NUR 235 Exam 1

impairment

loss or abnormality of psychological, physiologic, or anatomic structure of function at the organ level

chronic disease

medical or health problem with associated symptoms or disabilities that require long-term management; has also been referred to as noncommunicable disease, chronic condition, or chronic disorder

medicaid

medical services for the poor

altered breathing pattern

metabolic & O2 changes of resp. system

restlessness

metabolic changes and decreased oxygen to brain

disorientation

metabolic changes, decreased circulation to brain

what is the reaction of the body to stress? (fight or flight)

-increased HR and BP -increased blood glucose -mental acuity -dilated pupils -increased tension of skeletal muscles -increased ventilation -increased coagulability of blood

delirium vs dementia

1. Delirium- Acute, dramatic onset, common causes= illness, toxin, withdrawal, usually reversible. poor attention and fluctuating arousal level. 2. dementia: chronic, insidious onset, usually not reversible, attention usually unaffected and normal arousal level.

what are the five stages of kubler-ross?

1. Denial 2.Anger 3.Depression 4.Bargaining 5. Acceptance

how many inches should crutch pad fit under a client's axilla?

1.5-2 inches below axilla

functional capacity tool scale

1= independent 4= dependent

general adaptation syndrome (GAS)

Selye's concept of the body's adaptive response to stress in three phases—alarm, resistance, exhaustion.

the most frequently occurring chronic diseases that account for two thirds of the deaths globally include cardiovascular disease, cancers, ___________, and chronic lung diseases.

diabetes

a patient who is terminally ill is sleeping more than usual. what interventions could the nurse implement to promote comfort? a. spend time with the patient and hold their hand b. speak normally without expectation of a response c. encourage the person to stay awake d. use distractions so they don't fall asleep

a & b

what should the nurse do if a patient is disoriented and confused? a. identify self by name before speaking b. speak softly, clearly, truthfully c. call the health care provider to notify them of mental changes d. speak with family so they can reorient the patient

a & b

metaplasia

a cell transformation in which one type of mature cell is converted into another type of cell

adaptation

a change or alteration designed to assist in adjusting to a new situation or environment

handicap

a disadvantage imposed on an individual at the societal level

stress

a disruptive condition that occurs in response to adverse influences from the internal or external environments

noncommunicable diseases

a group of conditions that are not caused by an acute infection

complicated grief

a person has a prolonged or significantly difficult time moving forward after a loss

steady state

a stable condition that does not change over time

homeostasis

a steady state within the body; the stability of the internal environment

masked grief

a type of grief reaction when the person experiences symptoms and behavior which causes them difficulty, but they do not see or recognize the fact that these are related to the loss

a patient is in the final stages of dying. the patient is cool to the touch and there is mottling of the extremities. which of the following nursing interventions would promote comfort for the patient? a. place socks on feet b. cover with light cotton blankets c. use an electric blanket d. keep warm blankets on them

a, b, d

how could the nurse promote comfort to a patient who is experiencing trouble breathing due to increased secretions in their lungs nearing the end of life? a. elevate HOB b. turn their head to the side c. administer an anticholinergic d. place them in prone position to clear secretions

a,b,c

which interventions should the nurse implement for an agitated client nearing the end of life? a. calm them b. reduce light c. use gentle touch d. use restraints to ensure safety e. administer sedatives

a,b,c,e

which of the following are physical manifestations of death? a. slight mottling of the extremities b. no respirations or pulse c. agitated state d. cessation of eating and voiding

a,b,d

what vitamins are essential for wound healing?

