NCSBN Lesson 5: Basic Care and Comfort

Crutches

Keep tips of crutches 8-12 inches to side of feet. Adjust length to 3-4 finger widths from axilla Handlebars 15-30 degree of elbow flexion

B1

THIAMIN Supports energy metabolism and nerve function Lean meats, fish, dried beans, soy milk, legumes,watermelon *Alcoholic are usually deficient

Vitamin E

Antioxidant; regulation of oxidation reactions; supports cell membrane stabilization Leafy greens, polyunsaturated plant oils (soybean, corn and canola), wheat germ, nuts and seeds, avocado, shrimp, cod, sardines

Colostomy

Ascending- must wear appliance, semi-liquid stool Transverse- wear appliance, semi formed stool Sigmoid- formed stool, may be irrigated

Parents are concerned that their 11 year-old child is a very picky eater. The nurse suggests which of these approaches should be the best initial action? 1. Discuss the consequences of an unbalanced diet with the child 2. Encourage the child to keep a daily log of foods eaten 3. Provide fruit, vegetable and protein snacks 4. Consider a liquid supplement to increase calories

1 A priority is to educate the preadolescent as to appropriate diet, and the outcomes that result if the diet is not adequate. Afterwards the other options are appropriate to implement.

The nurse is making a home visit to a client diagnosed with chronic obstructive pulmonary disease (COPD). The client tells the nurse that he used to be able to walk from the house to the mailbox without difficulty. Now, he has to pause to catch his breath halfway through the trip. Which nursing diagnosis is appropriate for this client based on this assessment? 1. Activity intolerance related to chronic tissue hypoxia as evidenced by fatigue 2. Impaired mobility related to chronic obstructive pulmonary disease as evidenced by a change 3. Ineffective airway clearance related to increased bronchial secretions as evidenced by complaints 4. Self-care deficit related to dyspnea as evidenced by fatigue

1 Activity intolerance describes a condition in which the client's physiological capacity for activities is compromised. The other nursing diagnoses are not supported with data from the situation.

The client, who is four days post-op for a transverse colostomy and is scheduled for discharge tomorrow, asks the nurse to empty the colostomy pouch. What is the best response by the nurse? 1. "Show me what you have learned about emptying your pouch." 2. "What have you learned about emptying your pouch?" 3. "Let me demonstrate to you how to empty the pouch." 4. "You should be emptying the pouch yourself."

1 Adults learn best in a democratic, participatory and collaborative environment. They do not want to be lectured at or scolded (e.g., "you should be emptying the pouch yourself"). But anxiety about discharge, as well as fatigue or pain could have had an impact on the client's ability to be fully engaged in any previous learning. While the nurse could ask clients to explain what they have already learned, this client must demonstrate what they have learned about emptying the pouch. The nurse should support the client's efforts and positively reinforce how to care for the stoma and empty the pouch.

A client is admitted to the rehabilitation unit after having had a cerebral vascular accident (CVA) with residual mild dysphagia. The appropriate intervention for this client is which action? 1. Place the client in an upright position while eating 2. Initially place client on a clear liquid diet 3. Tilt head back while eating to facilitate the swallowing reflex 4. Offer finger foods such as crackers or pretzels

1 An upright position facilitates proper chewing and swallowing. A liquid diet is contraindicated with persons who have swallowing problems. Tilting the head back opens the airways and increases difficulty with swallowing. Tilting the chin down increase ease in swallowing. Finger foods are allowed; however, they are not the priority. Correct!

The nurse discusses nutrition with a pregnant woman who is iron-deficient and follows a vegetarian diet. The selection of which foods indicates the woman has learned food sources of iron? 1. Cereal and dried fruits 2. Fish and dairy products 3. Carrots and other yellow-orange vegetables 4. Whole grains and yellow vegetables

1 Cereals are often fortified with vitamins and iron. Fruits rich in iron include dried apricots, avocados, currants, raisins, dates, figs and prunes. Other dietary sources of iron for the vegetarian would be dark, leafy greens (spinach, collards); and beans, lentils, chick peas and soybeans.

The mother of a 3 month-old infant tells the nurse, "I want to change from formula to whole milk and add cereal and meats to my infant's diet." What should be emphasized as the nurse teaches about infant nutrition? 1. Whole milk is difficult for infants to digest 2. Solid foods should be introduced at three to four months 3. Supplemental apple juice can be used between feedings 4. Fluoridated tap water should be used to dilute milk

1 Cow's milk is not given to infants younger than a year old because the tough, hard curd that develops in the digestive tract is difficult to digest. In addition, it contains little iron and creates a high renal solute load. If infants drink milk with a minimal introduction to solid food they will have a tendency to develop anemia.

