130 Unit 4 - Omness

"You can use tap water instead of sterile saline to clean your wound." (For chronic wounds in the home, clean tap water and nonsterile supplies are acceptable and serve as cheaper alternatives to sterile supplies. Of course, if the wound becomes grossly infected, the client may end up in the hospital, but this response does not provide any helpful information. Good handwashing is important, but it is not the only consideration.)

A nurse assesses a client who has a chronic wound. The client states, "I do not clean the wound and change the dressing every day because it costs too much for supplies." How should the nurse respond? "You can use tap water instead of sterile saline to clean your wound." "If you don't clean the wound properly, you could end up in the hospital." "Sterile procedure is necessary to keep this wound from getting infected." "Good hand hygiene is the only thing that really matters with wound care."

"How are you coping with providing this care?" (A client with a Braden Scale score of 9 is at high risk for skin breakdown and requires moderate to maximum assistance to prevent further breakdown. Family members who care for clients at home may experience a disruption in family routines and added stress. The nurse should assess the wife's feelings and provide support for coping with changes. Asking about the client's toileting practices, prevention of pediculosis, and sleeping arrangements do not provide information about the caregiver's support and coping mechanisms and ability to continue to care for her husband.)

A nurse assesses a wife who is caring for her husband. She has a Braden Scale score of 9. Which question should the nurse include in this assessment? "Do you have a bedpan at home?" "How are you coping with providing this care?" "What are you doing to prevent pediculosis?" "Are you sharing a bed with your husband?"

A 65-year-old with hemi-paralysis and incontinence (Being immobile and being incontinent are two significant risk factors for the development of pressure ulcers. The client with pneumonia does not have specific risk factors. The young client who has a fractured leg and the client who needs assistance with ambulation might be at moderate risk if they do not move about much, but having two risk factors makes the 65-year-old the person at highest risk.)

A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure ulcer development? A 44-year-old prescribed IV antibiotics for pneumonia A 26-year-old who is bedridden with a fractured leg A 65-year-old with hemi-paralysis and incontinence A 78-year-old requiring assistance to ambulate with a walker

Change the dressing every 6 hours. (Wet-to-damp dressings are changed every 4 to 6 hours to provide maximum débridement. The wound should be assessed each time the dressing is changed. Dry gauze dressings should be changed when the outer layer becomes saturated. Synthetic dressings can be left in place for extended periods of time but need to be changed if the seal breaks and the exudate leaks.)

A nurse cares for a client who has a deep wound that is being treated with a wet-to-damp dressing. Which intervention should the nurse include in this client's plan of care? Change the dressing every 6 hours. Assess the wound bed once a day. Change the dressing when it is saturated. Contact the provider when the dressing leaks.

Use a lift sheet when moving the client in bed. Avoid tape when applying dressings. Implement pressure-relieving devices. (Using a lift sheet will prevent shearing forces from tearing skin. Tape should be avoided so that the skin won't tear. Using pressure-relieving devices for clients who are at risk for pressure ulcer formation, including older adults, is a proactive approach to prevent skin breakdown. No contraindication to using whirlpool therapy for the older client is known. Dressings should be applied as prescribed, not so loose that they do not provide required treatment, and not so tight that they decrease blood flow to tissues.)

A nurse cares for older adult clients in a long-term acute care facility. Which interventions should the nurse implement to prevent skin breakdown in these clients? (Select all that apply.) Use a lift sheet when moving the client in bed. Avoid tape when applying dressings. Avoid whirlpool therapy. Use loose dressing on all wounds. Implement pressure-relieving devices.

"Wash your hands before touching the client." "Wear gloves when bathing the client." (All health care providers should follow Standard Precautions when caring for clients who have any open skin areas. This includes hand hygiene and wearing gloves when in contact with the lesions. The UAP is not qualified to assess the client's skin. The other statements are not appropriate for the care of open skin lesions.)

A nurse delegates care for a client who has open skin lesions. Which statements should the nurse include when delegating this client's hygiene care to an unlicensed assistive personnel (UAP)? (Select all that apply.) "Wash your hands before touching the client." "Wear gloves when bathing the client." "Assess skin for breakdown during the bath." "Apply lotion to lesions while the skin is wet." "Use a damp cloth to scrub the lesions."

