Unit 6
Love
: Connectedness with others
During a mumps outbreak at a local school, a patient, who is a school teacher, is exposed. She has previously been immunized for mumps. What type of immunity does she possess?
Acquired immunity
What is a nursing implication when it comes to culture/religion barriers
Assess client's cultural needs when planning learning activites
A nurse is teaching a client who has gastroesophaegeal reflux disease about managing his illness. Which of the following recommendations should the nurse include in the teaching?
Avoid eating within 3 hours of bedtime
Jehovah's Witnesses
Blood transfusions are not allowed Patient may want contact with local Jehovah's Witness hospital liaisoncommittee
Key risk factors of delirium (from textbook)
Cognitive impairment, sleep deprivation, immobility, visual or hearing impairment, and dehydration.
Which of the following is a age-related change associated with the immune system?
Decreased antibody production
A school nurse is talking about infection with a high school health class. What would be the nurse's best explanation of the process of phagocytosis?
Engulfment and digestion of bacteria and foreign material
Explain the role of the nurse in consumer education/prevention.
Establishing relationships and identifying readiness for change.
A nurse is caring for an older adult client who has been confined to bed for several weeks following a fall. The client has been exhibiting symptoms of sundowner's syndrome. Which of the following are characteristics of sundowner's syndrome?
Feeling agitated and wakeful at night
Anti-psychotic
Haldol (haloperidol)
A nurse is providing discharge teaching to a client who has asthma and new prescriptions for cromolyn and albuterol, both by nebulizer. Which of the following statements by the client indicates an understanding of the teaching
I will be sure to take the albuterol before taking the cromolyn.
Hope
Ingredient in life responsible for a positiveoutlook
The nurse is completing a focused assessment addressing a client's immune function. What should the nurse prioritize in the physical assessment?
Palpation of the client's lymph nodes
antinuclear antibody (ANA)
Screening test for autoimmune disorders, positive ANA indicates autoimmune disorder
Roman Catholics
Seven Sacraments
What are the primary participants in the immune system?
T and b cell lymphocytes
The anatomy and physiology instructor is explaining a cell-mediated response to the pre-nursing students. What actions would the instructor explain occur in a cell-mediated response?
T-cell lymphocytes survey proteins in the body and attack the invading antigens.
Which situation would lead the client's family to suspect onset of dementia?
The client has increasingly experienced disorientation to familiar surroundings.
A client has been diagnosed with AIDS and tuberculosis (TB). A nursing student asks the nurse why the client's skin test for TB is negative if the client's physician has diagnosed TB. The nurse's correct reply is which of the following?
The client's immune system cannot mount a response to the skin test.
A client arrives at the clinic and reports a very sore throat as well as a fever. A rapid strep test returns a positive result and the client is given a prescription for an antibiotic. How did the streptococcal organism gain access to the client to cause this infection?
Through the mucous membranes of the throat
Why would it be important for the nurse to question the client about sexual practices, history of substance use disorder, and the client's lifestyle during the interview process?
To determine if the client has practices that the client at risk for acquired immunodeficiency syndrome (AIDS)
A nurse has accepted a position on a pediatric unit and is learning about psychosocial development. Place Erikson's stages of psychosocial development in order from birth to adolescence.
Trust vs Mistrust Autonomy vs shame and doubt Initiative vs guilt Industry vs inferiority Identity vs role confusion
A nurse has been administering seasonal influenza vaccinations to the residents of a long-term care facility. One resident has refused the vaccinations, stating that he believes the vaccination to be a cause of influenza infection rather than a protection against it. The nurse's response to this resident should encompass which of the following facts about vaccination?
Vaccination prompts the body to produce antibodies against influenza.
A nurse is providing discharge teaching about nutrition to the parents of a child who has cystic fibrosis (CF). Which of the following responses by the parents indicates an understanding of the teaching?
We will give our child pancreatic enzymes with snacks and meals.
A nurse is teaching a client who has a urinary tract infection and is taking ciprofloxacin. Which of the following instructions should the nurse give to the client?
You should report any tendon discomfort you experience while taking this medication.
