Unit 6

Love

: Connectedness with others

During a mumps outbreak at a local school, a patient, who is a school teacher, is exposed. She has previously been immunized for mumps. What type of immunity does she possess?

Acquired immunity

What is a nursing implication when it comes to culture/religion barriers

Assess client's cultural needs when planning learning activites

A nurse is teaching a client who has gastroesophaegeal reflux disease about managing his illness. Which of the following recommendations should the nurse include in the teaching?

Avoid eating within 3 hours of bedtime

Jehovah's Witnesses

Blood transfusions are not allowed Patient may want contact with local Jehovah's Witness hospital liaisoncommittee

Key risk factors of delirium (from textbook)

Cognitive impairment, sleep deprivation, immobility, visual or hearing impairment, and dehydration.

Which of the following is a age-related change associated with the immune system?

Decreased antibody production

A school nurse is talking about infection with a high school health class. What would be the nurse's best explanation of the process of phagocytosis?

Engulfment and digestion of bacteria and foreign material

Explain the role of the nurse in consumer education/prevention.

Establishing relationships and identifying readiness for change.

A nurse is caring for an older adult client who has been confined to bed for several weeks following a fall. The client has been exhibiting symptoms of sundowner's syndrome. Which of the following are characteristics of sundowner's syndrome?

Feeling agitated and wakeful at night

Anti-psychotic

Haldol (haloperidol)

A nurse is providing discharge teaching to a client who has asthma and new prescriptions for cromolyn and albuterol, both by nebulizer. Which of the following statements by the client indicates an understanding of the teaching

I will be sure to take the albuterol before taking the cromolyn.

Hope

Ingredient in life responsible for a positiveoutlook

The nurse is completing a focused assessment addressing a client's immune function. What should the nurse prioritize in the physical assessment?

Palpation of the client's lymph nodes

antinuclear antibody (ANA)

Screening test for autoimmune disorders, positive ANA indicates autoimmune disorder

Roman Catholics

Seven Sacraments

What are the primary participants in the immune system?

T and b cell lymphocytes

The anatomy and physiology instructor is explaining a cell-mediated response to the pre-nursing students. What actions would the instructor explain occur in a cell-mediated response?

T-cell lymphocytes survey proteins in the body and attack the invading antigens.

Which situation would lead the client's family to suspect onset of dementia?

The client has increasingly experienced disorientation to familiar surroundings.

A client has been diagnosed with AIDS and tuberculosis (TB). A nursing student asks the nurse why the client's skin test for TB is negative if the client's physician has diagnosed TB. The nurse's correct reply is which of the following?

The client's immune system cannot mount a response to the skin test.

A client arrives at the clinic and reports a very sore throat as well as a fever. A rapid strep test returns a positive result and the client is given a prescription for an antibiotic. How did the streptococcal organism gain access to the client to cause this infection?

Through the mucous membranes of the throat

Why would it be important for the nurse to question the client about sexual practices, history of substance use disorder, and the client's lifestyle during the interview process?

To determine if the client has practices that the client at risk for acquired immunodeficiency syndrome (AIDS)

A nurse has accepted a position on a pediatric unit and is learning about psychosocial development. Place Erikson's stages of psychosocial development in order from birth to adolescence.

Trust vs Mistrust Autonomy vs shame and doubt Initiative vs guilt Industry vs inferiority Identity vs role confusion

A nurse has been administering seasonal influenza vaccinations to the residents of a long-term care facility. One resident has refused the vaccinations, stating that he believes the vaccination to be a cause of influenza infection rather than a protection against it. The nurse's response to this resident should encompass which of the following facts about vaccination?

Vaccination prompts the body to produce antibodies against influenza.

A nurse is providing discharge teaching about nutrition to the parents of a child who has cystic fibrosis (CF). Which of the following responses by the parents indicates an understanding of the teaching?

We will give our child pancreatic enzymes with snacks and meals.

A nurse is teaching a client who has a urinary tract infection and is taking ciprofloxacin. Which of the following instructions should the nurse give to the client?

You should report any tendon discomfort you experience while taking this medication.