Body mass index (BMI) of 17 Weight loss of 6% since last month's visit Hemoglobin level of 8.2 g/dL (A BMI of 18.5 to 24.9 is normal, and this patient's BMI is below normal; a major weight loss is defined as more than a 2% weight change over 1 week; and the expected hemoglobin level for a man is 14 to 18 g/dL. The patient's values may also indicate dehydration. The expected level for prealbumin is 15 to 36 mg/dL. A hematocrit level of 50% is within normal limits.)

A nurse in a home setting is assessing a 79-year-old male patient's risk for malnutrition. The nurse suspects malnutrition when reviewing which laboratory results? Select all that apply. Body mass index (BMI) of 17 Waist-to-hip ratio of 1.0 Weight loss of 6% since last month's visit Prealbumin level of 16 mg/dL Hematocrit level of 50% Hemoglobin level of 8.2 g/dL

Assess the right leg for pulses, skin color, and temperature. (A client with an ulcer on the foot should be assessed for interruption in arterial flow to the area. This begins with the assessment of pulses and color and temperature of the skin. The nurse can also assess for pulses noninvasively with a Doppler flowmeter if unable to palpate with his or her fingers. Tests to determine nutritional status and risk assessment would be completed after the initial assessment is done. Wound cultures are done after it has been determined that drainage, odor, and other risks for infection are present. Elevation of the foot would impair the ability of arterial blood to flow to the area.)

A nurse is caring for a client who has a pressure ulcer on the right ankle. Which action should the nurse take first? Draw blood for albumin, prealbumin, and total protein. Prepare for and assist with obtaining a wound culture. Place the client in bed and instruct the client to elevate the foot. Assess the right leg for pulses, skin color, and temperature.

Place a small pillow between bony surfaces. Use a lift sheet to assist with re-positioning. Keep the client's heels off the bed surfaces. (A small pillow decreases the risk for pressure between bony prominences, a lift sheet decreases friction and shear, and heels have poor circulation and are at high risk for pressure sores, so they should be kept off hard surfaces. Head-of-the-bed elevation greater than 30 degrees increases pressure on pelvic soft tissues. Fluids and proteins are important for maintaining tissue integrity. Clients should be repositioned every hour while sitting in a chair. A rubber ring impairs capillary blood flow, increasing the risk for a pressure sore.)

A nurse plans care for a client who is immobile. Which interventions should the nurse include in this client's plan of care to prevent pressure sores? (Select all that apply.) Place a small pillow between bony surfaces. Elevate the head of the bed to 45 degrees. Limit fluids and proteins in the diet. Use a lift sheet to assist with re-positioning. Re-position the client who is in a chair every 2 hours. Keep the client's heels off the bed surfaces. Use a rubber ring to decrease sacral pressure when up in the chair.

Recent wound assessment, including size and appearance (The hospital nurse should provide details about the wound, including size and appearance and any special wound needs, in a hand-off report to the home health nurse. Insurance information is important to the home health agency and manager, but this is not appropriate during this hand-off report. The nurse should report focused assessment findings instead of a complete health history and physical assessment. The home health nurse should work with the client to identify community resources.)

A nurse prepares to discharge a client who has a wound and is prescribed home health care. Which information should the nurse include in the hand-off report to the home health nurse? Recent wound assessment, including size and appearance Insurance information for billing and coding purposes Complete health history and physical assessment findings Resources available to the client for wound care supplies

b. "Imodium does not cause physical dependence." (Although the drug exhibits many characteristics of the opiate class, physical dependence on loperamide has not been reported. All antidiarrheal drugs are orally administered. The other options are incorrect.)

A patient asks the nurse about the difference between diphenoxylate with atropine (Lomotil) and the over-the-counter drug loperamide (Imodium). Which response by the nurse is correct? a. "Lomotil acts faster than Imodium." b. "Imodium does not cause physical dependence." c. "Lomotil is available in suppository form." d. "Imodium is a natural antidiarrheal drug."

b. Sildenafil (Viagra), an erectile dysfunction medication (Drugs that interact with alpha blockers such as tamsulosin include erectile dysfunction drugs; additive hypotensive effects may occur. The other drugs do not interact with tamsulosin.)

