Foundations Test 2

Explain the following types of incontinence. Urge incontinence

Urge: sudden, involuntary contraction of the muscles of the urinary bladder resulting in the urge to urinate

Explain the following alterations in urinary elimination. Urinary retention

Urinary retention is an accumulation of urine resulting from an inability of the bladder to empty properly

Polypharmacy

Use of a number of different drugs by a patient who may have one or several health problems.

Medical nutrition therapy (MNT)

Use of specific nutritional therapies to treat an illness, injury, or condition.

The nurse knows that which technique is best for assessing pain in a child who is 4 years of age?

Use the FACES scale.

Physical assessment involved in Assessment of Sensory Alterations:

Used to identify sensory deficits and their severity, use physical assessment techniques to assess vision, hearing, olfaction, taste, and the ability to discriminate light touch, temp, pain and position

A nurse is assessing a patient who started to have severe pain 3 days ago. When the nurse asks the patient to describe the pain, the patient states, "The pain feels like it is in my stomach. It is a burning pain, and it spreads out in a circle around the spot where it hurts the most." What type of pain does the nurse document that the patient is having at this time?

Visceral pain

Chyme

Viscous, semifluid contents of the stomach present during digestion of a meal that eventually pass into the intestines.

Water-soluble vitamins

Vitamins that cannot be stored in the body and must be provided in the daily food intake, such as vitamin C and B complex.

When a nerve impulse is created:

it travels along pathways to the spinal cord or directly to the brain

good oral hygiene:

keeps the taste buds well hydrated

Pharmacokinetics

Study of how drugs enter the body, reach their site of action, are metabolized, and exit from the body.

Food Security

The ability of individuals to obtain sufficient food on a day-to-day basis

Nutrients

A substance in foods that the body needs to regulate bodily functions, promote growth, repair body tissues, and obtain energy

Explain the following alterations in urinary elimination. Urinary diversion

A urinary diversion is a surgical formation (temporary or permanent) that bypasses the bladder and has a stoma on the abdomen to drain the urine

What creates high risk for illness and functional deterioration?

reduced ability to respond to stress, experience of multiple losses, physical changes associated with normal aging all combine

olfaction loss:

reduced sensitivity to odors

Gerentology Nursing

requries creative approaches for maximizing the potential of older adults; w/comprehensive assessment info regarding strengths, limitations and resources, the nurse and older adult identify needs and problems

A nurse is caring for a patient who recently had an abdominal hysterectomy and states that she is experiencing severe pain. The patient's blood pressure is 110/60, and her heart rate is 60. Additionally, the patient does not appear to be in any distress. Which response by the nurse is most therapeutic?

"What would you like to try to alleviate your pain?"

A nurse has brought the patient his scheduled pain medication. The patient asks the nurse to wait to give pain medication until the time for the dressing change, which is 2 hours away. Which response by the nurse is most therapeutic?

"Would you like medication to be given for dressing changes on top of your regularly scheduled medication?"

Developmental Tasks for Older Adults - General

researchers have developed frameworks outlining develpmental tasks for older adults; these tasks are common to many older adults and are associated with varying degrees of change and loss; more common losses are of health, significant others, a sense of being useful, socialization, income, and independent living

Which of the following statements made by the patient indicates to the nurse that teaching on a patient-controlled analgesia (PCA) device has been effective?

"I feel less anxiety about the possibility of overdosing."

A nurse is supervising a student who is caring for a patient with chronic pain. Which statement by the student indicates an understanding of pain management?

"I need to reassess the patient's pain 1 hour after administering oral pain medication."

A nurse is providing medication education to a patient who just started taking ibuprofen, a nonselective nonsteroidal antiinflammatory drug (NSAID). Which statement made by the nurse best indicates how ibuprofen works?

"Ibuprofen helps to decrease the production of prostaglandins."

The nurse is caring for a patient who recently had surgery to repair a hernia. The patient's pain was 7 out of 10 before receiving pain medication. One hour after receiving an oral opioid, the patient ranks his pain at 3 out of 10. The patient asks the nurse why he isn't receiving more pain medication. Which is the nurse's best response?

"It can take 2 hours for oral pain medication to work, and your pain is going down. Let's try boosting you up in bed and putting an ice pack on the incision to see if that helps."

A nursing student is planning care for an elderly patient who is experiencing pain. Which of the following statements made by the nursing student indicates the need for the nursing professor to clarify the nursing student's knowledge?

"It is safe to administer opioids to older adults as long as you start with small doses and frequently assess the patient's response to the medication."

Which of the following statements made by a patient reflects that the patient understands the relationship between the gate control theory of pain and the use of meditation to relieve pain?

"Meditation controls pain by blocking pain impulses from coming through the gate."

The nurse is teaching a student nurse about pain assessment scales. Which statement by the student indicates correct understanding?

"Pain assessment scales determine the quality of a patient's pain."

Which statement made by a nursing educator best explains why it is important for nurses to determine a patient's medical history and recent drug use?

"This information is useful in determining what type of pain interventions will most likely be effective in providing pain relief."

A nurse is caring for a patient who is experiencing pain following abdominal surgery. What information is important for the nurse to tell the patient when providing patient education about effective pain management?

"We should work together to create a regular schedule of medications that does not allow for breakthrough pain."

The nurse is assessing how a patient's pain is affecting mobility. Which assessment question is most appropriate?

"What activities, if any, has your pain prevented you from doing?"

A patient who has had type 2 diabetes for 26 years is beginning to experience peripheral neuropathy in the feet and lower legs, which is causing the patient to have a decreased ability to feel pain in the lower extremities. The nurse is providing education to the patient to prevent injury to the feet. The nurse tells the patient to always wear shoes or slippers when walking. Which of the following statements made by the nurse best explains the rationale for this instruction?

"You have lost the ability to withdraw from pain because of your peripheral neuropathy. If you step on something and are not wearing shoes, you will not feel it; this could possibly cause injury to your foot."

A nurse is providing discharge teaching for a patient with a fractured humerus. The patient is going home with Vicodin (5/325). What important patient education does the nurse provide?

"You need to drink plenty of fluids and eat a diet high in fiber."

IM Injections

-90 degree angle - length: very obese= 3in| thin = .5-1in -Amt Meds: Adult 2-5ml | child/old adult/thin: up to 2ml

ANS: A The presence of white blood cells in urine indicates a urinary tract infection. Difficulty with urinary elimination indicates blockage or renal damage. Increased blood pressure is associated with renal disease or damage and some medications. Abnormal blood sugars would be seen in someone with ketones in the urine, as this finding indicates diabetes.

21. What signs and symptoms would the nurse expect to observe in a patient with excessive white blood cells present in the urine? a. Fever and chills b. Difficulty holding in urine c. Increased blood pressure d. Abnormal blood sugar

Myths and Stereotypes

1) ill, disabled and physically unatractive (most nonistitutionalized older adults assess their health as excellent or very good); 2) mistaken ideas about living arrangements and finances, either that many rae affluent or that many are poor; 3) society values attractiveness, energy, youth and productiveness so undervalue older adults (demonstrates ageism);

ANS: B, D, F, G All specimens should be labeled appropriately and processed in a timely fashion. Allow patients time and privacy to void. Children may have difficulty voiding; attaching a plastic bag gives the child more time and freedom to void. Urine cultures can take up to 48 hours to develop. Gown, gloves, and mask are not necessary for specimen handling unless otherwise indicated. Urine should not be squeezed from diapers.

1. Which nursing actions are acceptable when collecting a urine specimen? (Select all that apply.) a. Growing urine cultures for up to 12 hours b. Labeling all specimens with date, time, and initials c. Wearing gown, gloves, and mask for all specimen handling d. Allowing the patient adequate time and privacy to void e. Squeezing urine from diapers into a urine specimen cup f. Transporting specimens to the laboratory in a timely fashion g. Placing a plastic bag over the child's urethra to catch urine

Hearing changes occuring with age include:

1. decreased hearing acuity 2. decreased speech intelligibility 3. decreased pitch discrimination

Safety Hazards to include in assessing a patients room in the hospital setting:

1. is the call light within easy, safe reach? 2. are IV poles on wheels easy to move? 3. are suction machines, IV pumps or drainage bags positioned so a patient can rise from a bed or chair easily?