A nurse is performing a nutritional assessment on a 2 year-old child. Which of these principles should the nurse apply? 1. A serving size at this age is about two tablespoons 2. Increased serum albumin or prealbumin levels indicate malnutrition 3. An accurate measurement of intake is not reliable 4. Total intake varies greatly each day

1 In children, a general guide to serving sizes is one tablespoon of solid food per year of age. Understanding this, the nurse can assess adequacy of intake for any aged child.

A client is diagnosed with severe pneumonia. Which intervention by the nurse promotes the client's comfort? 1. Keep conversations short 2. Monitor vital signs frequently 3. Encourage visits from family 4. Increase oral fluid intake

1 Keeping conversations short will promote the client's comfort by decreasing the demands on a client's breathing and energy. Increased intake of fluids and monitoring vital signs are not related to comfort. While the presence of family is supportive, demands on the client to interact with the visitors may interfere with the client's rest.

The nurse is providing care to a client in labor. The client has chosen natural childbirth with assistance from a doula, her mother and boyfriend. Which of the following nursing actions can help the client achieve her goal of an unmedicated labor and birth? 1. Assess the effectiveness of the labor support team and offer suggestions as needed 2. Offer pain medication on a regular basis 3. Limit the number of interactions with the doula 4. Encourage the client to stay in bed in a side-lying position or semi-Fowler's position

1 The nurse's role involves clinical skills and administrative responsibilities that are not part of the doula's role. The RN is responsible for assessing both the mother and baby and remains an important part of the labor and birth in this scenario. The RN's expertise allows the RN to make helpful suggestions to the support persons and the client, such as encouraging the client to find comfortable positions, both in and out of bed. It is appropriate to let the client and her support persons know all of the pain control options, but it would be inappropriate to continually offer pain medication to someone who has chosen natural childbirth. Doulas use techniques such as imagery, massage, acupressure and patterned breathing to reduce a woman's pain.

A nurse is caring for a client diagnosed with an unstable spinal cord injury at the T-7 level. Which intervention should take priority during the planning of care? 1. Place client on a pressure-reducing support surface 2. Increase fluid intake to prevent dehydration 3. Increase caloric intake to aid healing 4. Use skin care products designed for use with incontinence

1 This client is at greatest risk for skin breakdown because of immobility and decreased sensation below the level of injury. The initial approach should be the selection and then placement of the client on the best support surface for the relief of pressure, shear and friction forces. The other options are correct and later actions.

The nurse is providing care for a client with subluxation of the finger joints and deformity of the hands due to rheumatoid arthritis. The client's partner states that it is increasingly difficult for the client to perform activities of daily living. Which assistive devices will the nurse teach the client about and include in the plan of care? (Select all that apply.) 1. Hand splints 2. Built-up eating utensils 3. Button hooks 4. Four wheeled walker 5. Raised toilet seat

1,2,3 Due to the deformity of the hands, assistive devices should be targeted to help the client with activities of daily living. Built-up eating utensils are easier to hold and will help the client feed herself. Button hooks can help the client with getting dressed, without needing assistance with buttons. Hand splints support the finger joints and may help to improve dexterity. A four-wheeled walker and raised toilet seat would be used in a client with lower-extremity impairment and are not necessary for this client.

The client with newly diagnosed irritable bowel syndrome (IBS) states: "All this fiber I have to eat now is making me full of gas! It makes me want to stop taking it." What instruction by the nurse will help the client manage this side effect and increase compliance with the diet? (Select all that apply.) 1. Discuss a work-up for lactose intolerance with the health care provider. 2. Cut back on fiber and then add it again slowly to the diet 3. Eat three regularly-scheduled meals every day 4. Eat a balanced and nutritious variety of foods 5. Reduce intake of gas-forming foods

1,2,5 Adequate fiber intake is critical to controlling IBS but can result in bloating and gas if added to the diet too quickly. Increasing fiber intake by two to three grams per day will help reduce the risk of gas and bloating. Some foods, as well as dairy products, also contribute to gas formation. Eating a balanced, nutritious diet is a good self-care practice but does not decrease gas production. Large meals can cause cramping (and diarrhea) so eating four to five small meals a day is recommended instead of less-frequent big meals.

The nurse is caring for a client in labor. Which non-pharmacologic measures can the nurse implement to provide the laboring client with a sense of control and comfort? (Select all that apply.) 1. Counterpressure 2. Intrauterine pressure catheter 3. Aromatherapy 4. Childbirth education 5. Amnioinfusion 6. Lamaze breathing techniques

1,3,4,6 Nonpharmacologic labor pain management techniques incorporate special attention to all the senses, using aromatherapy (the sense of smell), relaxing music (for the auditory channel), and using counterpressure, massage or effleurage (for the tactile sense). Childbirth education helps to prepare the client and her support person(s) to understand what to anticipate prior to, during, and after labor and delivery, giving the client a sense of control. Initiation of breathing techniques to close the "gate" to nerve stimulation caused by pain is also used. The intrauterine pressure catheter, which provides an exact measurement of contractions, and amnioinfusion, which involves the infusion of fluid into the uterus during labor, are unrelated to pain management.