A patient has a new prescription for tamsulosin (Flomax) as treatment for benign prostatic hyperplasia. The nurse is checking his current medication list and will contact the prescriber regarding a potential interaction if the patient is also taking which drug? a. Levothyroxine (Synthroid) for hypothyroidism b. Sildenafil (Viagra), an erectile dysfunction medication c. Omeprazole (Prilosec), a proton pump inhibitor d. Low-dose aspirin for stroke prevention

Vaginal pessary therapy (A prolapse occurs when the supportive tissue in the vagina weakens and stretches, allowing the pelvic organs to protrude into the vaginal lumen. A ring-shaped pessary inserted into the vagina is helpful when the prolapsed uterus or bladder is contributing to urinary incontinence. Vaginal cone therapy strengthens the pelvic muscles and decreases stress incontinence but may not help with pelvic prolapse. Magnetic resonance therapy reduces stress-induced incontinence similar to drug-induced relaxation of muscles and nerves. Electrical stimulation therapy helps in the treatment of both urge and stress incontinence by decreasing the sensation of urgency through either intravaginal or intrarectal stimulation.)

A patient has urinary incontinence due to protrusion of pelvic organs into the vaginal lumen. Which treatment strategy would be beneficial to the patient in this situation? Vaginal cone therapy Vaginal pessary therapy Magnetic resonance therapy Electrical stimulation therapy

d. Polyethylene glycol (Miralax) (Polyethylene glycol is a very potent laxative that induces total cleansing of the bowel and is most commonly used before diagnostic or surgical bowel procedures. The other options are incorrect.)

A patient is about to undergo a diagnostic bowel procedure. The nurse expects which drug to be used to induce total cleansing of the bowel? a. Docusate sodium (Colace) b. Lactulose (Enulose) c. Mineral oil d. Polyethylene glycol 3350 (Miralax)

"The exact cause of BPH is unclear." (While BPH is likely the result of a combination of aging and the influence of androgens, it is not a natural part of the aging process and the exact cause is unclear. An improved diet can reduce the symptoms of BPH, but a poor diet is not the cause. BPH does not affect a man's ability to reproduce.)

A patient is diagnosed with benign prostatic hyperplasia (BPH). When discussing the diagnosis with the patient, the nurse would likely make which statement? "BPH is caused by a poor diet." "The exact cause of BPH is unclear." "BPH affects men's ability to reproduce." "BPH is a natural occurrence in aging men."

Trospium Oxybutynin Tolterodine (Anticholinergics and antispasmodics increase intraocular pressure and worsen glaucoma. They also increase the possibility of side effects when crushed or chewed by releasing the drug all at once. Therefore, the nurse finds anticholinergic drugs such as trospium, tolterodine, and antispasmodics such as oxybutynin in the patient's prescription. Midodrine and mirabegron do not worsen glaucoma nor increase the possibility of side effects. However, midodrine causes a supine hypertension, and mirabegron has some potential to increase blood pressure.)

A patient is diagnosed with stress urinary incontinence. The nurse checks the patient's medical history for the presence of glaucoma and also instructs the patient to avoid crushing or chewing tablets. Which medications does the nurse find in the patient's prescription? Select all that apply. Midodrine Trospium Mirabegron Oxybutynin Tolterodine

A thin application of cream is adequate. (Teach the patient that a thin application of estrogen cream is all that is needed. The patient taking tricyclic antidepressants must change positions slowly, especially in the mornings, because these drugs cause dizziness, orthostatic hypotension, and increase the risk for falls. The patient taking antispasmodics or anticholinergics should report urine output that is significantly lower than fluid intake because these drugs cause urine retention. Dry mouth is another side effect of antispasmodics and anticholinergics. The patient can use hard candy to moisten the mouth.)

A patient is prescribed estrogen therapy for urinary incontinence. What does the nurse teach the patient about this therapy? Use hard candy to moisten the mouth. A thin application of cream is adequate. Change positions slowly, especially in the mornings. Report urine output that is significantly lower than fluid intake.