Faith
a confident belief in something for whichthere is no proof or evidence
Allergen
a substance that CAUSES the allergic reaction (pollen, medication)
Type 3 hypersensitivity
acute inflammation, excess of antigen is not cleared from circulation
Type 1 hypersensitivity
anaphylaxis
Spirituality
anything that pertains to the person'srelationship with a nonmaterial life force or higherpower
Confusion can
be sudden (acute) or gradual (chronic)
C-reactive protein (CRP)
blood test used to measure the level of inflammation in the body; ITS INCREASED WITH INFLAMMATION.
Autoimmune response
body attacks itself.
Prostaglandins
cause inflammation, fever, and pain.
T lymphocytes
cellular immune
Affective Domain:
changing attitudes, values, and feelings
Exemplars of cognition
confusion, delirium.
Type 2 hypersensitivity
cytotoxic
The nurse is caring for an older client admitted to the health-care facility with a new onset of confusion and a low-grade fever. Which age-related changes might contribute to decreased functioning of the immune system?
decreased kidney function
Type 4 hypersensitivity
delayed reaction, mediated by T cells
Corticosteroids
delays inflammatory response and suppresses immune system Side effects: bone loss, hyperglycemia, weight gain.
neurocognitive disorders (dementia)
develops over time, alzheimers is the most common type of dementia.
A patient is stressed about surgery and she asks you to pray with her, would you? How can you facilitate religious practices for this patient?
•Ask them how they want to pray •Or they facilitate it and you just be there with them while they pray.
The nurse is working in a long-term care facility and overhears a group of unlicensed assistive personnel (UAP) discussing some of the residents of the facility. What statement made by a UAP indicates that education regarding older adult clients is needed?
"All old people start to deteriorate mentally."
A parent of a child who has been having frequent bouts of tonsillitis brings the child back to the clinic for another sore throat. The parent asks the nurse, "What are tonsils good for anyway?" What is the best response by the nurse?
"These tissues filter bacteria from tissue fluid."
Causes of delirium
- Being hospitalized, out of normal routine - Infection - Drug interactions or sensitivity - Dehydration - Electrolyte Imbalances - Kidney failure - Liver failure - Brain tumors or other head trauma - Fever - Hypoxia - Adverse reactions to medications
Risk factors for cognitive impairments
-Personal behaviors- substance abuse, safety. -Environmental exposures- pesticides and lead -Congenital and Genetic conditions- fetal alcohol syndrome, downs syndrome -Physical disability and reduced mobility- slow gait, health conditions.
When providing care to a client with dementia, which interventions would be most appropriate? Select all that apply.
-maintain levels of sensory stimulation that are tolerable -ensuring the use of assistive sensory devices -using validation therapy
A nurse is providing care to an older adult who is experiencing delirium. Which risk factors would the nurse identify as being most common? Select all that apply.
-pre-existing cognitive impairment -advanced age -sleep deprivation
Which of the following is the most severe form of hypersensitivity reaction? (should be on test)
Anaphylaxis
A 15-year-old client has been brought to the clinic by their mother and is suspected of having an immune system disorder. What tests would you expect to be ordered for this young client?
Complete blood count with differential
What is the most frequent complication of hospitalization in the elderly population
Delirium
An older adult is prescribed an antipsychotic. The nurse understands that this medication is used to treat which manifestation? Select all that apply.
Delusions Hallucinations
What should the nurse do after they get done teaching the client?
Document the teaching.
Teaching tips for children
Dress up, Coloring books, Story books, dolls, puppet play, and health fairs.
Anti-Alzheimer's agents
Memantine, Donepezil, Rivastigmine
What are the three spiritual needs?
Need for meaning and purpose Need for love and relatedness Need for forgiveness
Hinduism
Nurse should avoid touching client's lips when administering medication
A nurse is discussing culturally competent care at a nursing staff inservice. Which of the following information should the nurse include when discussing clients' cultures
Nurses should focus on clients' culture, rather than their ethnicity, when providing care
A nurse is caring for a client who is terminally ill and exhibiting signs of impending death. The client's medical record states that the client is practicing Roman Catholic. Which of the following nursing actions is appropriate?