The nurse is caring for a client in labor. Which non-pharmacologic measures can the nurse implement to provide the laboring client with a sense of control and comfort? (Select all that apply.) 1. Lamaze breathing techniques 2. Amnioinfusion 3. Aromatherapy 4. Intrauterine pressure catheter 5. Childbirth education 6. Counterpressure

1,3,5,6 Nonpharmacologic labor pain management techniques incorporate special attention to all the senses, using aromatherapy (the sense of smell), relaxing music (for the auditory channel), and using counterpressure, massage or effleurage (for the tactile sense). Childbirth education helps to prepare the client and her support person(s) to understand what to anticipate prior to, during, and after labor and delivery, giving the client a sense of control. Initiation of breathing techniques to close the "gate" to nerve stimulation caused by pain is also used. The intrauterine pressure catheter, which provides an exact measurement of contractions, and amnioinfusion, which involves the infusion of fluid into the uterus during labor, are unrelated to pain management.

The female client is newly diagnosed with urge incontinence. She confides that she is often incontinent of large amounts of urine and expresses a fear of falling when rushing to the bathroom. What are the most appropriate nursing interventions to review with the client? (Select all that apply.) 1. Perform pelvic floor muscle exercises 2. Assist with pessary insertion 3. Review preoperative instructions 4. Schedule urination 5.Restrict foods that may irritate the bladder

1,4,5 Urge incontinence involves periodic, but frequent, leakage of urine. Treatment involves treating the underlying cause, but in most cases, no cause can be found. Medication and behavioral interventions are tried before surgery is considered. Behavioral changes include bladder retraining with urge suppression, restricting foods that may irritate the bladder, drinking less than eight ounces of fluid at one time and pelvic floor muscle exercises. A pessary is commonly used in the management of pelvic support defects such as cystocele and rectocele; it can also be used in the treatment of urinary stress incontinence, but not urge incontinence.

A client is diagnosed with gastroesophageal reflux disease (GERD). The nurse's instruction to the client about approaches to dietary changes should include which topic? 1.Decrease intake of fatty foods 2. Focus on three average size meals a day 3. Increase intake of milk products 4. Avoid all raw fruits and vegetables

1. GERD may be aggravated by a fatty diet. A diet low in fat would decrease the symptoms of GERD. Other agents that should also be decreased or avoided are: cigarette smoking because of the nicotine, caffeine, alcohol, chocolate, and the narcotic analgesic meperidine (Demerol).

The mother of a 3 month-old infant tells the nurse, "I want to change from formula to whole milk and add cereal and meats to my infant's diet." What should be emphasized as the nurse teaches about infant nutrition? 1. Whole milk is difficult for infants to digest 2. Fluoridated tap water should be used to dilute milk 3. Supplemental apple juice can be used between feedings 4. Solid foods should be introduced at three to four months

1. Cow's milk is not given to infants younger than a year old because the tough, hard curd that develops in the digestive tract is difficult to digest. In addition, it contains little iron and creates a high renal solute load. If infants drink milk with a minimal introduction to solid food they will have a tendency to develop anemia.

A nurse is caring for a client in skeletal traction. Which nursing intervention is appropriate for this client? 1. Maintain correct body alignment 2. Use alcohol or iodine-based products to clean around the pins 3. Maintain a supine position at all times 4. Remove the weights when turning the client

1. The best response is to maintain correct body alignment. Skeletal traction is used to maintain proper alignment of the bones while healing. A pin or wire is inserted through the bone and weights are applied, using a system of ropes and pulleys attached to the bed frame, to provide a constant pulling pressure - the weights should not be removed or lifted. Iodine-based solutions or alcohol should not be used for pin care because they can corrode the pin(s) and/or stain the skin. Skeletal traction allows the client to change positions without interfering with the pull of traction, but the head of the bed must be completely lowered several times a day to prevent hip flexion contractures.

During a 12-hour shift, a client who underwent a transurethral resection of the prostate (TURP) had an IV fluid intake of 1200 mL, an oral intake of 400 mL, continuous bladder irrigation of 2400 mL, two antibiotic piggybacks of 50 mL each and an indwelling urinary catheter output of 3000 mL. What is the end-of-shift intake/output (I/O) balance? (Write the answer using a whole number.)mL.

1100 net output, or I/O balance. The amount of irrigation fluid must be included in the client's intake. Only the urine collected from the indwelling urinary catheter is considered output.