Swallow the tablet whole. (Extended-release forms of anticholinergic drugs have a gradual effect over time. The patient should swallow the drug whole because chewing or crushing the tablet destroys the extended-release feature of the drug, causing the entire dose to be absorbed quickly and increasing its side effects. The patient who is prescribed collagen or a Siloxane injection to manage urge incontinence must take an allergy test before being injected with the drug. This would not be the case for oxybutynin.)

A patient is prescribed the extended-release form of the anticholinergic drug oxybutynin as first-line management for urge incontinence. Which instruction would the nurse give the patient regarding drug administration? Chew the tablet. Swallow the tablet whole. Crush and dissolve the tablet in water. Perform an allergy test before taking the tablet.

Perfusion assists the cell by delivering oxygen and removing waste products. (Perfusion delivers much needed oxygen to the cells of the body and then helps to remove waste products. Perfusion does not prevent clots, does not increase cardiac output, and does not increase mental alertness.)

A patient is questioning the nurse about circulation and perfusion. What is the nurse's best response? Perfusion assists the body by preventing clots and increasing stamina. Perfusion assists the cell by delivering oxygen and removing waste products. Perfusion assists the heart by increasing the cardiac output. Perfusion assists the brain by increasing mental alertness.

b. increased hair growth. (Finasteride is given to reduce prostate size in men with benign prostatic hyperplasia. It has been noted that men taking this medication experience increased hair growth. The other options are incorrect.)

A patient is receiving finasteride (Proscar) for treatment of benign prostatic hyperplasia. The nurse will tell him that a possible effect of this medication is: a. alopecia. b. increased hair growth. c. urinary retention. d. increased prostate size.

Sexual function is not usually affected with TURP. (Sexual function is usually not affected with TURP, although retrograde ejaculation may occur. Permanent urinary incontinence does not occur after TURP. While the catheter is in place and immediately after its removal, there may be small blood clots and tissue debris in the urine; it is therefore normal for the urine to be blood-tinged after surgery. Epidural or spinal anesthesia is preferred over general anesthesia during TURP because it is easier to monitor for water retention or fluid overload during the procedure when the patient is awake.)

A patient is scheduled for a transurethral resection of the prostate (TURP) for benign prostatic hyperplasia. What preoperative information must the patient understand? Permanent incontinence occurs after TURP. Sexual function is not usually affected with TURP. Blood-tinged urine after the procedure must be reported. General anesthesia will be administered during the surgery.

a. Orthostatic hypotension (Orthostatic hypotension can occur with any dose of an alpha blocker, and patients must be warned to get up slowly from a supine position. The other responses are not drug effects of alpha blockers.)

A patient is taking an alpha blocker as treatment for benign prostatic hyperplasia. The nurse will monitor for which potential drug effect? a. Orthostatic hypotension b. Increased blood pressure c. Decreased urine flow d. Discolored urine

Overflow incontinence (This patient's condition is known as overflow incontinence. The urethra in the patient is obstructed because of the enlarged prostate; the urethra fails to relax sufficiently to allow the urine to flow, resulting in incomplete bladder emptying or complete urinary retention. Loss of urine following physical exertion, cough, or sneeze is documented as stress incontinence. Stress incontinence occurs because of intrinsic sphincter deficiency or acquired anatomic damage to the urethral sphincter. The patient with urge incontinence experiences an involuntary loss of urine with a strong desire to urinate. The patient with reflex incontinence has a post-void residual less than 50 mL.)

A patient reports experiencing involuntary loss and constant dribbling of urine because of an enlarged prostate. How does the nurse document this incontinence? Urge incontinence Stress incontinence Reflex incontinence Overflow incontinence

Assess for excessive bleeding. (Patients who undergo TURP are at risk for severe postoperative bleeding. The bleeding most often occurs within the first 24 hours and may require critical rescue. Vital signs are assessed every 4 hours. The nurse assesses pain every 2 to 4 hours and provides interventions to control it. Urine output is assessed every 2 hours.)