Faith

a confident belief in something for whichthere is no proof or evidence

Allergen

a substance that CAUSES the allergic reaction (pollen, medication)

Type 3 hypersensitivity

acute inflammation, excess of antigen is not cleared from circulation

Type 1 hypersensitivity

anaphylaxis

Spirituality

anything that pertains to the person'srelationship with a nonmaterial life force or higherpower

Confusion can

be sudden (acute) or gradual (chronic)

C-reactive protein (CRP)

blood test used to measure the level of inflammation in the body; ITS INCREASED WITH INFLAMMATION.

Autoimmune response

body attacks itself.

Prostaglandins

cause inflammation, fever, and pain.

T lymphocytes

cellular immune

Affective Domain:

changing attitudes, values, and feelings

Exemplars of cognition

confusion, delirium.

Type 2 hypersensitivity

cytotoxic

The nurse is caring for an older client admitted to the health-care facility with a new onset of confusion and a low-grade fever. Which age-related changes might contribute to decreased functioning of the immune system?

decreased kidney function

Type 4 hypersensitivity

delayed reaction, mediated by T cells

Corticosteroids

delays inflammatory response and suppresses immune system Side effects: bone loss, hyperglycemia, weight gain.

neurocognitive disorders (dementia)

develops over time, alzheimers is the most common type of dementia.

A patient is stressed about surgery and she asks you to pray with her, would you? How can you facilitate religious practices for this patient?

•Ask them how they want to pray •Or they facilitate it and you just be there with them while they pray.

The nurse is working in a long-term care facility and overhears a group of unlicensed assistive personnel (UAP) discussing some of the residents of the facility. What statement made by a UAP indicates that education regarding older adult clients is needed?

"All old people start to deteriorate mentally."

A parent of a child who has been having frequent bouts of tonsillitis brings the child back to the clinic for another sore throat. The parent asks the nurse, "What are tonsils good for anyway?" What is the best response by the nurse?

"These tissues filter bacteria from tissue fluid."

Causes of delirium

- Being hospitalized, out of normal routine - Infection - Drug interactions or sensitivity - Dehydration - Electrolyte Imbalances - Kidney failure - Liver failure - Brain tumors or other head trauma - Fever - Hypoxia - Adverse reactions to medications

Risk factors for cognitive impairments

-Personal behaviors- substance abuse, safety. -Environmental exposures- pesticides and lead -Congenital and Genetic conditions- fetal alcohol syndrome, downs syndrome -Physical disability and reduced mobility- slow gait, health conditions.

When providing care to a client with dementia, which interventions would be most appropriate? Select all that apply.

-maintain levels of sensory stimulation that are tolerable -ensuring the use of assistive sensory devices -using validation therapy

A nurse is providing care to an older adult who is experiencing delirium. Which risk factors would the nurse identify as being most common? Select all that apply.

-pre-existing cognitive impairment -advanced age -sleep deprivation

Which of the following is the most severe form of hypersensitivity reaction? (should be on test)

Anaphylaxis

A 15-year-old client has been brought to the clinic by their mother and is suspected of having an immune system disorder. What tests would you expect to be ordered for this young client?

Complete blood count with differential

What is the most frequent complication of hospitalization in the elderly population

Delirium

An older adult is prescribed an antipsychotic. The nurse understands that this medication is used to treat which manifestation? Select all that apply.

Delusions Hallucinations

What should the nurse do after they get done teaching the client?

Document the teaching.

Teaching tips for children

Dress up, Coloring books, Story books, dolls, puppet play, and health fairs.

Anti-Alzheimer's agents

Memantine, Donepezil, Rivastigmine

What are the three spiritual needs?

Need for meaning and purpose Need for love and relatedness Need for forgiveness

Hinduism

Nurse should avoid touching client's lips when administering medication

A nurse is discussing culturally competent care at a nursing staff inservice. Which of the following information should the nurse include when discussing clients' cultures

Nurses should focus on clients' culture, rather than their ethnicity, when providing care

A nurse is caring for a client who is terminally ill and exhibiting signs of impending death. The client's medical record states that the client is practicing Roman Catholic. Which of the following nursing actions is appropriate?