Offer to make arrangements for the Sacrament of the Sick.
A nurse is completing discharge teaching with a client. Of the following barriers is learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?
Pain
A nurse has given an 8-year-old client the scheduled vaccination for rubella. This vaccination will cause the client to develop which expected and desired condition?
Passive acquired immunity
Islam
Patient may prefer that nurse be the same gender Dietary practices avoid overeating, alcohol, pork and pork-based products
Morality
Personal standards of right or wrong
A client is admitted with cellulitis and experiences a consequent increase in white blood cell count. During what process will pathogens be engulfed by white blood cells that ingest foreign particles?
Phagocytosis
Three areas to consider when developing a teaching plan:
Physical maturation Psychosocial development Cognitive capacity
What problems could have delirium as the initial symptom
Pneumonia Urosepsis Myocardial Infarction
Buddhism
Practitioners generally prefer Eastern medicine Cure through mind, herbs Does not mean they will refuse Western medicine May use traditional therapies in addition to those prescribed by provider
The nurse is providing hygiene care to an older adult client diagnosed with Alzheimer disease and experiencing confusion, when the nurse is called to the nursing station. To ensure client safety the nurse must do what?
Put side rails up before leaving the older adult client.
Nursing interventions for delirium
Quiet environment, well lit rooms during waking hours, routine schedule of activities like mealtime at the same time each day.
An client 81 years of age is in a long-term-care facility. His family could no longer cope with his progressing senile dementia, including wandering away and unpredictable behavior. Late one night the nurse finds the client wandering in the hall. He says he is looking for his wife. What should the nursing approach should be?
Remind him of where he is and assess why he is having difficulty sleeping.
Which condition is associated with impaired immunity relating to the aging client?
Renal function decreases
Teaching tips for older adults
Return demonstration, using materials at a 5th-6th grade reading level.
A nurse is providing teaching to a client who has asthma and a new prescription for inhaled beclomethasone. Which of the following instructions should the nurse provide?
Rinse the mouth after administration
atypical antipsychotics
Risperidone (Risperdal)
Immunity protects from
diseases, its the body's response to a foreign agent
Complement system
enhances the abilities of antibodies and phagocytic cells
Hypersenstivity is an
exaggerated immune response.
Antigens are
foreign invaders
Stem cells
give rise to all cells
The nurse who works with elderly patients diagnosed with Alzheimer's disease recognizes that there are various symptoms of dementia and confusion including sundowning syndrome. The nurse recognizes sundowning syndrome as:
habitual increases in confusion, restlessness, and agitation after dark.
Delirium may include
hallucinations or delusions
Communicating with a client who is unconscious
hearing is the believed to be the last sense lost. Talk to the person normally. Speak before touching.
Histamine
helps the body get rid of allergens, H1 is found in the brain, H2 is found in gastric cells
B lymphocytes
humoral immunity
Allergy
immune system reacts abnormally to a foreign substance
confusion
inability to think or reason in a focused, clear manner
Antibodies fight
infection and disease, kills antigens.
Health
is a state of complete physical, mental, and social well being
Psychomotor Domain:
learning a physical skill
What are the purposes of consumer education/prevention
maintaining and promoting health, preventing illness, restoring health, facilitating coping.
Epinephrine
opens airway, increases BP, HR. Responsible for flight or fight response
Manifestations of confusion
reduced awareness, impaired thinking skills, changes in behavior
The nurse is caring for an older adult client post surgery in the critical care unit. The nurse finds that the client is acutely confused and trying to get out of bed. Which is the priority nursing intervention?
review with the client that he or she is in the hospital
What organ is considered lymphoid tissue?
spleen
Cognitive Domain:
storing and recalling of new knowledge in the brain
Delirium is a state of
temporary confusion (acute)
Religion
term used to describe cultural orinstitutional religion
What are some nursing interventions for clients who are confused?
•Use conversation, watches, clocks, calendar, newspaper, television, radio, and other such devices to help orient the patient to time, place, and person. •Vary environmental stimuli gradually while keeping the environment structured enough that the patient feels comfortable and at home.