A patient underwent a transurethral resection of the prostate (TURP) yesterday for benign prostatic hyperplasia. What intervention does the nurse perform for the patient during the first postoperative day? Assess vital signs every hour. Assess for excessive bleeding. Assess pain two times every day. Assess urine output every 4 hours.

b. Bulk-forming laxatives (Bulk-forming laxatives are the only laxatives recommended for long-term use. Stimulant laxatives are the most likely of all the laxative classes to cause dependence. The other options are incorrect.)

A patient wants to prevent problems with constipation and asks the nurse for advice about which type of laxative is safe to use for this purpose. Which class of laxative is considered safe to use on a long-term basis? a. Emollient laxatives b. Bulk-forming laxatives c. Hyperosmotic laxatives d. Stimulant laxatives

"The bladder muscle thins to help urine push past the enlarged prostate gland." (The bladder muscle thickens rather than thins to help urine push past the enlarged prostate gland. As the prostate gland enlarges, it extends upward into the bladder and inward, causing bladder outlet obstruction. The increased volume of residual urine often causes overflow urinary incontinence, in which the urine "leaks" around the enlarged prostate, causing dribbling. Urinary stasis can also result in urinary tract infections and bladder calculi (stones).)

A patient was recently diagnosed with benign prostatic hyperplasia (BPH). The nurse is teaching the patient the physiology of the bladder and prostate in patients with BPH. Which statement by the patient indicates the need for further teaching? "The prostate gland enlarges, causing bladder outlet obstruction." "The increased volume of residual urine often causes overflow urinary incontinence." "Urinary stasis occurs, which can result in urinary tract infections and bladder calculi." "The bladder muscle thins to help urine push past the enlarged prostate gland."

d. Probiotics (Probiotics work by replenishing bacteria that may have been destroyed by antibiotic therapy, thus restoring the balance of normal flora and suppressing the growth of diarrhea-causing bacteria.)

A patient who has been on antibiotic therapy for 2 weeks has developed persistent diarrhea. The nurse expects which medication class to be ordered to treat this diarrhea? a. Lubricants b. Adsorbents c. Anticholinergics d. Probiotics

"The patient is losing sphincter control due to the dementia." (Anger, wanting to leave the hospital, and forgetting where the bathroom is really have no bearing on the urinary incontinence. The patient is incontinent due to the mental ability to voluntarily control the sphincter. This is happening because of the dementia.)

A patient who was diagnosed with senile dementia has become incontinent of urine. The patient's daughter asks the nurse why this is happening. The best response by the nurse is: "The patient is angry about the dementia diagnosis." "The patient is losing sphincter control due to the dementia." "The patient forgets where the bathroom is located due to the dementia." "The patient wants to leave the hospital."

silodosin (silodosin is a site specific alpha blocker and is the drug that the patient should be prescribed. prazosin is non-site specific and puts the patient at risk for lower blood pressure. oxybutynin and tolteradine are used for treatment of urge incontinence)

A patient with BP 96/68 presents with BPH. Which medication does the nurse expect the patient to receive? oxybutynin prazosin silodosin tolteradine

Fluid overload Hyponatremia Water intoxication (A large amount of irrigating fluid is using during a TURP procedure. This can place the patient at risk for hyponatremia, fluid overload, and water intoxication. Hydronephrosis may be caused by BPH and is one of the criteria that indicates the need for surgical management. Blood-tinged urine is usually normal after TURP, and the patient should be reassured about this finding.)

A patient with benign prostatic hyperplasia (BHP) is being considered for a transurethral resection of the prostate (TURP). What complications can occur as a result of this procedure? Select all that apply. Fluid overload Hyponatremia Hydronephrosis Water intoxication Blood-tinged urine

Be careful when changing positions. Avoid drugs used to treat erection problems. Keep all appointments for follow-up laboratory testing. (Drugs used to treat erectile dysfunction can worsen side effects, such as hypotension. Alpha-adrenergic blockers may cause orthostatic hypotension and can cause liver damage, so it is important to keep appointments for follow-up laboratory testing. These drugs do not affect hearing. Alpha-adrenergic blockers should be taken in the evening to decrease the risk of problems related to hypotension.)