a,c,b *vitamin C

the terminally ill client has incontinence. how could the nurse promote patient comfort? a. change the soiled bedding b. utilize an indwelling catheter c. keep them clean and dry d. use bedpans

a,c,d

the nurse visits the home of a client with terminal illness. which assessment findings indicate to the nurse that the client might die within a few months? select all that apply. a. refuses to eat b. sleeps most of the day c. reports feeling fatigue d.onset of generalized weakness e. does not want to visit with family members

a,c,d,e

which of the following is a physiologic change in the older adult? a. decrease in muscle mass and bone density b. decline in cognition, judgement, and memory c. disappearance of sexual desire in both sexes d. increase in sweat gland function in both sexes

a. decrease in muscle mass and bone density

a nurse is working with a family of a deceased client and assisting them in working through their grief and mourning. which of the following would be the priority to promote healthy accommodation of the loss by the family? a. helping the family recognize the loss has occurred b. assisting the family in expressing their feelings of loss c. encouraging the family to remember the relationship they had with the client d. urging them to give up their old attachments to the client

a. helping the family recognize the loss has occurred ;before you grieve acknowledge death

a client with a terminal diagnosis has just been placed on palliative care. the goal of palliative care is to: a. improve the patient's and family's quality of live b. support aggressive treatment for cure c. provide physical support for patient d. help the patient develop a separate plan with each discipline of the health care team

a. improve the patient's and family's quality of life

which patient scenario is an example of the cellular adaptation known as dysplasia? a. malignant cells in the lungs of a smoker b. an enlarged thyroid gland due to a deficit in thyroid hormone c. bulging muscles of an athlete that engages in body building d. decreased size of muscles in the legs of a paraplegic

a. malignant cells in the lungs of a smoker

the client who has the chronic condition of diabetes, reports blurry vision, and admits to non-adherence to the diet and medications. The home health nurse checks the client's fasting blood glucose level, which is 412 mg/dL. what phase of the Trajectory Model of Chronic Illness does the nurse assess this client is in?

acute

resistance stage

adaptation occurs to stressor; cortisol activity still increased

the "fight-or-flight" reaction described by Selye is known as the ____________ stage in the general adaptation syndrome.

alarm

disease

an abnormal variation in the structure or function of any part of the body

hyperplasia

an increase in the number of cells in a tissue or organ

stressor

an internal or external even or situation that creates the potential for physiologic, emotional, cognitive, or behavioral changes

secondary health conditions

any physical, mental, or social disorders resulting directly or indirectly from an initial disabling condition

disabling

any physical/mental health problem that can cause disability, can occur at any age as a result of an acute incident or progression of chronic

ineffective coping

discuss feelings

self-care deficit interventions

assistive/adaptive devices; energy conservation

the client cannot bear weight on their right leg. they need crutches to assist with ambulation. the nurse must instruct them on how to use the crutches with knowledge of risks. which of the following are correct? a. the nurse should teach the client to allow the crutch pad to rest in the axilla b. the client should put on shoes c. the crutches should be positioned lateral and forward d. rubber suction tips should be placed on bottom of crutches

b,c,d

in Selye's theory of adaptation, there are two syndromes: GAS and LAS. events that may be seen in the LAS include which of the following. select all. a. a fight or flight response occurs b. occurs in small injuries c. may lead to activation of the GAS d. death may be the end result

b. & c. occurs in small injuries, may lead to activation of the GAS

which of the following is an example of a developmental disability? a. right sided hemiparesis after injury b. down syndrome c. alzheimer's

b. down syndrome

a client is dying, and the client and loved ones are in the grieving period. The nurse wants to support them in the grieving process. Which is the best intervention the nurse could perform? a. tell the family "they lived a long life" b. encourage loved ones to express feelings c. helping the family recognize that loss has occurred

b. encourage loved ones to express feelings; already in grieving period

the difference between an acute and chronic illness is that an acute illness: a. lasts longer than 3 months b. has a rapid onset c. does not have an identifiable cause d. has no end

b. has a rapid onset

rehabilitation nursing deals with many and varied problems. When caring for a male client with urinary incontinence, the nurse should avoid which of the following interventions: a. intermittent self-catheterization b. indwelling urinary catheter c. external condom catheter d. incontinence pads

b. indwelling urinary catheters; makes person more prone to UTIs

which of the following is considered an IADL? a. dressing b. meal prep c. feeding d. bathing