Three types of sensory deprivation:

1. reduced sensory input 2. the elimination of patterns or meaning from input 3. restrictive environments that produce monotony and boredom

Sensory Assessment includes

1. risk factors (age, environmental or cultural factors) 2. sensory alterations history 3. mental status 4. physical assessment

Adult visual changes include:

1. the cornea becomes flatter and thicker 2. aging changes lead to astigmatism 3. pigment is lost from the iris 4. collegen fibers build up in the anterior chamber, which increases the risk of glaucoma

Assess the patients home for common hazards in their environment such as:

1. uneven, cracked walkways 2. extension and phone cords in the main route of walking 3. loose area rugs and runners placed over carpeting

ANS: A To obtain an accurate assessment, the nurse should first determine the source of the discomfort. Urinary retention causes the bladder to be firm and distended. Further assessment to determine the pathology of the condition can be performed later. Questions concerning fever and chills, changing urination patterns, and losing urine during coughing or sneezing focus on specific pathological conditions.

10. Upon palpation, the nurse notices that the bladder is firm and distended; the patient expresses an urge to urinate. The nurse should follow up by asking a. "When was the last time you voided?" b. "Do you lose urine when you cough or sneeze?" c. "Have you noticed any change in your urination patterns?" d. "Do you have a fever or chills?"

ANS: B The main purpose of the kidney is to maintain fluid and electrolyte balance by filtering waste products and regulating pressures. The kidneys filter the byproducts of medication metabolism. The bladder stores and excretes urine. The kidneys help to maintain red blood cell volume by producing erythropoietin.

11. Which of the following is the primary function of the kidney? a. Metabolizing and excreting medications b. Maintaining fluid and electrolyte balance c. Storing and excreting urine d. Filtering blood cells and proteins

ANS: B Older adults often experience poor muscle tone, which leads to an inability of the bladder to fully empty. Residual urine greatly increases the risk of infection. Following Maslow's hierarchy of needs, physical health risks should be addressed before emotional/cognitive risks such as anxiety and self-esteem. Decreased mobility can lead to self-care deficit; the nurse's priority concern for this diagnosis would be infection, because the elderly person must rely on others for basic hygiene.

13. Which nursing diagnosis related to alternations in urinary function in an older adult should be a nurse's first priority? a. Self-care deficit related to decreased mobility b. Risk of infection c. Anxiety related to urinary frequency d. Impaired self-esteem related to lack of independence

ANS: A Poor muscle tone leads to an inability to control urine flow. The nurse should recommend pelvic muscle strengthening exercises such as Kegel exercises; this solution best addresses the patient's problem. Drinking cranberry juice is a preventative measure for urinary tract infection. The nurse should not encourage the patient to reduce voiding; residual urine in the bladder increases the risk of infection. Wearing an adult diaper could be considered if attempts to correct the root of the problem fail. DIF: Analyze REF: 1056 OBJ: Identify nursing diagnoses appropriate for patients with alterations in urinary elimination.

14. A patient asks about treatment for urge urinary incontinence. The nurse's best response is to advise the patient to a. Perform pelvic floor exercises. b. Drink cranberry juice. c. Avoid voiding frequently. d. Wear an adult diaper.

ANS: C Cystitis is inflammation of the bladder; associated symptoms include hematuria and urgency/frequency. Dysuria is a commo n symptom of a lower urinary tract infection. Flank pain, fever, and chills are all signs of pyelonephritis.

15. The nurse suspects that a urinary tract infection has progressed to cystitis when the patient complains of which symptom? a. Dysuria b. Flank pain c. Frequency d. Fever and chills

ANS: C Stress incontinence can be related to intra-abdominal pressure causing urine leakage, as would happen during coughing or sneezing. Asking the patient about the fullness of his bladder would rule out retention and overflow. An inability to void completely can refer to urge incontinence. Physiological causes and medications can effect elimination, but this is not related to stress incontinence.

16. Which assessment question should the nurse ask if stress incontinence is suspected? a. "Does your bladder feel distended?" b. "Do you empty your bladder completely when you void?" c. "Do you experience urine leakage when you cough or sneeze?" d. "Do your symptoms increase with consumption of alcohol or caffeine?"

Developmental Tasks for Older Adults

Adjusting to decreasing health and physical strenght; adjusting to retirement and reduced or fixed income; Adjusting to death of a spouse, choldren, siblings, friends; Accepting self as aging person; Maintaining satisfactory living arrangements; Redefining relationships with adult children and siblings; Finding ways to maintain quality of life

ANS: D The nurse should assess first to determine cause, then should discuss and create goals with the patient, so nurse and patient can work in tandem to normalize voiding. The nurse should incorporate the patient's input into creating a plan of care for the patient. Drinking excessive fluid will not help and may worsen alterations in urinary elimination. The nurse does not need to monitor every void attempt by the patient; instead the nurse should provide patient education. The nurse asks the patient about normal voiding patterns, but establishing voiding patterns is a later intervention.

17. When establishing a diagnosis of altered urinary elimination, the nurse should first a. Establish normal voiding patterns for the patient. b. Encourage the patient to flush kidneys by drinking excessive fluids. c. Monitor patients' voiding attempts by assisting them with every attempt. d. Discuss causes and solutions to problems related to micturition.

ANS: C The patient should hold the labia apart to reduce bacterial levels in the specimen. The urethral meatus should be cleansed from the area of least contamination to greatest contamination (or front-to-back). The initial steam flushes out microorganisms in the urethra and prevents bacterial transmission in the specimen. Drink fluids 30 to 60 minutes before giving a specimen.

18. To obtain a clean-voided urine specimen for a female patient, the nurse should teach the patient to a. Cleanse the urethral meatus from the area of most contamination to least. b. Initiate the first part of the urine stream directly into the collection cup. c. Hold the labia apart while voiding into the specimen cup. d. Drink fluids 5 minutes before collecting the urine specimen.

ANS: A Bacteria indicate a urinary tract infection. Crystals would be seen with renal stone formation. Casts indicate renal alterations. Protein is not visible under a microscope and indicates renal disease.

19. When viewing a urine specimen under a microscope, what would the nurse expect to see in a patient with a urinary tract infection? a. Bacteria b. Casts c. Crystals d. Protein

Intracardiac

Administered directly into cardiac tissue, usually limited to physician administration.

ANS: D Flank pain and calcium phosphate crystals are associated with renal calculi. An intravenous pyelogram allows the provider to observe pathological problems such as obstruction of the ureter. A renal ultrasound is performed to identify gross structures. A bladder scan measures the amount of urine in the bladder. A KUB x-ray shows size, shape, symmetry, and location of the kidneys.

22. The nurse would anticipate an order for which diagnostic test for a patient who has severe flank pain and calcium phosphate crystals revealed on urinalysis? a. Renal ultrasound b. Bladder scan c. KUB x-ray d. Intravenous pyelogram

ANS: A, B When obtaining a 24-hour urine specimen, it is important to keep the urine in cool condition. The patient should be asked to void and to discard the urine before the procedure begins. Medications do not need to be held unless indicated by the provider. If properly educated about the collection procedure, the patient can maintain autonomy and perform the procedure alone, taking care to maintain the integrity of the solution.

2. The nurse properly obtains a 24-hour urine specimen collection by (Select all that apply.) a. Asking the patient to void and to discard the first sample. b. Keeping the urine collection container on ice. c. Withholding all patient medications for the day. d. Asking the patient to notify the staff before and after every void.

Intraarticular

Administered directly into the joint, usually limited to physician administration.

ANS: C Incomplete fat metabolism and buildup of ketones give urine a sweet or fruity odor. Cloudy urine may indicate infection or renal failure. Discolored urine may result from various medications. Painful urination indicates an alteration in urinary elimination.