A patient with benign prostatic hyperplasia is being discharged with alpha-adrenergic blockers. Which information is important for the nurse to include when teaching the patient about this type of pharmacologic management? Select all that apply. Be careful when changing positions. Take the medication in the afternoon. Avoid drugs used to treat erection problems. Hearing tests will need to be conducted periodically. Keep all appointments for follow-up laboratory testing.

Functional incontinence (Functional incontinence, which is leakage of urine caused by factors other than disease of the lower urinary tract, is most likely to occur in individuals with decreased cognition such as with dementia, and with an inability to walk to the toilet. Urge incontinence is more likely to result from idiopathic causes, brain and nerve disorders, bladder inflammation or infection, and bladder cancer. Stress incontinence can result from weakening of bladder neck supports, intrinsic sphincter deficiency, acquitted anatomic damage to the urethral sphincter, or vaginal prolapse from vaginal birth or aging. Deltrusor hyperreflexia often results from central nervous system lesions from stroke, multiple sclerosis, and parasacral spinal cord lesions. )

A patient with dementia and problems with mobility is most likely to experience which type of incontinence? Urge incontinence Stress incontinence Detrusor hyperreflexia Functional incontinence

"If his tailbone is red and tender in the morning, I will massage it with baby oil." (Massage of reddened areas over bony prominences such as the coccyx, or tailbone, is contraindicated because the pressure of the massage can cause damage to the skin and subcutaneous tissue layers. The other statements are appropriate for the care of a client at home.)

After educating a caregiver of a home care client, a nurse assesses the caregiver's understanding. Which statement indicates that the caregiver needs additional education? "I can help him shift his position every hour when he sits in the chair." "If his tailbone is red and tender in the morning, I will massage it with baby oil." "Applying lotion to his arms and legs every evening will decrease dryness." "Drinking a nutritional supplement between meals will help maintain his weight."

Antispasmodic drugs Monitoring for anemia (Although not a common occurrence, bleeding may occur in the postoperative period. Venous bleeding is more common than arterial bleeding. The surgeon may apply traction on the catheter for a few hours to control the venous bleeding. Traction on the catheter is uncomfortable and increases the risk for bladder spasms, so analgesics or antispasmodics are usually prescribed. Hemoglobin and hematocrit would be monitored and trended for indications of anemia.Emergency surgery and increased intermittent irrigation would be indicated for an arterial bleed, which would be a brighter red color. Forced fluids are indicated after the catheter is removed.)

After returning from transurethral resection of the prostate, the client's urine in the continuous bladder irrigation system is a burgundy color. Which client needs does the nurse anticipate after the surgeon sees the client? Select all that apply. Antispasmodic drugs Emergency surgery Forced fluids Increased intermittent irrigation Monitoring for anemia

High-protein diet with vitamins and mineral supplements (The preferred diet is high in protein to assist in wound healing and prevention of new wounds. Fat is also needed to ensure formation of cell membranes, so any of the options with low fat would not be good choices. A vegetarian diet would not provide fat and high levels of protein.

After teaching a client who is at risk for the formation of pressure ulcers, a nurse assesses the client's understanding. Which dietary choice by the client indicates a good understanding of the teaching? Low-fat diet with whole grains and cereals and vitamin supplements High-protein diet with vitamins and mineral supplements Vegetarian diet with nutritional supplements and fish oil capsules Low-fat, low-cholesterol, high-fiber, low-carbohydrate diet

Terazosin (Terazosin will treat the patient's BPH without the risk of lowering his libido. Finasteride includes lowered libido as a side effect and is not the best of medication in this situation. Bisacodyl and oxybutynin do not treat BPH.)

A 46 year old man present with BPH. Which medication is the best choice to be prescribed? Bisacodyl Oxybutynin Finasteride Terazosin

d. "The doctor will need to draw some blood and do a digital rectal exam first." (A prostatic-specific antigen test and digital rectal examination needs to be performed before initiation of treatment with saw palmetto for benign prostatic hyperplasia. Adverse effects may include gastrointestinal upset, headache, back pain, and dysuria.)

A 63-year-old male patient is scheduled for a physical examination, and he tells the nurse that he wants to start taking a vitamin formula that includes saw palmetto for prostate health. Which is the nurse's best response? a. "I've heard many good things about saw palmetto." b. "It's not a good idea to start herbal therapy at your age." c. "There are very few adverse effects with saw palmetto therapy." d. "The doctor will need to draw some blood and do a digital rectal exam first."