Offer to make arrangements for the Sacrament of the Sick.

A nurse is completing discharge teaching with a client. Of the following barriers is learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?

Pain

A nurse has given an 8-year-old client the scheduled vaccination for rubella. This vaccination will cause the client to develop which expected and desired condition?

Passive acquired immunity

Islam

Patient may prefer that nurse be the same gender Dietary practices avoid overeating, alcohol, pork and pork-based products

Morality

Personal standards of right or wrong

A client is admitted with cellulitis and experiences a consequent increase in white blood cell count. During what process will pathogens be engulfed by white blood cells that ingest foreign particles?

Phagocytosis

Three areas to consider when developing a teaching plan:

Physical maturation Psychosocial development Cognitive capacity

What problems could have delirium as the initial symptom

Pneumonia Urosepsis Myocardial Infarction

Buddhism

Practitioners generally prefer Eastern medicine Cure through mind, herbs Does not mean they will refuse Western medicine May use traditional therapies in addition to those prescribed by provider

The nurse is providing hygiene care to an older adult client diagnosed with Alzheimer disease and experiencing confusion, when the nurse is called to the nursing station. To ensure client safety the nurse must do what?

Put side rails up before leaving the older adult client.

Nursing interventions for delirium

Quiet environment, well lit rooms during waking hours, routine schedule of activities like mealtime at the same time each day.

An client 81 years of age is in a long-term-care facility. His family could no longer cope with his progressing senile dementia, including wandering away and unpredictable behavior. Late one night the nurse finds the client wandering in the hall. He says he is looking for his wife. What should the nursing approach should be?

Remind him of where he is and assess why he is having difficulty sleeping.

Which condition is associated with impaired immunity relating to the aging client?

Renal function decreases

Teaching tips for older adults

Return demonstration, using materials at a 5th-6th grade reading level.

A nurse is providing teaching to a client who has asthma and a new prescription for inhaled beclomethasone. Which of the following instructions should the nurse provide?

Rinse the mouth after administration

atypical antipsychotics

Risperidone (Risperdal)

Immunity protects from

diseases, its the body's response to a foreign agent

Complement system

enhances the abilities of antibodies and phagocytic cells

Hypersenstivity is an

exaggerated immune response.

Antigens are

foreign invaders

Stem cells

give rise to all cells

The nurse who works with elderly patients diagnosed with Alzheimer's disease recognizes that there are various symptoms of dementia and confusion including sundowning syndrome. The nurse recognizes sundowning syndrome as:

habitual increases in confusion, restlessness, and agitation after dark.

Delirium may include

hallucinations or delusions

Communicating with a client who is unconscious

hearing is the believed to be the last sense lost. Talk to the person normally. Speak before touching.

Histamine

helps the body get rid of allergens, H1 is found in the brain, H2 is found in gastric cells

B lymphocytes

humoral immunity

Allergy

immune system reacts abnormally to a foreign substance

confusion

inability to think or reason in a focused, clear manner

Antibodies fight

infection and disease, kills antigens.

Health

is a state of complete physical, mental, and social well being

Psychomotor Domain:

learning a physical skill

What are the purposes of consumer education/prevention

maintaining and promoting health, preventing illness, restoring health, facilitating coping.

Epinephrine

opens airway, increases BP, HR. Responsible for flight or fight response

Manifestations of confusion

reduced awareness, impaired thinking skills, changes in behavior

The nurse is caring for an older adult client post surgery in the critical care unit. The nurse finds that the client is acutely confused and trying to get out of bed. Which is the priority nursing intervention?

review with the client that he or she is in the hospital

What organ is considered lymphoid tissue?

spleen

Cognitive Domain:

storing and recalling of new knowledge in the brain

Delirium is a state of

temporary confusion (acute)

Religion

term used to describe cultural orinstitutional religion

What are some nursing interventions for clients who are confused?

•Use conversation, watches, clocks, calendar, newspaper, television, radio, and other such devices to help orient the patient to time, place, and person. •Vary environmental stimuli gradually while keeping the environment structured enough that the patient feels comfortable and at home.