20. The nurse would expect the urine of a patient with uncontrolled diabetes mellitus to be a. Cloudy. b. Discolored. c. Sweet smelling. d. Painful.

Parenteral nutrition (PN)

Administration of nutrition into the vascular system.

ANS: D Intravenous pyelography is performed by administering iodine-based dye to view functionality of the urinary system. Many individuals are allergic to shellfish; therefore, the first nursing priority is to assess the patient for an allergic reaction that could be life threatening. The nurse should then encourage the patient to drink fluids to flush dye resulting from the procedure. Narcotics can be administered but are not the first priority. Turning the patient on the side will not affect patient safety.

23. A nurse is caring for a patient who just underwent intravenous pyelography that revealed a renal calculus obstructing the left ureter. What is the nurse's first priority in caring for this patient? a. Turn the patient on the right side to alleviate pressure on the left kidney. b. Encourage the patient to increase fluid intake to flush the obstruction. c. Administer narcotic medications to alleviate pain. d. Monitor the patient for fever, rash, and difficulty breathing.

ANS: C Patients are not put under anesthesia for a CT scan; instead the nurse should educate patients about the need to lie perfectly still and about possible methods of overcoming feelings of claustrophobia. The other options are correct. Patients need to be assessed for an allergy to shellfish if receiving contrast for the CT. Bowel cleansing is often performed before CT. Listening to music will help the patient relax and remain still during the examination.

24. Which statement by the patient about an upcoming computed tomography (CT) scan indicates a need for further teaching? a. "I'm allergic to shrimp, so I should monitor myself for an allergic reaction." b. "I will complete my bowel prep program the night before the scan." c. "I will be anesthetized so that I lie perfectly still during the procedure." d. "I will ask the technician to play music to ease my anxiety."

ANS: D Before the procedure is begun, the nurse should assess the patient for food and other allergies and should administer an antihistamine, because a contrast iodine-based dye is used for the procedure. Baseline vitals should be obtained before the start of the procedure and frequently thereafter. The procedure site is monitored and the patient kept on bed rest after the procedure is complete.

25. The nurse anticipates preparing a patient who is allergic to shellfish for an arteriogram by a. Obtaining baseline vital signs after the start of the procedure. b. Monitoring the extremity for neurocirculatory function. c. Keeping the patient on bed rest for the prescribed time. d. Administering an antihistamine medication to the patient.

ANS: A Urodynamic testing evaluates the muscle function of the bladder and is used to look for the cause of urinary incontinence. Severe flank pain indicates renal calculi; CT scan or IVP would be a more efficient diagnostic test. Blood indicates trauma to the urethral or bladder mucosa. Pain on elimination may warrant cultures to check for infection.

26. A nurse anticipates urodynamic testing for a patient with which symptom? a. Involuntary urine leakage b. Severe flank pain c. Presence of blood in urine d. Dysuria

ANS: B To stimulate micturition, the nurse should attempt noninvasive procedures first. Running warm water or stroking the inner aspect of the upper thigh promotes sensory perception that leads to urination. A patient should not be left alone on a bedpan for 30 minutes because this could cause skin breakdown. Catheterization places the patient at increased risk of infection and should not be the first intervention attempted. Diuretics are useful if the patient is not producing urine, but they do not stimulate micturition.

27. A patient is having difficulty voiding in a bedpan but states that she feels her bladder is full. To stimulation micturition, which nursing intervention should the nurse try first? a. Exiting the room and informing the patient that the nurse will return in 30 minutes to check on the patient's progress b. Utilizing the power of suggestion by turning on the faucet and letting the water run c. Obtaining an order for a Foley catheter d. Administering diuretic medication

ANS: A Nightly incontinence and nocturia are often resolved by limiting fluid intake 2 hours before bedtime. Setting the alarm clock to wake does not correct the physiological problem, nor does lining the bedding with plastic sheets. Emptying the bladder may help with early nighttime urination, but will not affect urine produced throughout the night from late-night fluid intake.

28. A nurse is caring for an 8-year-old patient who is embarrassed about urinating in his bed at night. Which intervention should the nurse suggest to reduce the frequency of this occurrence? a. "Drink your nightly glass of milk earlier in the evening." b. "Set your alarm clock to wake you every 2 hours, so you can get up to void." c. "Line your bedding with plastic sheets to protect your mattress." d. "Empty your bladder completely before going to bed."

ANS: B Assuming a normal voiding position helps patients relax and be able to void; lying in bed is not the typical position in which people void. Men usually are most comfortable when standing; women are more comfortable when sitting and squatting. Embarrassment at using the bedpan and worrying about a urinary tract infection are not related to the lying-in-bed position. Fear of loss of independence is not related to use of the bedpan or urinal.

29. Many individuals have difficulty voiding in a bedpan or urinal while lying in bed because they a. Are embarrassed that they will urinate on the bedding. b. Would feel more comfortable assuming a normal voiding position. c. Feel they are losing their independence by asking the nursing staff to help. d. Are worried about acquiring a urinary tract infection.

ANS: A Using cold solutions, instilling solutions too quickly, and prolonging filling of the bladder can cause discomfort and cramping. To reduce this, ensure that the solution is at room temperature, lower the solution bag so it instills slowly, and drain the bladder fully after an ordered amount of time.

37. To reduce patient discomfort during closed catheter irrigation, the nurse should a. Use room temperature irrigation solution. b. Administer the solution as quickly as possible. c. Allow the solution to sit in the bladder for at least 1 hour. d. Raise the bag of irrigation solution at least 12 inches above the bladder.

Medication allergy

Adverse reaction such as rash, chills, or gastrointestinal disturbances to a medication. Once this happens, the patient can no longer receive that particular medication.

Retention

Accumulation of urine in the bladder with the inability to empty fully

ANS: A Recording an output that is greater than what was irrigated into the bladder shows progress that the bladder is draining urine. The other observations do not objectively measure the increase in urine output.

38. Which observation by the nurse best indicates that bladder irrigation for urinary retention has been effective? a. Recording an output that is larger than the amount instilled b. Presence of blood clots or sediment in the drainage bag c. Reduction in discomfort from bladder distention d. Visualizing clear urinary catheter tubing

ANS: A Urinary diversion would be needed in a patient with abdominal trauma who might have injury to the urinary system. Genital warts are not needed for urinary diversion. Patients with a prostatectomy may require intermittent catheterization after the procedure. End-stage renal disease would not be affected by rerouting the flow of urine.

39. The nurse anticipates urinary diversion from the kidneys to a site other than the bladder for which patient? a. A 12-year-old female with severe abdominal trauma b. A 24-year-old male with severe genital warts around the urethra c. A 50-year-old male with recent prostatectomy d. A 75-year-old female with end-stage renal disease

ANS: A, B, D Catheter irrigation is used to flush and remove blockage that may be impeding the catheter from properly draining the bladder. Irrigation is used to remove blood clots in the bladder following surgery. For patients with bladder infection, an antibiotic irrigation is often ordered. A ruptured catheter balloon will involve extensive follow-up and possible surgery to remove the particles. Renal calculi obstruct the ureters and therefore the flow of urine before it reaches the bladder.

3. Which of the following are indications for irrigating a urinary catheter? (Select all that apply.) a. Sediment occluding within the tubing b. Blood clots in the bladder following surgery c. Rupture of the catheter balloon d. Bladder infection e. Presence of renal calculi

Hearing changes begin at the age of:

30

ANS: C A Coudé catheter has a curved tip that is used for patients with enlarged prostates. This would be indicated for a middle-aged male who needs bladder irrigation. Coudé catheters are not indicated for children or women.

30. The nurse would anticipate inserting a Coudé catheter for which patient? a. An 8-year-old male undergoing anesthesia for a tonsillectomy b. A 24-year-old female who is going into labor c. A 56-year-old male admitted for bladder irrigation d. An 86-year-old female admitted for a urinary tract infection.