Slow down the bladder irrigation if the urine is pink. (The serum sodium is decreased due to large-volume bladder irrigation (normal is 136 to 145 mEq/L). By slowing the irrigation, there will be less fluid overload and sodium dilution. The hemoglobin and hematocrit values are a low normal, with a slight decrease in the red blood cell count. Therefore, a blood transfusion or frequent vital signs should not be necessary. Immediate report to the surgeon is not necessary.)

A 70-year-old client returned from a transurethral resection of the prostate 8 hours ago with a continuous bladder irrigation. The nurse reviews his laboratory results as follows: Sodium: 128 mEq/L Hemoglobin: 14 g/dL Hematocrit: 42% RBC count: 4.5 What action by the nurse is the most appropriate? Consider starting a blood transfusion. Slow down the bladder irrigation if the urine is pink. Report the findings to the surgeon immediately. Take the vital signs every 15 minutes.

Changes the dressing frequently (The nurse knows that frequent dressing changes help with healing and help the client feel clean. This is the best method of support for this client.A diet high in protein would not be directly helpful for this client. Whirlpool therapy may not be appropriate for this client. Room deodorizers do not address the source of the problem and may be offensive to the client and the family.)

A client has an odorous, purulent wound. How does the nurse best support this client? Changes the dressing frequently Encourages a diet high in protein Suggests whirlpool therapy Places room deodorizers in the room

Take vital signs and notify the surgeon immediately. (Bright red urinary drainage with clots may indicate arterial bleeding. Vital signs should be taken and the surgeon notified. The traction on the three-way catheter should not be released since it places pressure at the surgical site to avoid bleeding. The nurse's review of hemoglobin and hematocrit and reminding the client not to pull on the catheter are good choices, but not the priority at this time.)

A client has returned from a transurethral resection of the prostate with a continuous bladder irrigation. Which action by the nurse is a priority if bright red urinary drainage and clots are noted 5 hours after the surgery? Review the hemoglobin and hematocrit as ordered. Take vital signs and notify the surgeon immediately. Release the traction on the three-way catheter. Remind the client not to pull on the catheter.

Administer antispasmodic medications. Assist the client to mobilize as soon as permitted. (Antispasmodic drugs can be administered to decrease the bladder spasms that may occur due to catheter use. Assisting the client to a chair as soon as permitted postoperatively will help to decrease the risk of complications from immobility. An indwelling catheter and continuous bladder irrigation are in place for about 24 hours after TURP.The client would not try to void around the catheter. This would cause the bladder muscles to contract and may result in painful spasms. Intermittent urinary catheterization is not necessary and increases the risk for infection. Typically, the catheter is taped to the client's thigh, so he needs to keep his leg straight.)

A client has undergone transurethral resection of the prostate (TURP). Which interventions does the nurse incorporate in this client's postoperative care? Select all that apply. Administer antispasmodic medications. Encourage the client to urinate around the catheter if pressure is felt. Perform intermittent urinary catheterization every 4 to 6 hours. Place the client in a supine position with his knees flexed. Assist the client to mobilize as soon as permitted.

"Nocturia could cause interruption of your sleep and cause changes in mood." (Frequent visits to the bathroom during the night could cause sleep interruptions and affect the client's mood and mental status. Incontinence could cause the client to feel embarrassment and cause him to limit his activities outside the home. The social isolation could lead to clinical depression and should be treated professionally. The nurse should not give advice before exploring the client's response to his change in behavior. The statement about age has no validity.)

A client is diagnosed with benign prostatic hyperplasia and seems sad and irritable. After assessing the client's behavior, which statement by the nurse would be the most appropriate? "The urine incontinence should not prevent you from socializing." "You seem depressed and should seek more pleasant things to do." "It is common for men at your age to have changes in mood." "Nocturia could cause interruption of your sleep and cause changes in mood."

Encourages participation in care of the wound (The nurse's best response is to encourage client participation in wound care. This gives the client a sense of autonomy.Encouraging visitors is not the best suggestion for this client. By telling the client that he or she understands the client's feelings, the nurse not only fails to address the underlying issue but also is patronizing. Assuring the client that everything will be all right not only fails to address the underlying issue, but also may be untrue.)