Parents are concerned that their 11 year-old child is a very picky eater. The nurse suggests which of these approaches should be the best initial action? 1. Consider a liquid supplement to increase calories 2. Discuss the consequences of an unbalanced diet with the child 3. Provide fruit, vegetable and protein snacks 4. Encourage the child to keep a daily log of foods eaten

2 A priority is to educate the pre-adolescent as to appropriate diet, and the outcomes that result if the diet is not adequate. Afterwards the other options are appropriate to implement.

A nurse is providing home care for a client with chronic bilateral heart failure. Which nursing diagnosis should have the priority when planning care for this client? 1. Impaired skin integrity related to dependent edema 2. Activity intolerance related to an imbalance in oxygen supply and demand 3. Constipation related to immobility from challenges with breathing 4. Risk for infection related to ineffective mobilization of secretions

2 Findings of bilateral heart failure may include dyspnea, fatigue, chronic cough, lack of appetite, mental confusion or impaired thinking, peripheral edema and weight gain. Due to an inadequate supply of oxygen and the stress of the extra heart muscle mass, the client will experience exertional dyspnea. Therefore, activity intolerance is the priority nursing diagnosis for this client. While there may be a concern about skin integrity, risk for infection and even constipation, oxygen needs are more important.

Which of these clients should the nurse assess and monitor for Clostridium difficile (C. difficile) diarrhea? 1. A young adult at home taking a prescribed aminoglycoside 2. A hospitalized middle-aged client receiving IV cephalexin (Keflex) 3. An older adult client living in a retirement center taking prednisone 4. An adolescent taking tetracycline for acne

2 Hospitalized clients, especially those receiving antibiotic therapy, are primary targets for C. difficile. Examples of antibiotics that frequently cause C. difficile are ampicillin, amoxicillin and cephalosporins, including cephalexin (Keflex). Antibiotics that occasionally cause C. difficile include penicillin, erythromycin, trimethoprim and quinolones, such as ciprofloxacin (Cipro).

Which of these clients should the nurse assess and monitor for Clostridium difficile (C. difficile) diarrhea? 1. An adolescent taking tetracycline for acne 2. A hospitalized middle-aged client receiving IV cephalexin (Keflex) 3. A young adult at home taking a prescribed aminoglycoside 4. An older adult client living in a retirement center taking prednisone

2 Hospitalized clients, especially those receiving antibiotic therapy, are primary targets for C. difficile. Examples of antibiotics that frequently cause C. difficile are ampicillin, amoxicillin and cephalosporins, including cephalexin (Keflex). Antibiotics that occasionally cause C. difficile include penicillin, erythromycin, trimethoprim and quinolones, such as ciprofloxacin (Cipro).

The nurse is caring for a client with a pressure ulcer on the heel that is covered with black hard tissue. Which would be an appropriate goal in planning the care of this client? 1. Protection for the granulation tissue 2. Keep the tissue intact 3. Debride the eschar 4. Heal the infection

2 If the black tissue (eschar) is dry and intact, no treatment is necessary; the stable eschar serves as the body's natural cover. If the area changes with cellulitis or pain, then this is a sign of infection and requires debridement.

The nurse is assisting clients diagnosed with trigeminal neuralgia (tic douloureux) to meet their nutritional needs. Which approach should the nurse recommend? 1. Provide additional servings of fruits and raw vegetables 2. Offer small meals consisting of high calorie, soft foods 3. Assist the client to sit in a chair for meals 4. Encourage the client to eat fish, liver and chicken

2 If the client is losing weight because of poor appetite due to the pain in the jaw, the nurse needs to teach about foods that are high in calories and nutrients as well as food that require less chewing. To minimize jaw movements when eating, foods may be pureed. The nurse can also suggest frequent, small meals that are eaten every two hours instead of three large meals per day.

A nurse is performing a nutritional assessment on a 2 year-old child. Which of these principles should the nurse apply? 1. Increased serum albumin or prealbumin levels indicate malnutrition 2. A serving size at this age is about two tablespoons 3. Total intake varies greatly each day 4. An accurate measurement of intake is not reliable

2 In children, a general guide to serving sizes is one tablespoon of solid food per year of age. Understanding this, the nurse can assess adequacy of intake for any aged child.

A nurse is caring for a client in skeletal traction. Which nursing intervention is appropriate for this client? 1. Remove the weights when turning the client 2. Maintain correct body alignment 3.Maintain a supine position at all times 4. Use alcohol or iodine-based products to clean around the pins

2 The best response is to maintain correct body alignment. Skeletal traction is used to maintain proper alignment of the bones while healing. A pin or wire is inserted through the bone and weights are applied, using a system of ropes and pulleys attached to the bed frame, to provide a constant pulling pressure - the weights should not be removed or lifted. Iodine-based solutions or alcohol should not be used for pin care because they can corrode the pin(s) and/or stain the skin. Skeletal traction allows the client to change positions without interfering with the pull of traction, but the head of the bed must be completely lowered several times a day to prevent hip flexion contractures.