ANS: C Placing the drainage bag on the side rail of the bed could allow the bag to be raised above the level of the bladder and urine to flow back into the bladder. The urine in the drainage bag is a medium for bacteria; allowing it to reenter the bladder can cause infection. The drainage bag should be emptied and output recorded every 8 hours or when needed. Urine specimens are obtained by temporarily kinking the tubing; a prolonged kink could lead to bladder distention. Failure to secure the catheter to the patient's thigh places the patient at risk for tissue injury from catheter dislodgment.

31. The nurse knows that which indwelling catheter procedure places the patient at greatest risk for acquiring a urinary tract infection? a. Emptying the drainage bag every 8 hours or when half full b. Kinking the catheter tubing to obtain a urine specimen c. Placing the drainage bag on the side rail of the patient's bed d. Failing to secure the catheter tubing to the patient's thigh

ANS: C If the patient has not produced urine in 2 hours, the physician needs to be notified immediately because this could indicate renal failure. Discomfort upon catheter insertion is unpleasant but unavoidable. The nurse is responsible for maintaining the integrity of the catheter by ensuring that the drainage bag is below the patient's bladder. Stool left on the catheter can cause infection and should be removed as soon as it is noticed. The nurse should ensure that frequent perineal care is being provided.

32. A nurse notifies the provider immediately if a patient with an indwelling catheter a. Complains of discomfort upon insertion of the catheter. b. Places the drainage bag higher than the waist while ambulating. c. Has not collected any urine in the drainage bag for 2 hours. d. Is incontinent of stool and contaminates the external portion of the catheter. ANS: C

ANS: B Urinary catheterization places the patient at increased risk for infection and should be performed only when necessary. Urine can be obtained via clean-catch technique for a drug screening or urinalysis. Spinal cord injury, surgery, and renal failure wi h critical t intake and output monitoring are all appropriate reasons for catheterization.

33. The nurse would question an order to insert a urinary catheter on which patient? a. A 26-year-old patient with a recent spinal cord injury at T2 b. A 30-year-old patient requiring drug screening for employment c. A 40-year-old patient undergoing bladder repair surgery d. An 86-year-old patient requiring monitoring of urinary output for renal failure

ANS: B Hand hygiene helps prevent infection in patients with a urinary catheter. A catheter should be inserted in the hospital setting using sterile technique. Inflating the balloon fully prevents dislodgement and trauma, not infection. Disconnecting the drainage bag from the catheter creates a break in the system and an open portal of entry and increases risk of infection. DIF: Apply REF: 1048 OBJ: Discuss nursing measures

34. When caring for a hospitalized patient with a urinary catheter, which nursing action best prevents the patient from acquiring an infection? a. Inserting the catheter using strict clean technique b. Performing hand hygiene before and after providing perineal care c. Fully inflating the catheter's balloon according to the manufacturer's recommendation d. Disconnecting and replacing the catheter drainage bag once per shift

ANS: D Cranberry juice and other acidic foods decrease adherence of bacteria to the bladder wall. Urinary tract infections are avoidable in the elderly population with proper knowledge and hygiene. Perineal skin should be cleansed from front to back to avoid spreading fecal matter to the urethra. Increasing fluids will help to flush bacteria, thus preventing them from residing in the bladder for prolonged periods of time.

35. An 86-year-old patient asks the nurse what lifestyle changes will reduce the chance of a urinary tract infection. Which response is accurate? a. Urinary tract infections are unavoidable in the elderly because of a weakened immune system. b. Decreasing fluid intake will decrease the amount of urine with bacteria produced. c. Making sure to cleanse the perineal area from back to front after voiding will reduce the chance of infection. d. Increasing consumption of acidic foods such as cranberry juice will reduce the chance of infection.

ANS: C Some anti-infective medications turn urine colors; this is normal and will dissipate as the medication leaves the system. Even if the patient is on medication, hygiene is important to prevent spread or reinfection. Fluid intake should be increased to help flush out bacteria; however, 15 to 20 glasses is too much. Sexual intercourse is allowed with a urinary tract infection, as long as good hygiene and safe practices are used.

36. A nurse is providing education to a patient being treated for a urinary tract infection. Which of the following statements by the patient indicates an understanding? a. "Since I'm taking medication, I do not need to worry about proper hygiene." b. "I should drink 15 to 20 glasses of fluid a day to help flush the bacteria out." c. "My medication may discolor my urine; this should resolve once the medication is stopped." d. "I should not have sexual intercourse until the infection has resolved."

Nursing diagnoses relevant to patients with sensory alterations:

risk prone health behavior, impaired verbal communication, risk for injury, impaired physical mobility, bathing self care deficit, dressing self care deficit, toileting self care deficit, situational low self esteem, risk for falls, social isolation

ANS: B, C, D Uremic syndrome is associated with end-stage renal disease. Signs and symptoms include headache, altered mental status, coma, seizures, nausea, vomiting, and pericarditis.

4. Which of the following symptoms are most closely associated with uremic syndrome? (Select all that apply.) a. Fever b. Nausea and vomiting c. Headache d. Altered mental status e. Dysuria

Assess the patients home for common hazards in their environment such as:

4. bathrooms without shower or tub grab bars 5. water faucets unmarked to designate hot and cold 6. unlit stairways, lack of handrails

Hearing changes occuring with age include:

4. low pitch sounds are easiest to hear 5. it is difficult to hear conversations over background noise 6. difficult to discriminate the consonants (z,t,f,g) 7. difficult to discriminate high frequency sounds (s, sh, ph, k)

ANS: B, C Osmosis and diffusion are the two processes used to clean the patient's blood in both types of dialysis. In peritoneal dialysis, osmosis and dialysis occur across the semi-permeable peritoneal membrane. In hemodialysis, osmosis and dialysis occur through the filter membrane on the artificial kidney. In peritoneal dialysis, the dialysate flows by gravity out of the abdomen.Gravity has no effect on cleansing of the blood. Filtration is the process that occurs in the glomerulus as blood flows through the kidney.

5. The nurse understands that peritoneal dialysis and hemodialysis use which processes to clean the patient's blood? (Select all that apply.) a. Gravity b. Osmosis c. Diffusion d. Filtration

Sensory Assessment includes

5. ability to perform self care 6. health promotion habits 7. environmental hazards 8. communication methods 9. social support

Adult visual changes include:

5. reduced visual fields 6. increased glare sensitivity 7. impaired night vision 8. reduced depth perception 9. reduced color discrimination

Gustatory and olfactory changes begin around age:

50

What age is lower boundry for "old age"?

65 yo in demographics and social policu in US

ANS: C Reducing fluids, especially caffeine and alcohol, before bedtime can reduce nocturia. Clearing a path to the restroom or illuminating the path, or shortening the distance to the restroom, may reduce falls but will not correct the urination problem. Kegel exercises are useful if a patient is experiencing incontinence.

8. A patient has fallen several times in the past week when attempting to get to the bathroom. The patient informs the nurse that he gets up 3 or 4 times a night to urinate. Which recommendation by the nurse is most appropriate in correcting this urinary problem? a. Clear the path to the bathroom of all obstacles before bed. b. Leave the bathroom light on to illuminate a pathway. c. Limit fluid and caffeine intake before bed. d. Practice Kegel exercises to strengthen bladder muscles.

ANS: B A urinary catheter would relieve urinary retention. Reducing fluids would reduce the amount of urine produced but would not alleviate the urine retention. Diuretic medication would increase urine production and may worsen the discomfort caused by urine retention. A renal angiogram is an inappropriate diagnostic test for urinary retention.

9. When caring for a patient with urinary retention, the nurse would anticipate an order for a. Limited fluid intake. b. A urinary catheter. c. Diuretic medication. d. A renal angiogram.

The nurse anticipates administering an opioid fentanyl patch to which patient?

