Exam 2 (part 2)..

a nurse is caring for a client who has terminal illness. The family wants to care for the client at home. which of the following statement indicates that the nurse understands family-centered care?

"let's set up a meeting time with the doctor to discuss your options for home care"

Which of the following actions would a nurse perform when properly applying restraints to a patient? (Select all that apply.)

- Check agency policy for the application of restraints and secure a physician's order. - Pad bony prominences. - Remove the restraint at least every 2 hours or according to agency policy and patient need

Which of the following are examples of isometric exercise? (Select all that apply.)

- Contracting the quadriceps - Contracting and releasing the gluteal muscles - Kegel exercises

Which of the following are recommended nursing interventions for problems related to mobility? (Select all that apply.)

- For orthostatic hypotension, have the patient sleep sitting up or in an elevated position. - For impaired skin integrity, reposition the patient in correct alignment at least every 1 to 2 hours. - For constipation, increase fluid intake and roughage

Which of the following are effects of immobility on body systems? (Select all that apply.)

- Increased risk for electrolyte imbalance - Increased risk for renal calculi - Increased cardiac workload

Which of the following are effects of exercise on body systems? (Select all that apply.)

- Increases blood flow to kidneys - Increases intestinal tone - Increases efficiency of metabolic system

Which of the following would be an age-appropriate method to prevent accidents and promote safety in a preschooler? (Select all that apply.)

- Instruct the child to wear proper safety equipment when riding bicycles or scooters. - Do not leave the child alone in the bathtub or near water. - Practice emergency evacuation measures.

Which of the following are accurate steps when assisting with passive ROM exercises? (Select all that apply.)

- Move each joint in a smooth, rhythmic manner. - Adjust the bed to the flat position or as low as the patient can tolerate. - Begin ROM exercises at the patient's head and move down one side of the body at a time.

Which of the following are accurate guidelines when teaching crutch walking to patients? (Select all that apply.)

- Prevent crutches from getting closer than 3 inches to the feet. - Keep elbows close to sides. - Use the four-point gait for patients who may bear weight on both feet.

Which of the following statements reflect considerations a nurse should keep in mind when assessing a patient for safety? (Select all that apply.)

- Some people are more prone to have accidents than others. - A medication regimen that includes diuretics or analgesics places an individual at risk for falls. - A person with a history of falls is likely to fall again.

When collecting a urine specimen for urinalysis, the nurse should be aware of which of the following facts? (Select all that apply)

- Strict aseptic technique must be used when collecting and handling urine specimens. - Sterile urine specimens may be obtained by catheterizing the patient's bladder. - clean-catch specimen of urine may be collected in midstream.

Which of the following statements accurately describe kidney function?

- The basic unit of the kidney is the nephron, which removes the end products of metabolism. - The kidneys filter and excrete blood constituents that are not needed and retain those that are. - One of the most significant functions of the kidneys is to maintain the composition and volume of body fluids.

Which of the following is a normal characteristic of urine? (Select all that apply)

- The normal range of the specific gravity of urine is 1.010 to 1.025 - Fresh urine should be clear and translucent - A freshly voided specimen is pale yellow, straw-colored, or amber, depending on its concentration

Which of the following actions would a nurse perform when measuring a patient's urinary output? (Select all that apply)

- The nurse asks the patient to void into a bedpan, urinal, or specimen hat, either in bed or in the bathroom. - The nurse discards the urine into the toilet unless a specimen is required - The nurse records the total amount voided during each shift and the 24-hour period on the patient's permanent record. - The nurse pours the urine from the collection device into the appropriate measuring device

metabolic changes due to immobility

- decreased protein resulting in loss of muscle; - alterations in calcium, fluid, and electrolytes; - resorption of calcium from bones; - decreased urinary elimination of calcium --- results in hypercalcemia

Safety Guidelines for Nursing Skills

-Determine the amount and type of assistance required for safe positioning .•During positioning raise the side rail on the side of the bed opposite of where you are standing. •Arrange equipment so that it does not interfere with the positioning process. •Evaluate the patient for correct body alignment and pressure risks after repositioning.

Physical activity

-Elevates mood and attitude. •Enables physical fitness. •Helps one to quit smoking and stay tobacco-free. •Boosts energy levels. •Helps in the management of stress. •Promotes a better quality of sleep. •Improves self-image and self-confidence.

Passive ROM

-Unable to move independently •Nurse moves each joint through ROM

A nurse determines that her patient has costovertebral tenderness. Which of the following conditions is indicated by this physical finding?