b. meal prep

after teaching a group of nursing students about living arrangements for older adults, the instructor determines that teaching was successful when the group identifies which housing option as being most used by most older adults: a. continuing care retirement communities b. the client's own home c. assisted living facilities d. long-term care facilities

b. the client's own home

the client has just died. the client's spouse says, "I knew this was coming, but I feel so numb and hollow inside." the nurse knows that this statement is characteristic of: a. depression stage of dying b. uncomplicated grief and mourning c. acceptance stage of dying d. complicated grief and mourning

b. uncomplicated grief and mourning

which of the following is an adaptive coping mechanism in response to stress? a. binge drinking b. using guided imagery to decrease stress c. substance use d. procrastination

b. using guided imagery to decrease stress

pre-trajectory

before the illness course occurs, the preventive phase, no signs or symptoms present

dysplasia

bizarre cell growth resulting in cells that differ in size, shape, or arrangement from other cells of the same tissue type

decreased intake

body conservation of energy for function

negative feedback example

body temperature regulation

constipation interventions

bowel training, drug therapy, nutrition

a patient with a fractured left fibula is being taught how to use crutches. Which statement by the patient indicates that the teaching was effective? a. "I should make sure my underarms are supported by the tops of the crutches." b. "I need to learn to use one type of gait for getting around." c. "I need to allow my arms and hands to support my body weight." d. "I need to position the crutches even with my heels when standing."

c. "I need to allow my arms and hands to support my body weight."

which of the following statements is an example of "people first language"? a. "the COPDer in room 20" b. "the diabetic is learning health promotion activities" c. "the patient with a disability in room 13"

c. "the patient with a disability"

an occupational health nurse overhears an employee talking to his manager about a 65 year old coworker. the employee states, "he should just retire and make way for some "new blood" the phenomenon that the nurse identifies this as is: a. nonspecific prejudice b.dependence c. ageism d. intolerance

c. ageism

the nurse is participating in a family meeting with a client who is identifying preferences for end-of-life care. which action will the nurse take to follow end-of-life care choices? a. tell the family to file the client's living will with an attorney b. encourage the family to petition the court for a durable power of attorney c. contact the primary health care provider for a prescription for life-sustaining treatment d. discontinue medications and treatments for a "do not resuscitate" (DNR) prescription

c. client is not in end stages, identifying preferences

the most common affective (mood) disorder of the older adult is: a. anxiety disorder b. schizophrenia c. depression d. phobias

c. depression

hospice care

care provided for the dying in institutions devoted to those who are terminally ill

a client has had multiple admissions for heart failure. the client is now on continuous oxygen, bedridden, and provided care by his family. The nurse discusses end-of-life preferences with the client. the nurse assesses the client is in the phase of the Trajectory Model of Chronic Illness known as

downward

positive feedback example

childbirth and blood clotting

which term, according to Lazarus, refers to the process through which an event is evaluated with respect to what is at stake and what might and can be done?

cognitive appraisal

uncomplicated grief

common, universal reaction characterized by complex emotional, cognitive, social, physical, behavioral, and spiritual responses to loss and death.

total incontinence

continuous and unpredictable loss of urine, resulting from surgery, trauma, or physical malformation

what are the physical signs and symptoms associated with the final stages of dying?

coolness of the skin, increased sleeping, disorientation, bowel & bladder incontinence, congestions/gurgling, restlessness, decreased I & O, altered breathing pattern

major causes of disability

coronary artery disease (CAD), COPD, arthritis, accidents, war & terrorism

the hypothalamic-pituitary response to stress causes the adrenal cortex to produce ________________, which stimulates protein catabolism and inhibits glucose uptake.