A 50-year-old patient with prostate cancer

Theories of Aging

stochastic theories, nonstochastic theories, disengagement threory, active theory, continuity (developmental) theory, gerotranscendence theory

Vision health suggestions:

suggest the use of yellow or amber lenses and shades or blinds on windows to minimize glare

4. A patient requests the nurse's assistance to the bedside commode and becomes frustrated when unable to void in front of the nurse. The nurse understands the patient's inability to void because a. Anxiety can make it difficult for abdominal and perineal muscles to relax enough to void. b. The patient does not recognize the physiological signals that indicate a need to void. c. The patient is lonely, and calling the nurse in under false pretenses is a way to get attention. d. The patient is not drinking enough fluids to produce adequate urine output.

ANS: A Attempting to void in the presence of another can cause anxiety and tension in the muscles that make voiding difficult. The nurse should give the patient privacy and adequate time if appropriate. No evidence suggests that an underlying physiological or psychological condition exists.

2. When reviewing laboratory results, the nurse should immediately notify the health care provider about which finding? a. Glomerular filtration rate of 20 mL/min b. Urine output of 80 mL/hr c. pH of 6.4 d. Protein level of 2 mg/100 mL

ANS: A Normal glomerular filtration rate should be around 125 mL/min; a severe decrease in renal perfusion could indicate a life-threatening problem such as shock or dehydration. Normal urine output is 1000 to 2000 mL/day; an output of 30 mL/hr or less for 2 or more hours would be cause for concern. The normal pH of urine is between 4.6 and 8.0. Protein up to 8 mg/100 mL is acceptable; however, values in excess of this could indicate renal disease.

6. The nurse knows that urinary tract infection (UTI) is the most common health care-associated infection because a. Catheterization procedures are performed more frequently than indicated. b. Escherichia coli pathogens are transmitted during surgical or catheterization procedures. C.Perineal care is often neglected by nursing staff. D.Bedpans and urinals are not stored properly and transmit infection.

ANS: B E. coli is the leading pathogen causing UTIs; this pathogen enters during procedures. Sterile technique is imperative to prevent the spread of infection. Frequent catheterizations can place a patient at high risk for UTI; however, infection is caused by bacteria, not by the procedure itself. Perineal care is important, and buildup of bacteria can lead to infection, but this is not the greatest cause. Bedpans and urinals may become bacteria ridden and should be cleaned frequently. Bedpans and urinals are not inserted into the urinary tract, so they are unlikely to be the primary cause of UTI.

1. If obstructed, which component of the urination system would cause peristaltic waves? a. Kidney b. Ureters c. Bladder d. Urethra

ANS: B Ureters drain urine from the kidneys into the bladder; if they become obstructed, peristaltic waves attempt to push the obstruction into the bladder. The kidney, bladder, and urethra do not produce peristaltic waves. Obstruction of both bladder and urethra typically does not occur.

5. The nurse knows that indwelling catheters are placed before a cesarean because a. The patient may void uncontrollably during the procedure. b. A full bladder can cause the mother's heart rate to drop. c. Spinal anesthetics can temporarily disable urethral sphincters. d. The patient will not interrupt the procedure by asking to go to the bathroom.

ANS: C Spinal anesthetics may cause urinary retention due to the inability to sense or carry out the need to void. The patient is more likely to retain urine, rather than experience uncontrollable voiding. With spinal anesthesia, the patient will not be able to ambulate during the procedure. A full bladder has no impact on the pulse rate of the mother.

3. A patient is experiencing oliguria. Which action should the nurse perform first? a. Increase the patient's intravenous fluid rate. b. Encourage the patient to drink caffeinated beverages. c. Assess for bladder distention. d. Request an order for diuretics.

ANS: C The nurse first should gather all assessment data to determine the potential cause of oliguria. It could be that the patient does not have adequate intake, or it could be that the bladder sphincter is not functioning and the patient is retaining water. Increasing fluids is effective if the patient does not have adequate intake, or if dehydration occurs. Caffeine can work as a diuretic but is not helpful if an underlying pathology is present. An order for diuretics can be obtained if the patient was retaining water, but this should not be

7. An 86-year-old patient tells the nurse that she is experiencing uncontrollable leakage of urine. Which nursing diagnosis should the nurse include in the patient's plan of care? a. Urinary retention b. Hesitancy c. Urgency d. Urinary incontinence

ANS: D Age-related changes such as loss of pelvic muscle tone can cause involuntary loss of urine known as Urinary incontinence. Urinary retention is the inability to empty the bladder. Hesitancy occurs as difficulty initiating urination. Urgency is the feeling of the need to void immediately.

Metabolism .

Aggregate of all chemical processes that take place in living organisms, resulting in growth, generation of energy, elimination of wastes, and other functions concerned with the distribution of nutrients in the blood after digestion

Indispensible amino acids

Amino acids that the body cannot synthesize

Dispensable amino acids

Amino acids that the body synthesizes

Basal Metabolic Rate (BMR)

Amount of energy used in a unit of time by a fasting, resting subject to maintain vital functions.

Verbal order

An order for a medication or medical treatment given verbally to the nurse.

Telephone order

An order for a medication or medical treatment made over the telephone.

Glycogenesis

Anabolism of glucose into glycogen for storage.

Ability to perform self care (Assessment of Sensory Alterations)

Assess whether a patient with altered vision is able to find items on a meal try and read directions on a prescription. Ability to perform IADLs

The nurse recognizes that which of the following is a modifiable contributor to a patient's perception of pain?

Anxiety and fear

Medication error

Any event that could cause or lead to a patient's receiving inappropriate drug therapy or failing to receive appropriate drug therapy

Lipid

Any of the free fatty acid fractions in the blood

Medication reconciliation

Any process that ensures that the medications given to and taken by the patient are the same as those prescribed by the health care provider.

Side effect

Any reaction or consequence that results from medication or therapy.

Describe the following characteristics of urine. Clarity

Appear transparent at voiding; becomes more cloudy on standing in a container

A nurse receives an order from a health care provider to administer Vicodin ES, which contains 750 mg acetaminophen and 7.5 mg hydrocodone, to a patient who is experiencing 8/10 postsurgical pain. The order is to give 2 tablets every 6 hours by mouth as needed for pain. What is the nurse's best next action?

Ask the health care provider to verify the dosage and frequency of the medication.

The nurse is caring for a patient who suddenly experiences chest pain. What is the nurse's first priority?

Ask the patient to rate and describe the pain.

What is the most appropriate way to assess the pain of a patient who is oriented and has recently had surgery?

Ask the patient to rate the level of pain.

Hematuria

Blood in the urine

Amino acids

Building blocks that construct proteins; the end products of protein digestion

NPH

Can be mixed w/ rapid-acting insulin, must be 15 min before meal!

Glycogenolysis

Catabolism of glycogen into glucose, carbon dioxide, and water.

Incontinence

Cause by loss of pelvic muscle tone, fecal impaction, overactive bladder

Hesitancy

Caused by prostate enlargement, anxiety, or urethral edema

Unsaturated fatty acids

Fatty acids in which an unequal number of hydrogen atoms are attached and the carbon atoms attach to each other with a double bond.

Biotransformation

Chemical changes that a substance undergoes in the body such as by the action of enzymes.

Triglycerides

Circulate in the blood and are made up of three fatty acids attached to a glycerol.

Describe the following types of urine specimens collected got testing. Clean-voided or midstream

Clean-voided or midstream: Use a sterile specimen cup. For girl and women: After donning sterile gloves, spread the labia with thumb and forefinger of the nondominant hand. Cleanse the area with a cotton ball or gauze, moving from front (above urethral orifice) to back (toward anus). Using a fresh swab each time, repeat the front-to-back motion three times (begin with the center, then left side, then right side). If agency policy indicates, rinse the area with sterile water and dry with dry cotton ball or gauze. While continuing to hold the labia apart, have the patient initiate the urine tream. After the patient achieves a stream, pass the container into the stream and collect 30 to 60 mL. Remove the specimen container before the flow of urine stops and before releasing the labia. The patient finishes voiding in a bedpan or toilet. For boys and men: After donning sterile gloves , hold the penis with one hand, and using circular motion and antiseptic swab, clean the end of the penis, moving from the center to the outside. In uncircumcised men, retract the foreskin before cleansing. If agency procedure indicates , rinse the area with sterile water and dry with cotton or gauze. After the patient has initiated the urine stream pass the specimen collection container into the stream and collect 30 to 60 mL. Remove the specimen container before the flow of urine stops and before releasing the penis . The patient finishes voiding in a bedpan or toilet.