A inflamed kidney

TJC (The Joint Commission)

A national agency that conducts surveys of inpatient and ambulatory facilities and certifies their compliance with established quality standards.

Hypothalamus

A neural structure lying below the thalamus; it directs several maintenance activities (eating, drinking, body temperature), helps govern the endocrine system via the pituitary gland, and is linked to emotion and reward.

Clinical conditions which can result in impaired physical mobility include: (Select all that apply)

A.Pain B.Limited range of motion (Arthritis, back pain) C.Chronic lung disease (COPD) D.Fractured Hip F.Cognitive impairment (dementia) G.Severe depression

What is a critical step when inserting an indwelling catheter into a male client?

Advanced the catheter to the bifurcation of the drainage and balloon ports.

which nursing intervention should a nurse implement when removing an indwelling urinary catheter in an adult patient?

Allow the balloon to drain into the syringe by gravity

A patient with a long history of arthritis complains of sensitivity and warmth in the knees. To determine the degree of limitation, the nurse should assess:

Atelectasis

COAL

Cane Opposite Affected Leg

CMS

Centers for Medicare and Medicaid Services

a nurse is caring for a client who is having difficulty with muscle coordination following a head injury. The nurse should suspect injury to which of the following areas of the brain?

Cerebellum

a nurse is caring for a client who is immobile. The nurse should recognize that immobility places the client at risk of which of the following health alterations?

Decrease cardiac output

Mrs. Bob has had four urinary tract infections in the past year. Which physiologic change of aging is likely causing Mrs. Bob's problem?

Decreased bladder contractility

oliguria

Decreased urine output

a nurse is auscultating a client's lungs and identifies rhonchi over the trachea and bronchi. Which of the following actions should the nurse take?

Encourage the client to cough

an 86 year old client is admitted to the unit with chills and a fever of 104 degree Fahrenheit. What physiological processes explains why the client is at risk for dyspnea?

Fever increases metabolic demands requiring increased oxygen need

On assessing an ambulatory patient, you observe that both arms swing freely in alternation with leg swings. You are assessing which of the following?

Gait

Mr. Gonos is being transferred to the hospital from a nursing home with a diagnosis of dehydration and urinary bladder infection. His skin is also excoriated from urinary incontinence. Which of the following is the most appropriate nursing diagnosis for Mr. Gonos?

Impaired Skin Integrity related to functional incontinence

Swimming, jogging, and bicycling are examples of which of the following types of exercises?

Isotonic exercises

the catheter slips into the vagina during a straight catheterization of a female client. What is the appropriate nursing action?

Leaves the catheter in place and gets a new sterile catheter

Which of the following statements concerning fires is accurate?

Most people who die in house fires do not die from burns, but from smoke inhalation.

Retractions

Movements in which the skin pulls in around the ribs during inspiration.

Urinary Elimination Changes

Normal flow of urine is altered Urinary stasis Increases chance of UTI and renal calculi Perineal care and infection Urinary catheters

A nurse is caring for a client who upon awakening was disoriented to person, place and time. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nursing priority?

Obtain baseline vital signs and oxygen saturation

Active ROM

Patient moves all joints independently

a nurse is reviewing urinalysis results for four clients. Which of the following urinalysis result indicates a urinary tract infection?

Positive for WBC

A patient who is bedridden may experience which of the following conditions?

Predisposition to renal calculi

PASS

Pull the pin, Aim at the base of fire, Squeeze the handle, Sweep side to side

You notice a respiratory change in your immobilized postoperative patient. The change you note is most consistent with:

Range of joint motion

Which assessment findings indicate that the patient is experiencing an acute disturbance in oxygenation and requires immediate intervention?

Retractions

PMART DR

Right patient, Right medication, Right dose or amount, Right route, Right time and frequency, Right documentation, Right reason, Right response

Which of the following statements presents an accurate statistic that should be considered when planning safety for patients?

Some people are more likely than others to have falls; for instance, some children have multiple mishaps, resulting in fractured bones.

A body that is in correct alignment when standing maintains which of the following positions?

The base of support is on the soles of the feet.

Which of the following facts about the lower urinary tract system should be kept in mind when considering catheterization?

The bladder normally is a sterile cavity.

The doctor has ordered the collection of a fresh urine sample for a particular examination. Which urine sample would the nurse discard?