The 78 year-old reports having difficulty moving his bowels. What information is most important for the nurse to obtain during the assessment process? 1. Elimination patterns over the past week 2. Health history and client's diet 3. Trends in weight gain or loss 4. Labs reports, including a complete blood count with a differential

2 The nurse should obtain the client's health history, noting risk factors, comorbid conditions, and medications. The nurse should also assess the client's diet, including fiber intake. The nurse can then ask the client to clarify what he means when he reports having difficulty moving his bowels (and determine if there are any misconceptions about bowel habits.) Assessing the client's health history and diet should uncover any eating or swallowing difficulties that could contribute to weight loss.

The nurse is caring for a client who had a sigmoid colostomy and requests assistance with removing flatus from a one-piece drainable ostomy pouch. Which should be the the correct intervention by the nurse? 1. Pierce the plastic of the ostomy pouch with a pin to vent the flatus 2. Open the bottom of the pouch to allow the flatus to be expelled 3. Pull the adhesive seal around the ostomy pouch to allow the flatus to escape 4. Assist the client to ambulate to reduce the flatus in the pouch

2 The only correct way to vent the flatus from a one-piece drainable ostomy pouch is to instruct the client to obtain privacy because the release of the flatus will cause odor. The client should open the bottom of the pouch, allow the flatus to escape, and then close the bottom of the pouch.

A nurse is caring for a client who has reported pain at his surgical site. Which statement(s) suggests the nurse understands the pain phenomena? (Select all that apply.) 1. Postoperative pain should only be assessed by the doctor. 2. Pain exists when and where the client says it exists. 3. Pain is universal and can be easily described most of the time. 4. Pain is an emotional response to tissue inflammation or damage. 5. Pain will never be assessed when clients are from eastern cultures. 6. Pain can be treated using pharmacologic or complimentary therapies.

2,6 Assessing pain is an important part of the nurse's responsibility in all nursing care circumstances, including postoperative pain and pain in clients from other countries. Pain is complex and is often not easily described by the client.

A client tells the nurse, "I'm in a lot of pain." As the nurse collects more information about the client's pain, what should be the first step in pain assessment? 1. Have the client identify previous methods that relieved the pain 2. Determine the location of the pain 3. Accept the client's report of pain 4. Ask the client to rate the pain on a scale of 1 to 10

3 Before anything else, the nurse must simply accept the fact the the client is experiencing pain, i.e., pain is whatever the client says it is. The nurse would then determine the intensity or severity of the pain (based on the pain scale), the quality and location of the pain, when the pain started, and what helped relieve the pain in the past.

A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile-colored liquids. Which nursing intervention would provide the most comfort to the client? 1. Swab the mouth with glycerin swabs 2. Provide mints to freshen the breath 3. Perform frequent oral care using a tooth sponge 4. Allow the client to melt ice chips in the mouth

3 Frequent cleansing and stimulation of the mucous membrane is important for a client with a nasogastric tube to prevent development of lesions and to promote comfort. Ice chips or mints could be contraindicated with a nasogastric tube. Glycerin swabs have no mechanical or cleansing value and should not be used.

The client needs assistance to insert bilateral in-the-ear hearing aids. What action should the nurse take before inserting the hearing aids? 1. Adjust the volume control to its highest setting 2. Clean the hearing aid with plain soap and water 3. Identify the hearing aid that goes in the right ear and left ear 4. Grasp the open battery door to use as a handle

3 Since hearing aids are customized for each ear, the nurse should make sure the correct hearing aid is inserted in the correct ear (a red dot indicates the right ear.) The volume should be turned down when inserting the devices and adjusted after they are in the ear. Hearing aids should only be cleaned with a soft cloth; water or alcohol can damage the device. The battery door should never be used as a handle.

Following a major burn to the lower extremities, a diet high in protein and carbohydrates is ordered for a 7 year-old child. What reason would the nurse give the family that would help explain these dietary requirements? 1. Strengthen the immune system to prevent infection 2. Stimulate peristalsis for enhanced absorption of nutrients 3. Spare protein catabolism to meet the child's metabolic needs 4. Provide a well-balanced and nutritionally complete diet

3 The child's energy and protein requirements will be very high due to catabolism of trauma, heat loss, and the demands of tissue regeneration. Good nutrition is important for wound healing and helps reduce the risk of infection, but a child who has been burned needs about 2 to 3 times more calories and protein to help him/her heal and grow.

The nurse is teaching a client about their new ostomy. Which statement by the client suggests the client understands the nurses teaching? 1. "It is normal to empty my pouch every thirty minutes." 2. "It is normal to take a laxative as needed for constipation." 3. "It is normal for my stoma to remain red in color." 4. "It is normal for the skin around my stoma to be irritated."