Catabolism

Complex metabolic process in which energy is liberated for use in work, energy, storage, or heat production by oxidation of carbohydrates, lipids, and proteins; carbon dioxide and water, as well as energy, are produced.

Hypervitaminosis

Condition caused by excessive intake of a vitamin; less likely to occur with water-soluble vitamins.

Anorexia

Condition in which ill or debilitated clients have poor appetites.

Anabolism

Constructive metabolism characterized by conversion of simple substances into more complex compounds of living matter

Vegetarianism

Consumption of a diet consisting predominantly of plant foods.

Peristalsis

Coordinated, rhythmic, serial contractions of smooth muscle that force food through the digestive tract.

Saturated fatty acids

Fatty acids in which each carbon in the chain has an attached hydrogen atom.

Monosaturated (fatty acids)

Fatty acids that have one carbon bond.

Polyunsaturated (fatty acids)

Fatty acids that have two or more carbon double bonds.

Therapeutic effect

Desired benefit of a medication, treatment, or procedure.

Carbohydrate

Dietary classification of food such as sugars, starches, cellulose, and gum.

Dysphagia .

Difficulty swallowing

Oliguria

Diminished urinary output relative to intake

Anorexia nervosa

Disease characterized by a prolonged refusal to eat, resulting in emaciation, amenorrhea, emotional disturbance concerning body image, and an abnormal fear of becoming obese.

Ophthalmic

Drugs given into the eye in the form of either eye drops or ointments.

Frequency

Due to increased fluid intake, pregnancy, and diuretics

Toxic effect

Effect of a medication that results in an adverse response.

Synergistic effect

Effect resulting from two drugs acting synergistically. The effect of the two drugs combined is greater than the effect that would be expected if the individual effects of the two drugs acting alone were added together.

Nurse Practice Acts (NPAs)

Statutes enacted by legislature of any of the states or the appropriate officers of the districts or possessions that describe and define the scope of nursing practice.

Renin

Enzyme that converts angiotensinogen into angiotension I

Ideal body weight (IBW)

Estimate of what a person should weigh.

Urgency

Feeling of the need to void immediately

Briefly describe the following urinary diversions. Nephrostomy

For a nephrostomy, a tube is placed directly into the renal pelvis to drain urine directly from one or both of the kidneys

Briefly describe the following urinary diversions. Ileal conduit

For an ileal conduit, ureters are implanted into the isolated segment of ileum and used as a conduit for continuous drainage. The patient wears a stomal pouch continuously

Dietary reference intakes (DRIs)

Format presenting a range of acceptable intake in place of absolute values.

Gluconeogenesis

Formation of glucose or glycogen from substances that are not carbohydrates, such as proteins or lipids.

Nephron

Functional unit of the kidneys that forms the urine

Erythropoietin

Functions within the bone marrow to stimulate red blood cell production

Which of the following is the best way for the nurse to manage pain for a patient with chronic pain from arthritis?

Give medications around-the-clock.

Parenteral administration

Giving medication by a route other than the gastrointestinal tract.

DO NOT MIX (insulin)

Glargine Detemir

Residual urine

Greater than 100mL of urine remaining after voiding

Pressurized metered-dose inhaler (pMDI)

Handheld inhalers that disperse medication through an aerosol spray. Often used by children and adults with chronic respiratory diseases.

Adverse Effect

Harmful or unintended effect of a medication, diagnostic test, or therapeutic intervention.

Describe the following characteristics of urine. Odor

Has a characteristic odor; the more concentrated the urine, the stronger the odor

Explain the following alterations in urinary elimination. Urinary tract infection (UTI)

Hospital-acquired UTIs result from catheterization or surgical manipulation. Escherichia coli is the most common pathogen

Anaphylactic reaction

Hypersensitive condition induced by contact with certain antigens.

The nurse is assessing a patient for opioid tolerance. Which finding supports the nurse's assessment?

Increasingly higher doses of opioid are needed to control pain.

Idiosyncratic reaction

Individual sensitivity to effects of a drug caused by inherited or other bodily constitution factors.

The nurse is caring for an infant in the intensive care unit. Which of the following is the most accurate description of factors that will influence the perception and management of pain for this patient?

Infants respond behaviorally and physiologically to painful stimuli.

Intravenous (IV)

Injection directly into the bloodstream. Action of the drug begins immediately.

Intradermal (ID)

Injection given between layers of the skin into the dermis. Given at a 5-15 degree angle.

Intramuscular (IM)

Injection given into muscle tissue. Provides a fast rate of absorption that is related to greater vascularity of the muscle. Injections are given at a 90 degree angle.

Subcutaneous (sub-Q)

Injection given into the connective tissue under the dermis. Absorbs drugs more slowly than those injected into the muscle. Injections are usually given at a 45-degree angle.

Minerals

Inorganic elements essential to the body because of their role as catalysts in biochemical reactions.

Bulimia nervosa

Insatiable craving for fond, often resulting in episodes of continuous eating that are followed by purging, depression, and self-deprivation.

Infusion

Introduction of fluid into the vein, giving intravenous fluid over time.

Renal calculus

Kidney stone

What nursing intervention is most effective in preventing injury to a patient following administration of epidural anesthesia?

Labeling the tubing that leads to the epidural catheter

Polyuria

Large amounts of urine voided

Metric system

Logically organized decimal system of measurement; metric units can easily be converted and computed through simple multiplication and division. Each basic unit of measurement is organized into units of 10.

Reflex incontinence

Loss of voluntary control; micturition reflex pathway is intact

Dribbling

May be caused by stress incontinence

The nurse is caring for two patients; both are having a hysterectomy. The first patient is having the hysterectomy after a complicated birth. The second patient has uterine cancer. What will most likely influence the experience of pain for these two patients?

Meaning of pain

Kilocalorie (kcal)

Measurement of heat that is equal to the amount of heat required to raise the temperature of one kilogram of water by one degree at one atmosphere pressure; used by nutritionists to characterize the energy-producing potential in food

Body mass index (BMI)

Measurement of weight, corrected for height, which serves as an alternative to traditional height-weight relationships.

Resting energy expenditure (REE)

Measurement that accounts for BMR plus energy to digest meals and perform mild activity.

Transdermal disk

Medication delivery device in which the medication is saturated on a waferlike disk, which is affixed to the patient's skin. This method ensures that the patient receives a continuous level of medication.

Intraocular

Method of medication delivery that involves inserting a medication disk similar to a contact lens into the patient's eye

Macromineral

Minerals classified as having a daily requirement of 100 mg or more.

Trace elements

Minerals when less than 100 mg is needed daily; microminerals.

Solution

Mixture of one or more substances dissolved in another substance. The molecules of each of the substances disperse homogeneously and do not change chemically. Can be a liquid, gas, or solid.

Simple carbohydrates

Monosaccharides and disaccharides, found primarily in sugars.

Nocturia

Nighttime voiding often caused by coffee or alcohol

Fiber

Nutrient that contains cellulose, pectin, hemicellulose, and lignin; sources are mainly fruits and vegetables.

Fatty acids

Nutrients composed of chains of carbon atoms and hydrogen atoms with an acid group on one end of the chain and a methyl group at the other.

Buccal

Of or pertaining to the inside of the cheek or gum next to the cheek.

Ketone

Organic chemical compound characterized by having in its structure a carbonyl, or keto, group, =CO, attached to two alkyl groups.

Fat-soluble vitamins

Organic compounds essential for normal physiological and metabolic functioning; classified on the basis of their fat solubility.

Vitamins

Organic compounds essential in small quantities for normal physiological and metabolic functioning of the body. With few exceptions, vitamins cannot be synthesized by the body and must be obtained from the diet or dietary supplements.

