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 The client appears to be withdrawn and depressed when the nurse asks how the client is doing today.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.