cortisol

all of the following are considered chronic diseases except for? a. Diabetes b. CVD c. COPD d. Pneumonia

d. Pneumonia

an older adult has a score of 12 on the geriatric depression scale. the nurse's first action should be to: a. assess the client for potential for self-harm b. notify the client's health care provider c. encourage the client to participate in exercise activities d. encourage the client to discuss his/her feelings

d. encourage the client to discuss his or her feelings; ventilation of feelings is always priority

the nurse is caring for a patient that has been in an accident. initially what symptoms should the nurse expect caused by the body's sympathetic nervous system response? a. decreased respirations b. sweating c. pupil constriction d. increased blood glucose

d. increased blood glucose

a 35 year old male has been diagnosed as a paraplegic secondary to a sky diving accident. The nurse anticipates that the client will react emotionally by: a. going through all stages of grief in a week so he can adapt to his new life b. needing to use humor c. progressing sequentially through 5 stages of grief process d. responding to grief in an individualistic manner

d. responding to grief in an individualistic manner

atrophy

decrease in cell size

decreased urine output

decreased fluid intake and decreased circulation to kidneys

local adaptation syndrome (LAS)

localized response of the body to stress, precipitated by trauma or pathology, can lead to GAS

the nurse is caring for the elderly patient who expresses, "I am not sure I lived a very meaningful life." according to Erikson's eight stages of life, what stage is the patient in?

ego integrity v. despair (old age/maturity 65+ years)

what can the nurse do for a patient experiencing altered breathing in their end stages?

elevate HOB, position to side, use fan/ac, hold hand and speak gently

exhaustion stage

endocrine activity continues, body will fail if exposure to stressor is prolonged

increased sleeping

energy conservation

chronic grief

excessive in duration and never comes to a satisfactory conclusion

chronic disability

existed more than 3 months, no identifiable cause

maturational loss

experienced as a result of natural developmental process

T or F; a can should be held on the weak side rather than the "good side"

false

T or F; a terminally ill patient has anorexia. the nurse should make them eat as the family is concerned

false

T or F: physical restraints do not need to be MD ordered, the nurse can apply restraints as they see fit.

false; MD ordered, q24hr

T or F; rehabilitation starts when the person is discharged from the hospital

false; rehabilitation begins the moment a patient enters a facility

medicare

federally funded program to help elderly meet cost of health care

non-modifiable risk factors

gender, age, genetics, family history

anticipatory grief

grief experienced prior to a loss

disenfranchised grief

grief involving a deceased person that is a socially ambiguous loss that can't be openly mourned or supported

the leading cause of death in older adults in the United States is ______________ disease.

heart

hypertrophy

increase in cell size

bowel & bladder incontinence

increased perineal muscle relaxation and decreased consciousness

a nurse is assessing a patient with post-traumatic stress disorder (PTSD) who is exhibiting physiologic manifestations. The nurse interprets these manifestations as being the result of which of the following?

increased sympathetic activity

personal loss

individual adaptation

delayed grief

inhibited, suppressed or postponed response to a loss

swing-through gait

lift and swing body PAST the crutches

swing-to gait

lift and swing the body TO the crutches

during the assessment of a patient presenting with elevated fasting blood glucose, you ask them when their last visit was. the patient appears uncomfortable and tells you that they have not been seen for years. for what reason could this barrier to health care exist?

negative experiences; interactions with health care influences frequency of care

exaggerated grief

occurs when the reactions to the loss are excessive and disabling

two-point gait

one crutch and opposite extremity move together followed by opposite crutch and extremity bear weight on both legs

what is a potential problem with transfers?

orthostatic hypotension

three examples of age-related disabilities that increase with age are osteoarthritis, hearing loss, and _____________________.

osteoporosis

coolness, color, and temperature change in extremities, perspiration

peripheral circulation diminished to facilitate increased circulation to vital organs

modifiable risk factors

physical activity, nutrition, tobacco & alcohol use

what are elderly patients at risk for regarding medication use?

polypharmacy; multiple use of drugs

congestions/gurgling

poor circulation of body fluids, inability to expectorate secretions

the nurse is teaching the client about health promotion techniques to prevent type 2 diabetes. what phase of illness is the client in?

pre-trajectory

multiple chronic conditions

presence of more than one chronic disease or condition

interface model

promotes care to empower patients rather than making them dependent

if neglect or abuse of any kind—including physical, emotional, sexual, neglect or financial abuse—is suspected, the local adult __________________ services agency must be notified.