Dysuria

Painful or difficult urination

Describe the following characteristics of urine. Color

Pale, straw-colored to amber-colored depending on its concentration

Absorption

Passage of drug molecules into the blood. Influencing factors include route of administrations, ability of the drug to dissolve and conditions of the site.

A nurse is caring for a patient with rheumatoid arthritis who is now going to be taking 2 acetaminophen (Tylenol) tablets every 6 hours to control pain. Which part of the patient's social history is the nurse most concerned about?

Patient drinks 1 to 2 glasses of wine every night.

Proteinuria

Presence of large proteins in the urine

Irrigation

Process of washing out a body cavity or wounded area with a stream of fluid

Nutrient density

Proportion of essential nutrients to the number of calories of a specific food.

Enzymes

Proteins produced by living cells that catalyze chemical reactions in organic matter

Enteral nutrition (EN)

Provision of nutrients through the gastrointestinal tract when the client cannot ingest, chew, or swallow food but can digest and absorb nutrients.

Describe the following types of urine specimens collected got testing. Random

Random: Collect during normal voiding from an indwelling catheter or urinary diversion collection bag. Use a clean specimen cup.

In is impossible to:

React to all stimuli entering the nervous system

Micturition

Reflux of urine from the bladder into the urethers

Nitrogen balance

Relationship between the nitrogen taken into the body, usually as food, and the nitrogen excreted from the body in urine and feces. Most of the body's nitrogen is incorporated into protein.

A 24-year-old Asian woman is in labor and refuses to receive any sort of anesthesia medication. Which alternative treatment is best for this patient?

Relaxation and guided imagery

Medication interaction

Response that occurs when one drug modifies the action of another drug. Can potentiate or diminish the actions of another drug; or it may alter the way a drug is metabolized, absorbed or excreted.

Sublingual

Route of medications administration in which the medication is placed underneath the patient's tongue.

Describe the following types of urine specimens collected got testing. Sterile

Sterile: If the patient has an indwelling catheter, collect a sterile specimen by using a septic technique through the pecial sampling port (Figure 45-7, p. 1053) found on the side of the catheter. Clamp the tubing below the port, allowing fresh, uncontaminated urine to collect in the tube. After the nurse wipes the port with an antimicrobial swab, insert a sterile syringe hub and withdraw at least 3 to 5 mL of urine (check agency policy). Using sterile aseptic technique, transfer the urine to a sterile container.

Explain the following types of incontinence. Stress incontinence

Stress: occurs when intrabdominal pressure exceeds urethral resistance

Daily values

Set of dietary standards for eight nutrients and food categories.

Malabsorption

Set of symptoms resulting from disorders in the intestinal absorption of nutrients; characterized by anorexia, weight loss, bloating of the abdomen, and muscle cramps.

Identify the primary structures that the nurse would assess.

Skin and mucosal membranes, kidneys, bladder, urethral meatus

A patient arrives at the emergency department experiencing a headache and rates the pain as 7 on a 0 to 10 pain scale. What nonpharmacological intervention does the nurse implement for this patient while awaiting orders for pain medication from the health care provider?

Softly plays music that the patient finds relaxing

A nurse is caring for a patient who fell on the ice and has connective tissue damage in the wrist and hand. What does type of pain does the nurse document that the patient has?

Somatic pain

Intravenous fat emulsions

Soybean or safflower oil based solutions that are isotonic and may be infused with amino acid and dextrose solution through a central or peripheral line

Injection

The forcing of a fluid into a vessel, tissue, or cavity.

Peak

The highest serum concentration of a medication after the medication dose is administered.

Trough

The lowest serum concentration of a medication before the next medication dose is administered.

A patient who had a motor vehicle accident 2 days ago is experiencing pain and is receiving patient-controlled analgesia (PCA). How does the nurse know that the patient is experiencing effective pain management with the PCA?

The patient rates pain at an acceptable level of 3 on a 0 to 10 scale.

The nurse is administering pain medication for several patients. Which patient does the nurse administer medication to first?

The patient who is experiencing 8/10 pain and has a STAT order for pain medication

A nurse is caring for a patient who recently had spinal surgery. The nurse knows that patients usually experience acute pain following this type of surgery. The patient refuses to get up and walk and is not moving around in the bed. However, the patient is stoic and denies experiencing pain at this time. What most likely explains this patient's behavior and response to surgery?

The patient's culture is possibly influencing the patient's experience of pain.

The nurse is evaluating the effectiveness of guided imagery for pain management as used for a patient who has second- and third-degree burns and needs extensive dressing changes. Which statement best describes that guided imagery is effectively controlling the patient's pain during dressing changes?

The patient's need for analgesic medication decreases during the dressing changes.

Examples of Assessing Mental Status of Sensory Perception:

a patient with severe sensory deprivation is not always able to carry on a conversation, remain attentive or display recent or past memory. An important step toward preventing cognition related disability is education by nurses about disease process, available services and assitive devices.

Biological half-life

Time it takes for the body to lower the amount of unchanged medication by half.

Describe the following types of urine specimens collected got testing. Timed urine

Timed urine: Time required may be 2-, 12-, or 24-hour collection . The timed period begins after the patient urinates and ends with a final voiding at the end of the time period. The patient voids into a clean receptacle, and the urine is transferred to the special collection container, which often contains special preservative . Each specimen must be free of feces and toilet tissue. Missed specimens make the whole collection inaccurate. Check with agency policy and the laboratory for specific instructions.

Instillation

To cause to enter drop by drop or very slowly.

Detoxify

To remove the toxic quality of a substance.

ANS: B Urinary incontinence is uncontrolled urinary elimination; if the urine has prolonged contact with the skin, skin breakdown can occur. An indwelling Foley catheter is a solution for urine retention. Blood clots and foul-smelling discharge are often signs of infection.

While receiving a shift report on a patient, the nurse is informed that the patient has urinary incontinence. Upon assessment, the nurse would expect to find a. An indwelling Foley catheter. b. Reddened irritated skin on the buttocks. c. Tiny blood clots in the patient's urine. d. Foul-smelling discharge indicative of a UTI.

Saccharide

Within carbohydrates, a classification of sugars.

Prescriptions

Written directions for a therapeutic agent (e.g., medication, drugs).

Example of of sensory deficit:

a blind patient deveops an acute sense of hearing to compensate for visual loss.

sensory deficit:

a deficit in the normal function of sensory reception and perception

expressive aphasia;

a motor type of aphasia, is the inability to name common objects or express simple ideas in words or writing.

Anorexia

a prolonged disorder of eating due to loss of appetite

List the signs or symptoms of UTIs. (8)

a. Dysuria b. Fever c. Chills d. Nausea e. Vomiting and malaise f. Cystitis g. Hematuria h. WBC's or bacteria in the urine

patients with reduced tactile sensation usually:

have the impairment over a limited portion of their bodies.

