the result of spores entering the body through small breaks in the skin

how can recent memory be improved for elderly people?

the use of memory aids, making notes or lists, and placing objects in consistent locations

Why was FEMA created?

to decrease loss of life and property, to protect the US from disaster and terrorism by an emergency management system

Sterile objects become unsterile when ______

touched by unsterile objects

what is gastrointestinal anthrax?

typically occurs as result of eating the meat of animals infected with B. anthracis

clean wounds

uninfected wounds in which there is minimal inflammation and the respiratory, gastrointestinal, genital, and urinary tracts are NOT entered. clean wounds are primarily closed wounds

sterile objects out of sight or below waist are ________

unsterile

the skin is ______

unsterile

The edges of a sterile filed are _______________

unsterile (1 inch)