protective

how often should the patient be repositioned?

q2h

acute disability

rapid onset, less than 3 months duration, identifiable cause, beginning and end

five cardinal signs of inflammation

redness, swelling, heat, pain, loss of function

to prevent elderly patients from falls, what intervention could the nurse implement?

remind the client to call for help, toilet q2h

why should crutches not rest up underneath the arm for extra support?

resting the crutches in the axilla can cause damage to the brachial plexus and possibly paralysis of the arm

disability

restriction or lack of ability to perform an activity in a normal manner

why are elderly patients at higher risk for side and toxic effects from drugs?

slower metabolism and excretion of drugs

the nurse is with a client who has a chronic illness and is reinforcing positive behaviors and teaching about health promotion. for which phase of the trajectory model of chronic illness are these nursing actions appropriate?

stable

urge incontinence

state in which a person experiences involuntary passage of urine that occurs soon after a strong sense of urgency to void

what is the leading cause of disability?

stroke

palliative care

supportive medical and nursing care that keeps the patient comfortable but does not cure the disease

alarm stage

sympathetic nervous system response; catecholamines released; onset of ACTH response; self-limiting

fight or flight response

the alarm stage in the General Adaptation Syndrome

which of the following describes the crisis phase of the trajectory model of chronic illness?

the client is experiencing a critical or life-threatening situation requiring emergency treatment.

coping

the cognitive and behavioral strategies used to manage the stressors that tax a person's resources

chronic illness

the experience of living with a chronic disease or condition; the individual's perception of the experience and response to the chronic disease or condition

stress incontinence

the inability to control the voiding of urine under physical stress such as running, sneezing, laughing, or coughing

palliative sedation

the lowering of patient consciousness with medication for the express purpose of limiting the patient's awareness of suffering that is intractable and intolerable

the hypothalamic-pituitary response occurs in persistent stress, and keeps blood glucose elevated. what would be an implication for a patient with diabetes?

the patient with diabetes may require more insulin because there is increased available energy

functional incontinence

the person has bladder control but cannot use the toilet in time

impaired physical mobility interventions

transfer techniques, gait training

impaired urinary elimination interventions

triggering techniques, intermittent catheterization, drug therapy, fluid intake, voiding schedule

T or F: age-related macular degeneration is the primary cause of vision loss and blindness in adults 65 years and older.

true

T or F: all of the following are maladaptive responses to stress: a. denial b. avoidance c. withdrawal d. distancing

true

T or F: black women are the population the highest mortality/morbidity rates in the u.s.

true

T or F: chronic diseases last longer than 3 months, are irreversible, and are the most common cause of death in the u.s.

true

T or F: prior to applying restraints the nurse must document. all other methods should be attempted first

true

T or F: the actions of the catecholamines (epinephrine and norepinephrine) and cortisol are the most important reactions in the body's general response to stress.

true

T or F; rehabilitation promotes client independence and self-care

true; key to being able to get back into community

T or F; the nurse is helping a client get dressed. the client has right sided paralysis. the nurse should put the right arm through the shirt first so the client can use their left arm to dress themselves.

true; paralyzed first

risk for impaired skin integrity interventions

turning and positioning, skin care, nutrition, mechanical devices

perceived loss

uniquely defined by the person experiencing the loss and is less obvious to other people

swing-to and swing-through gait

used by patients with hip or leg paralysis

four-point gait

used when both legs can bear some weight; right foot, left crutch, left crutch, right foot

three-point gait

used when only one leg can bear weight

actual tangible loss

usually understood by others

what are the emotional/spiritual symptoms of approaching death?

withdrawal, visions, restlessness, decreased socialization, unusual communication

the nurse is caring for a terminally-ill patient who is experiencing pain. the MD orders morphine sulfate around the clock for the patient's pain. using the nurse's knowledge that this order could lead to death of the patient, should the nurse push the morphine?

yes. if the goal is intention is to reduce the pain, and this is MD ordered, palliative sedation could occur.