Nurses Attitudes Toward Older Adults

important to assess your attitudes toward older adults; your own aging; and aging of your family, friends and pts; forming positive attitudes toward older adults and gaining specialized knowledge about aging and their health care needs are priorities for all nurses

List source of the factors that influence urination. (5)

a. Pathophysiological conditions (acute, chronic) b. Sociocultural factors c. Psychological factors d. Fluid balance e. Surgical and diagnostic procedures

List the three major factors to be explored during a nursing history in regard to urinary elimination. (3)

a. Pattern of urination b. Symptoms of urinary alterations c. Factors affecting urination

turning and repositioning also:

improve the quality of tactile sensation

Always ask the patient which foods are most appealing:

improving taste perception improves food intake and appetite as well

The absence of visitors during hospitalization or residency in an extended care facility

influences the degree of isolation a patient feels

older persons need to chew food thoroughly to:

allow more food to contact remaining taste buds

Carpal tunnel syndrome:

alters tactile sensation and is one of the most common industrial or work-related injuries

Most Frequent dianosed chronic conditions

arthritis (31%), hypertension (41%), all types of heart disease (31%), any cancer (22%) and diabetes (18%)

Health Promotion Habits involved in (Assessment of Sensory Aterations)

assess the daily routines that patients follow to maintain sensory function. What type of eye and ear care is part of the patients daily hygiene?

occupations involving risk of exposure to chemicals or flying objects (welders)

at risk for eye injuries and need to be screened for visual impairments

occupations involving exposure to high noise levels (factory or airport workers) are:

at risk for noise induced hearing loss and need to be screened for hearing impairments

The actual perception:

awareness of unique sensatios depend on the receiving region of the cerebral cortex, where specialized brain cells interpret the quality and nature of sensory stimuli

Reception:

begins with stimulation of a nerve cell called a receptor which is usually for only one type of stimulus such as light, touch or sound

Nonstochastic Theory of Aging

bilogical theory; view aging as result of genetically programmed physiological mehanisms within body that control the process of aging

Stochastic Theory of Aging

biological theory; view aging as result of random cellular damage that occurs over time; accumulated damge leads to physical changes that are recognized as characteristic of aging process

Color changes involved with vision loss and aging:

brighter colors such as red, orange and yellow are easier to see

Symptoms - Falls

can be common event for older adult and can cause injury; fall is a complex event that needs careful investigation to find out if it was result of evironmental causes or symptom of new-onset illness; probles w/cardiac, respiratory, musculoskeletal, neurological, urological and sensory body systmes can present with a fall as chief symptom

Cautions for Assessing

classic signs and synptoms of diseases are sometiems absent, blunted or atypical in older adults; masquerading of disease is possibly caused by age-related changes in organ systems, homeostatic mechanisms, progressive loss of physiological and functional reserves, or coexisting acute or chronic conditions; variations from norms of lab are sometimes caused by age-rlated changes in cardiac, pulmonary, renal and metabolic function;

Proprioceptive changes:

common after age 60 include difficulty with balance, spatial orientation, and coordination

Symptoms - Dehydration

common in older adults because of decreased oral intake related to a reduced thurst response and less free water as a consequence of a decrease in muscle mass; when vomiting and diarrhea accompany onset of acute illness, older adult is at risk for further dehydration

Symptoms - Decreased Appetite

common symptom w/onset of pneumonia, heart failure, urinary tract infection

Symptoms - Mental Status Changes

commononly occur as result of disease and psychological issues; some often drug related, cuased by drug toxicity or adverse drug events

Assessing Older Adult

comprehensive assessment takes more time than younger adult because of longer life, medical history and potential complexity of history; Sensory canges also affect data gatherrrrring; use tact when involving another person in assessment, additional person supplements answers of older adult but adult remains focus of interview

Perception includes:

integration and interpretation of stimuli based on the person's experience.

a person with a sensory deficit will:

intially withdraw and avoid communication and socialization, but will gradually learn to rely on unaffected senses. some senses may even become more acute to compensate for an alteration

Gerotranscendece Theory of aging

developmental theory; more recent; proposes older adult experiences a shift in perspective with age; person moves from a materialistic and national view of world to a more cosmic and transcendent one, causing an icrease in overall life satisfaction

Continuity Theory of Aging

developmental theory; suggests that personality remains stable and behavior becomes more predictable as people age; the personality and behavior patterns developed during a lifetime determine the degree of engagement and activity in older adulthood

The brains prevents sensory bombardment by:

discarding or storing sensory information

Acceptance of Personal Aging

does not mean retreat into inactivity, but does require a realistic review of strengths and limitations

One way to help an individual with a hearing loss is to:

ensure that the problem is not impacted cerumen. with aging cerumen thickens and builds up in the ear canal

Patients with visual impairments are unable to observe:

facial expressions and other nonverbal behaviors to clarify the content of spoken communication

During the assessment process, thoroughly assess each patient and critically analyze:

findings to ensure that you make patient centered clincial decisions required for safe nursing care

If the patient is willing to be touched:

hair brushing, a back rub and touching the arms or shoulders are ways of increasing tacticle contact.

Agism

has potential to undermine self-confidence of older adults, limit their access to care and distort caregivers' understanding of the uniqueness of each older adult; Older adult's who have positive image about aging actually live 7.5 yrs longer than those w/negative image.

Anthropometry

measurement system of the size and makeup of the body; height and weight obtained

The reaticular activating system in the brainstem:

mediates all sensory stimuli to the cerebral cortex

Symptoms to Watch For

note changes in mental status, occurrence and reason for falls, dehydration, decrease in appetitie, loss of function, dizzines, and incontince because these may be indicators not present in younger adults

Cultural factors that affect sensory alterations:

occur more in select ethnic groups

Symptoms - Loss of Functional Ability

occurs in a subtle fashion over a period of time; or it occurs suddenly, depending on underlying cause; Thyroid disease, infection, cardiac or pulmonary conditions, metabolic disturbances and anemia are ommon causes of functional decline

A concern with normal age-related sensory changes is:

older adults with a deficit are sometimes inappropriatly diagnosed with dementia

Disengagement Theory of Aging

oldest psychosocial theory; states that aging individuals withdraw from customary roles adn engage in more introspective, self-focused aging

Community-based and Institutional Care

outside of acute care hospital, nurses care for older adults in private homes and apartments, retirement communities, adult day care centers,assisted-living facilities, and nursing centers; help older adults and their families by providing info and answering quesitons as they make choices among care options

hyperesthesia:

overly sensitive to tactile stimulation

if a patient is in pain or restricted by a cast or traction:

overstimulation frequently is a problem

When a person becomes concious of a stimulus and receives the information, what takes place?

perception

Color changes involved with vision loss and aging:

perception of colors blue, violet and green usually decline

In the home meaningful stimuli include:

pets, music, television, picturers of family members, and a calendar and clock. The same stimuli need to be present in the health care setting

Nursing care of older adults

poses special challenges because of gret variation in theri physiological, cognitive, and psychosocial health; identify strengths and abilities during assessment and encourage independence as an intergral part of your plan of care

visual changes during adulthood include:

presbyopia and the need for glasses for reading occur usually between ages 40-50

Activity Theory of Aging

psychosocial theory; unlike disengagement theory, considers the continuation of activiteis performed during middle age as necessary for successful aging

The three components of any sensory experience:

reception, perception and reaction

meaningful stimuli:

reduce the indicidence of sensory deprivation.

Nursing Assessment for Older Adult

takes into account 5 key points to ensure age-specific approach: 1) interrelation between physical and psychosocial aspects of aging, 2) effects of disease and disability on functional status, 3) decreases efficiency of homeostatic mechanisms, 4) lack of standards for health and illness norms, 5) altered presentatoin and response to specific disease;

Gustatory and olfactory changes include:

the decrease in the number of taste buds and sensory cells in the nasal lining.

Global aphasia:

the inability to understand language or communicate orally

Sensory or receptive aphasia:

the inability to understand written or spoken language. A patient is able to express words but is unable to understand questions or comments of others.

Example of sensory alterations history:

the nature of sensory alterations or any problem related to an alteration. Have the patient self rate by asking "rate your hearing as excellent, good, fair, poor or bad"

the patient needs to avoid blending or mixing foods because:

these actions make it diffcult to identify tastes

promote the sense of taste by:

using measures to enhance remaining taste perception

aphasia:

varied degrees of inability to speak, interpret or understand language

Variability Among Older Adults

vary widely in levels of functional ability; most remain functionally independed despite the increasing prevelance of chronic disease; Chronic conditions add to complexity of assessment and care of older adult; most have at least one chronic condition, many have multiple conditions

vision health suggestions;

wear sunglasses outside

sensory overload:

when a person receives multiple sensory stimuli and cannot perceptually disregard or selectively ignore some stimuli

When does sensory alterations occur:

when an individual attempts to react to every stimulus within the environment or if the variety and quality of stimuli are insufficient

to maximize residual hearing function:

work closely with the patient to suggest ways to modify the environment

Communications Methods used in (assessment of sensory alterations)

you need to know whether a patient has trouble speaking, understanding, naming, reading, or writing