The first voiding of the day

cerebral cortex

The intricate fabric of interconnected neural cells covering the cerebral hemispheres; the body's ultimate control and information-processing center.

When filing a safety event report, the nurse should be aware of which of the following accurate statements?

The safety event report is not part of the medical record and should not be mentioned in the documentation.

SPHM programs

The use of SPHM techniques is a standard for best practices in the moving, handling, and transfer of patients.

Measurement of residual urine by catheterization after voiding verifies which of the following conditions?

Urinary retention

Which of the following events occurs when micturition is initiated?

Urine enters the posterior urethra.

a nurse working on a medicine unit in the hospital hears the fire alarm go off. As the nurse walks down the hallway, there is smoke coming from the family waiting area. Which of the following steps should the nurse take?

Work with the nurse technician to help move patients requiring wheelchairs from their rooms.

gait

a manner of walking, stepping, or running

anuria

absence of urine formation

micturition

act of passing urine

intramuscular injection

an injection into deep muscle tissue, usually of the buttock, thigh, or upper arm - 90 degree

chemical restraint

any drug that is used for discipline or convenience and not required to treat medical symptoms

physical restaint

any manual method or physical or mechanical device, material, or equipment attached to or near the person's body that he or she cannot remove easily and that restricts freedom of movement or normal access to one's body

Rights of Medication Administration

assist to ensure accuracy in drug therapy; rights include right drug, right dose, right patient, right route, right time, right reason, and right documentation

What is Disuse Syndrome?

deterioration of body systems as a result of prescribed or unavoidable musculoskeletal inactivity

Hesitancy (of urine flow)

difficulty with beginning the flow. Decrease in the force of the stream

polyuria

excessive urination

nocturia

excessive urination at night

Isometric exercises

exercises in which one contracts muscles but does not move body parts

Isokinetic exercises

exert resistance against a muscle as it moves through a range of motion at a steady rate of speed

psychosocial effects of immobility

hostility, giddiness, fear, anxiety; sleep-wake alterations; depression, sadness, dejection

subcutaneous injection

injection into the subcutaneous tissue that lies between the epidermis and the muscle - 45(5/8 needle) -90(1/2 needle) degree

intradermal injection

injection placed just below the epidermis - 15 degree

parental route types

intramuscular, subcutaneous, intradermal, intravenous, intrathecal, and epidural.

stress incontinence

involuntary leakage of small volumes result in weaknesses or injury to the urinary sphincter, weak pelvic muscles, etc

urge incontinence

involuntary passage of urine often associated with strong sense of urgency r/t to an overactive bladder, bladder inflammation, etc

What is Muscle Atrophy?

lack of muscle activity; reduces muscle size, tone, and power

pituatary

located in brain, releases growth hormone, regulate glands

dysuria

painful or difficult urination

Types of restraints

physical, chemical, enviroment

hematuria

presence of blood in the urine

2 track technique

prevents medication from leaking back into the tissues

After a patient has a stroke the next step you should do is

reorient the client to the environment

RACE

rescue, alarm, confine, extinguish

the nurse is assisting in putting out a fire on the unit. After the fire extinguisher is obtained, pulling the pin and aiming the fire extinguisher at the fire's base, what is the next action by the nurse?

squeezing the handle of the fire extinguisher

which factor does not contribute to falls in the elderly?

staircase with handrails

nonparental routes types

sublingual, topical, transdermal, opthalmic, otic, nasal, rectal, and vaginal

Cerebellum

the "little brain" at the rear of the brainstem; functions include processing sensory input and coordinating movement output and balance

intravenous injection

the administration of medication by injection directly into a vein - 25 degree

What is mobility?

the functional application of strength and endurance

What is activity tolerance?

type and amount of exercise or work that a person is able to perform

bedridden

unable to get out of bed

Principles of Body Mechanics

•Assess patient ability to transfer •Position as close to the patient as possible •Tighten abdominal muscles and keep feet and back aligned •Avoid twisting •Bend at the knees and keep feet wide apart •Use your arms and legs, not your back •Coordinate lifting efforts

Helping a patient walk

•Assess patient's ability to walk safely •Evaluate environment for safety •Assist patient to sitting position, dangle patient's legs over the side of the bed 1 to 2 minutes before standing •Provide support at the waist so the patient's center of gravity remains midline (gait belt)

Gravity and friction

•Unsteady patients fall if their center of gravity becomes unbalanced •Friction is a force that occurs in a direction to oppose movement.