3 The stoma will remain red in color because it is very vascular. If your client needs to empty the pouch every thirty minutes, a full bowel assessment should be obtained to gather more data.

The outpatient sleep clinic nurse is reinforcing information about sleep for a client diagnosed with insomnia. Which of the following client statements indicate that the client understands the information? (Select all that apply.) 1. "If I awaken during the night, I will stay in bed until I fall back asleep." 2. "I will exercise a few hours before my bedtime to make me tired so I can sleep." 3. "I will avoid drinking alcoholic beverages too close to bedtime." 4. "I will keep a sleep log and to track my sleep and awake hours daily." 5. "I will decrease my caffeine intake during the day and avoid coffee in the evening." 6. "I will start a set of bedtime rituals that I will consistently use to help me fall asleep."

3,4,5,6 Nurses can provide essential information to clients regarding symptom relief for insomnia. The client should use a sleep log, decrease caffeine intake overall and not drink caffeinated beverages in the evening, and establish a bedtime ritual. An increase in daily exercise is recommended; however, exercise within six hours before bedtime interferes with falling asleep and is not considered a part of good sleep hygiene. If the client awakens during the night, the client should get up and engage in a quiet, non-stimulating activity such as reading. Alcohol may speed the onset of sleep, but it disrupts sleep later in the night.

The nurse is making a home visit to a client diagnosed with chronic obstructive pulmonary disease (COPD). The client tells the nurse that he used to be able to walk from the house to the mailbox without difficulty. Now, he has to pause to catch his breath halfway through the trip. Which nursing diagnosis is appropriate for this client based on this assessment? 1. Impaired mobility related to chronic obstructive pulmonary disease as evidenced by a change 2. Self-care deficit related to dyspnea as evidenced by fatigue 3. Ineffective airway clearance related to increased bronchial secretions as evidenced by complaints 4. Activity intolerance related to chronic tissue hypoxia as evidenced by fatigue

4 Activity intolerance describes a condition in which the client's physiological capacity for activities is compromised. The other nursing diagnoses are not supported with data from the situation.

A nurse is caring for a client diagnosed with an unstable spinal cord injury at the T-7 level. Which intervention should take priority during the planning of care? 1. Increase caloric intake to aid healing 2. Increase fluid intake to prevent dehydration 3. Use skin care products designed for use with incontinence 4. Place client on a pressure-reducing support surface

4 This client is at greatest risk for skin breakdown because of immobility and decreased sensation below the level of injury. The initial approach should be the selection and then placement of the client on the best support surface for the relief of pressure, shear and friction forces. The other options are correct and later actions.

A client is admitted with a diagnosis of renal calculi. The client reports moderate-to-severe flank pain and nausea. The client's oral temperature is 100.8 F (38.2 C). Which of these goals is the priority nursing focus for this client? 1. Prevent infection 2. Control nausea 3. Maintain fluid balance 4. Manage pain

4. An immediate goal of therapy for clients diagnosed with kidney stones is to alleviate the client's pain, which can be quite severe. The other focuses are correct but not a priority.

1. Cane 2. Gait belt 3. Walker 4. Crutches

4. Keep the tips 8-12 inches (about 20-25 cm) to side of the client's feet. 2. Positioned over the client's clothing 4. Move the at same time as the weaker leg. 3. Do not allow the client to place hands on device to stand from a sitting position.

Vitamins- Fat Soluble

A D E K Stored primarily in the liver and adipose tissues, absorbed by the body from the intestinal tract

Basal Metabolism

Amount of energy (measured in calories) required to sustain life in a resting individual

ABC to Pain Management

Assess the client by asking about the pain Believe the clients pain is real Let the client make pain management choices

A nurse is caring for a client who is receiving enteral tube feeding. What is the first action the nurse should take before administering the feeding? 1. Elevate bed to 90° prior to administration 2. Check for tube placement prior to administration 3. Add dye to the tube feeding prior to administration 4. Request a nutritional assessment prior to administration

Before the nurse administers anything through a tube feeding, its placement needs to be verified. A better angle for the client to be while receiving tube feedings is 45°. It is no longer considered a best practice to add dye to tube feedings as a way to monitor for aspiration. Finally, a nutritional assessment is important to obtain or request, but this is not the first action to take prior to administration.

