week 2

A 53 y/o client is admitted to the hospital for hematuria. The client has no previous history of illness, is married, and has three children in high school. Which task of middle adulthood would most likely be disturbed by a physical disability? 1. Assisting the children to grow to adulthood 2. coping with a role transition 3. Renewing earlier relationships. 4. Developing adult leisure time activities.

1. According to Erickson, middle adulthood is the time of guiding the next generation; this occurs not only in family life but also in one's professional career; if this developmental task is not achieved, client becomes self-absorbed. Middle age is called the sandwich generation; are still involved with children, but are also involved in caring for aging parents or other relatives. Middle-aged adults are leaders in their professions and communities. middle-aged adults find that they have more financial resources and more leisure time; nurse should instruct client about the importance of engaging in daily leisure activity.

The nurse Identifies which as a risk factor for a client to develop a pressure ulcer? 1. Decreased skin moisture. 2. Ambulation with an assistive device 3. Anemia 4. Alzheimer's disease

3. Decreased oxygen-carrying capacity of the blood; clients with lower protein level aren't able to repair tissue. Prolonged contacted with increase moisture will contribute to skin breakdown. Prolonged sitting/lying without changing positions contributes to skin breakdown due to sensory loss. Alzheimer's does not predispose client to develop pressure ulcer.

The nurse identifies a staff member is using standard precautions appropriately if which action is observed. 1. the nurse wears gloves when taking the blood pressure of a client diagnosed with AIDS. 2. The staff member irrigates an abdominal wound wearing a gown and gloves. 3. The staff member places contaminated linens in a leak-proof bag. 4. The nurse removes gloves after bathing a client and puts on a clean pair of gloves to bathe another client.

3. The staff member places contaminated linens in a leak-proof bag. This prevents contact with skin and mucous membranes. wear gloves when touching blood, body fluids, secretions, excretions, not intact skin and mucous membranes; not necessary to wear gloves when taking BP; should also wear mask and eye wear if splashes or sprays of blood or body fluid may occur; always wash hands between contact with clients; wash hand immediately after removing gloves.

While a client is being treated for a wound infection, it is most important for the nurse to routinely perform which action? Check and record the clients temperature send samples of wound drainage for culture assess the perfusion in the area Evaluate the results of the blood culture.

A client with a wound infection is at risk for bacteremia or other complications, such as glomerulonephritis; nurse should evaluate for temperature elevation. Samples would be done initially; assess for indications of inflammation; health care provider will order appropriate antibiotics; place client on contact precautions

Which fear is most important for the nurse to consider when planning care for 4 y/o about to have surgery? Fear of losing independence Fear of losing control Fear of separation Fear of mutilation

Fear of mutilation preschool children are frightened of invasive procedures because they fear mutilation; allow child to play with models of equipment encourage expressions of feelings.

Post op care

Full system assessment required. TCDB unless brain, spinal, or eye surgery. Splint wound/offer pain medication. Educate using incentive spirometer. GI place NPO if no bowel tone and provide good mouth care, check for gas, stool, nausea, vomiting.

Pressure ulcer

Localized area of necrotic tissue that develops when soft tissue is compressed over a bony prominence; risk factor include impaired sensory perception, impaired mobility, alter LOC, shear, friction, moisture.

Wound infection

May occur from internal or external sources; bacterial; surgical wound infections evident 3 to 4 days postoperatively; indications include redness beyond line of incision, increased pain, warmth, swelling, increased drainage (may be purulent or foul smelling), fever, anorexia, malaise, leukocytosis, positive wound culture; nursing interventions include monitor temperature give broad spectrum antibiotics as ordered during 24 to 48 hours waiting period for culture results use contact precautions and aseptic technique, monitor drainage if drain inserted by health care provider after partial reopening of wound.

On the morning before surgery, the client signs an operative consent form. Soon afterward, the client tells the nurse that the client does not want the surgery. Which action does the nurse take first? Notifies the health care provider of the clients decision. Informs the client the decision has delayed the operating room schedule. Encourages the client to discuss reasons for canceling the surgery asks the clients family to encourage the client to have the surgery.

Nurse should assess clients reasons to withdraw consent; inform client of the outcome of decision. Client has the right tow withdraw consent; notify health care provider after first assessing the clients reasons. Client has the right to withdraw consent. Do not try to talk client into changing the mind; client must informed about outcomes of decision.

When witnessing the clients signature during informed consent, it is most important for the nurse to make which assessment? Does the client understand the procedure? Does the client have any questions? Does the client give consent voluntarily? Is the client able to write the name?

Nurses signature indicates that the client voluntarily gave consent, the clients signature is authentic, and the client is competent to give consent. It is the health care providers responsibility to explain the procedure and the risks and benefits associated with the procedure. It is not the nurses responsibility to answer questions; that responsibility belongs to the healthcare provider. Client is legally able to place a mark on the consent form.

Following surgery, the nurse becomes concerned because the client has not voided since before surgery which was 10 hours ago. Which nursing action is most appropriate? Insert a catheter into the bladder Encourage client to take sips of water Inform the health care provider immediately Palpate for bladder distetion

Palpate for bladder distention. Perform assessment before implementing. Assumes client is dehydrated, assess the status of the bladder. Perform assessment of client before contacting health care provider.

The nurse care for a client with an abdominal wound. The nurse notes there is purulent drainage from the wound. Which action should the nurse take first?

Place the client on contact precautions in a private room or in a room with same infection but no other infections; wear clean, sterile gloves when entering the clients room; change gloves after client contact; wash hands. Irrigation uses sterile technique. appropriate to assess pain but priority is to place client on contact precautions; manifestations of infection include redness and swelling; infected drainage may be yellow, green, or brown; systemic infections cause fever, fatigue and malaise; WBCs will be elevated; norm range is 5000-10000/mm3

Contact-Based infection precautions

ReRequired with client care activities that require physical skin-to-skin contact or those that occur between two clients or occur by contact with contaminated inanimate objects in clients environment; private room or with client with same infection but no other infection; clean non-sterile gloves when entering room. Change gloves after client contact with fecal material or wound drainage, remove gloves before leaving the clients environment and was hands with antimicrobial agent, wear gown when entering room if clothing has contact with client, environmental surfaces, or if client is incontinent, has diarrhea, an ileostomy, colostomy, or wound drainage.

Erickson's stages of psychosocial development

Theory of psychosocial development throughout the life span. Divided into 8 stages that define particular tasks that individuals need to accomplish before moving to the next stage. Each stage has a positive and negative outcome.

The nurse understand which is the primary reason that elderly adults have constipation. 1. They eat small volume of food with decreased bulk They have less activity and decreased muscle tone They have neurological changes in the gastrointestinal tract. They have decreased sensation in the gastrointestinal tract.

They have less activity and decreased muscle tone. After 65 there is less peristalsis and decreased muscle tone in the GI tract; this, combined with the normally reduced activity of older adults, results in constipation; may decrease their activity around the age of 65 to 70. Capacity of stomach decreases; encourage to eat smaller, more frequent meals. neuro changes include decreased short-term memory and decreased reaction time, and sensory perceptual changes such as decreased hearing. decreased peristalsis dose occur.

Standard Precautions

Used with all clients to prevent health care-associated infections; apply to blood, all body fluids, and secretions; wash hands immediately on contact with blood or body fluids, as soon as gloves are removed between client contact, procedures, or tasks with the same client, wear gloves when touching blood, body fluids, or before touching mucous membranes or non-intact skin; wear mask, face shield and gown if splashes and spray is likely.