B12

COBALAMINE Used in new cell synthesis; helps break down fatty acids and amino acids Fish, shellfish, lean red meats, poultry, dairy products, eggs

Major Minerals

Calcium, magnesium, sodium, potassium, phosphorus, sulfur, chlorine

Therapeutic Diet (Diabetic)

Carb counting is a key component Caloric distribution: 50-60% carbs, 20-30% fat and 10-20 %protein Decreasing serum lipid levels

HYPERmagnesemia

Causes: Chronic renal disease, overused of Mag containing antacids, addisons disease, uncontrolled diabetes S/S: lethargy, N/V, slurred speech, muscle weakness, paralysis, decreased deep tendon reflexes, slowing of cardiac conduction

HYPERcalcemia

Causes: hyperparathyroidism, mets of cancer, pagets disease of bone, prolonged immobilization S/S: weakness, paralysis, decreased deep tendon reflexes

HYPOmagnesemia

Causes: malnutrition, toxemia in pregnancy, malabsorption, ALCOHOLISM, diabetic acidosis S/S: mood irritability, cardiac irritability. muscle tingling, twitch, tetany, delirium, convulsions

HYPOcalcemia

Causes: rickets, vitamin D deficiency, renal failure, pancreatitis, chelation therapy, hypoparathyroidism S/S: muscle tingling, twitching, tetany

Anions (neg charge)

Chloride: helps balance sodium, normal value 96-106 Bicarb: Important in acid/base, normal value 22-26 mEq/L Phosphate: Combines with calcium in bone, participates in cellular energy metabolism, normal level 2.8-4.5 mg/dL

A nurse is admitting a client that is newly bedbound. During the nurse's initial assessment, the nurse must ask a client about any other medical diagnosis that affects their mobility status. Which would be most concerning? 1. Hypertension 2. Thyroid problems 3. Diabetes mellitus 4. Correct Response 5. Macular degeneration

Clients who are bedbound tend to suffer from hypotension rather than hypertension especially when moving from a lying to a sitting position. Thyroid issues and macular degeneration will be addressed but do not pose additional concern because of the client's mobility status. Diabetes is concerning because of the circulation and healing challenges diabetics routinely face. Immobility puts the client at a higher risk for skin breakdown. Diabetes increases the risk for skin breakdown and infection.

Clear Liquid Diet

Coffee w/o cream, tea, popsicles, fruit juices and carbonated beverages

Vitamin C

Collagen synthesis, immunity, antioxidant, iron absorption, amino acid metabolism Citrus fruits, kiwi, tomatoes, strawberries, broccoli, snow peas, sweet red peppers

Proteins

Complex organic compounds comprised of amino acids All but (8) amino acids are produced by the body Secondary energy source, essential for cell growth and wound healing, bodies only source of nitrogen. Daily intake: 0.8G per kg body weight per day

Magnesium

Constituent of bones and teeth, coenzyme in general metabolism, smooth muscle action, mag works with cal in muscle contraction and relaxation Adult: 300-400mg Milk, cheese, meat, seafood, whole grains, legumes, nuts, avocado

Phosphorus

Constituent of bones and teeth, participates in absorption of glucose, transport of fatty acids, energy metabolism Adolescent: 1250mg Adult: 700 mg Milk, cheese, meat, egg yolks, whole grains, legumes, nuts

Calcium

Constituent of bones and teeth, participates in nerve transmission, muscle action, permeability of cell membranes, blood clotting Adults: 1000mg-1200mg Milk, cheese, yogurt, dark green leafy veggies, whole sardines

Lacto vegetarian

Consumes dairy products, but excludes eggs, meat, poultry, seafood

Lacto-ovo vegetarian

Consumes eggs and dairy products, but excludes meat, poultry and seafood

Reversible causes of urinary incontinence

D R I P Delirium Restricted mobility Infection Pharmaceuticals

DASH Diet

Daily approach to stop HTN Help lower BP encourages sodium restriction and eating a variety of foods rich in nutrients, including potassium, calcium and mag 2,300 mg sodium/day Low in saturated fat, cholesterol and total fat

St Johns Wart

Interacts with over 60% of all prescription drugs makes them LESS effective: digoxin, cyclosporine, highly active antiretroviral, oral contraceptives

Trace Minerals

Iron, copper, iodine, manganese, cobalt, zinc

Cane

Elbow flexed 30 degree angle Hold cane close to body on unaffected side Move cane at same time as weaker leg

B9

FOLATE Supports DNA synthesis and new cell formation tomato juice, liver, dried beans and other legumes, green leafy veggies, asparagus, OJ

Renin/angiotensin

Hormone affecting renal tubule reabsorption of water

Where is the thirst center located?

Hypothalamus

Ileostomy

Liquid to semi formed stool, may skew fluid and electrolyte balance- especially potassium and sodium, NO LAXATIVES

Sodium

Major cation in extracellular fluid, water balance and acid base balance, cell membrane permeability, absorption of glucose Adult: 500mg

Potassium

Major cation in intracellular fluid Water balance and acid base balance Fruits raisins, veggies (baked potato with skin, legumes, nuts, meat, salmon, whole grains

Full Liquid Diet

Milk, cream, ice cream, pudding, yogurt, vegetable juice, creamy peanut butter

Gluten Free Diet

NO Wheat, Oats, Rye, Barley YES rice, corn, millet

Things To Remember

Nitrogen balance is achieved when dietary intake is balanced by excretion of urea wastes. A negative balance occurs if excretion is greater than the nitrogen content of the diet AS SEEN IN: burns, infections, fever or starvation Brain requires carbs, specifically glucose Small frequency loose stools or seepage of stool are often indicative of a fecal impaction GERD may be aggravated by fatty foods, a diet low in fat would decrease symptoms of GERD. Also avoid cigarette smoking (nicotine, caffeine, alcohol, chocolate, and demerol. Neutropenic diet- avoid raw fruits and veggies, undercooked meats and eggs, soft "moldy" cheese, lunch meat and salads from deli, no cold brewed teas and drinks. Only should consume cooked or canned foods, pasteurized dairy products and fruit juices. Continuous bladder irrigation must be included when determining intake General guide to serving size is one tablespoon of solid food per year of age Cereals are often fortified with vitamins and iron, fruits rich in iron include dried apricots, avocados, currants, raisins, dates, figs and prunes, dark leafy greens, beans, lentils, chick peas and soy beans

Assessing pain

PQRST What PROVOKES the pain What is the QUALITY of the pain Does the pain RADIATE What is the SEVERITY of the pain TIMING, or when do you experience the pain

B6

PYRIDOXINE Amino acid and fatty acid metabolism; red blood cell production Beans, liver, red meats, poultry, fish, banana, seeds and nuts, white rice, tomato juice

Lipids

Polyunsaturated fatty acids are the only fatty acids essential to humans Most concentrated source of energy Major form of stored energy Insulation Component of cell membranes Carries fat soluble vitamins A D E K Daily intake: should not exceed 30% of daily calories with saturated fats not exceeding 10% of total daily caloric intake

Nutritional needs pregnancy

Pre-pregnancy: 400 ug/day folic acid Pregnancy: Add 300 calories per day, 15 mg iron, 30 g protein, 400g calcium and 400 ug folic acid in first trimester Lactation: add 500 calories and 2 quarts extra of fluid

Low Purine Diet

Prevent uric acid stone; used for clients with gout Restrict glandular meat, gravies, fowl, anchovies, beer and wine High in complex carbs

Nutritional needs newborns and infants

Protein needs approx. 2.2 gm/kg/day Breast milk and formula ok for first 6 months, whole milk should be introduced around age 1 yr 6-8 wet diapers a day

Carbohydrates

Quickest source of energy Main source of fuel for brain, peripheral nerves, WBCs, RBCs and healing wounds Protein sparer Daily intake: 50-60% of total calories (complex carbs recommended)

Low Protein Diet

Renal disease such as pyelonephritis, uremia, kidney failure limit protein less than 40 g/day Restricted: meats and other foods high in protein such as legumes, fish, dairy

Vitamin A

Retinol Supports vision, skin, bone and tooth growth, immunity and reproduction Orange fruits and vegetables, dark leafy greens, butter, fortified milk, eggs, beef liver

Contracture

Shortening and hardening of muscles, tendons, or other tissue often leading to deformities and rigid joints

Somnambulism

Sleepwalking, night terrors or nightmares

Aldosterone

Sodium decreases or K+ increase>> adrenal cortex secretes aldosterone>> kidneys reabsorb sodium and eliminate K+>> passive water absorption, active sodium reabsorption and increased blood volume

Cations (pos charge)

Sodium, potassium, Calcium, Magnesium

Vitamin K

Synthesis of blood clotting proteins; regulates blood calcium Dairy products, broccoli, brussel sprouts, leafy green veggies, cabbage, liver, green tea

High Protein Diet

Used for burns, anemia, malabsorption syndromes, ulcerative colitis Promote intake more than 60 g/day

Low residue Diet

Used for diarrhea, acute diverticulitis reduce fiber intake: canned fruit, refined carbs, pasta, strained veggies

Vitamins- Water soluble

Vitamin C and B complex (thiamin, riboflavin, niacin, pantothenic acid, biotin, B6, folate, B12) Cannot be stored in body, daily intake required, excess is eliminated daily, little risk of toxicity

Checking Gastric residual

every 4-6 hrs if continuous feeding or prior to intermittent feedings If residual is greater than the volume given over the previous 2 hrs- might need to reduce rate of feeding Return residual to stomach flush tube with approx. 30 mL warm water every 4 hrs and after feedings

Urination

minimum 30 mL/hour

Parathyroid hormone PTH

stimulates release of calcium from bone, reabsorption in small intestines and kidneys Serum cal low? PTH secretion Serum cal high? PTH secretion falls Low levels of meg stimulate PTH secretion

Bruxism

tooth grinding during sleep