A client with a foot ulcer says, "I feel helpless." What is the nurse's best response? Encourages participation in care of the wound Encourages visitors Says, "I know how you feel" Assures the client that it will be all right

Avoid drugs used to treat erection problems. Be careful when changing positions. Keep all appointments for follow-up laboratory testing. (Drugs used to treat erectile dysfunction can worsen side effects, such as hypotension. Alpha-adrenergic blockers may cause orthostatic hypotension and can cause liver damage. The nurse needs to remind the client to be careful when changing positions and to keep all appointments for follow-up laboratory testing.These drugs do not affect hearing. Alpha-adrenergic blockers need to be taken in the evening to decrease the risk of problems related to hypotension.)

A client with benign prostatic hyperplasia is being discharged with alpha-adrenergic blockers. Which information is important for the nurse to include when teaching the client about this type of pharmacologic management? Select all that apply. Avoid drugs used to treat erection problems. Be careful when changing positions. Keep all appointments for follow-up laboratory testing. Hearing tests will need to be conducted periodically. Take the medication in the afternoon.

Habit training (Habit training (scheduled toileting) will be most effective in reducing incontinence for a cognitively impaired patient because the caregiver is responsible for helping the patient to a toilet on a scheduled basis. Bladder training, the Credé method, and learning Kegel exercises require that the patient be alert, cooperative, and able to assist in his or her own care. )

A cognitively impaired patient has urge incontinence. Which method for achieving continence would the nurse include in the patient's plan of care? Habit training Credé method Bladder training Kegel exercises

Determines whether the client can reach the affected area (Whether the obese client can access the dressing site is the most important thing to assess. If the dressing site cannot be accessed by the client, it will be difficult for the client to independently perform frequent dressing changes at home.The nurse would have already assessed the client's squeamishness during in-hospital dressing changes. A demonstration of how to change the dressing and providing the dressing materials are a good start, but they do not assess the client's ability to perform the task himself.)

A discharged obese client will require frequent dressing changes for a skin condition on his left foot. How does the nurse assess whether the client is able to perform this task at home? Asks the client if he is squeamish Demonstrates how to change the dressing Determines whether the client can reach the affected area Provides all of the necessary dressing materials

Wound eschar (A full-thickness pressure injury covered with a layer of black, gray, or brown nonviable, denatured collagen is called wound eschar. Cellulitis is the inflammation of skin cells. Urticaria is the formation of white or red edematous papules or plaques of different sizes (hives). Separation of skin layers at the wound margin from the underlying granulation tissue is known as undermining.)

A full-thickness pressure injury is covered by a layer of black nonviable, denatured collagen. What term is used to describe this condition? Cellulitis Urticaria Undermining Wound eschar

c. Abdominal pain of unknown origin (All categories of laxatives share the same general contraindications and precautions, including avoidance in cases of drug allergy and the need for cautious use in the presence of these: acute surgical abdomen; appendicitis symptoms such as abdominal pain, nausea, and vomiting; fecal impaction (mineral oil enemas excepted); intestinal obstruction; and undiagnosed abdominal pain. The other options are possible indications for laxatives.)

A laxative has been ordered for a patient. The nurse checks the patient's medical history and would be concerned if which condition is present? a. High ammonia levels due to liver failure b. Diverticulosis c. Abdominal pain of unknown origin d. Chronic constipation

"Increase your fiber intake with fruits, vegetables, beans, and unsalted nuts." (The nurse's BEST advice is to tell the client to eat more fruit, vegetables, beans, and unsalted nuts. For clients at risk for constipation, encourage fluids and plenty of fiber in the diet, such as whole grains, celery, fruits, and nuts.The client does not need a soft diet. The client should increase, rather than decrease, fluid intake to promote renal and bowel health. Eating two slices of whole wheat bread would be helpful, but is only a start in meeting the dietary needs of the client for preventing constipation.)

An 82-year-old client is being discharged after successful bladder and bowel training. Before going home, the client asks what foods can be eaten to prevent constipation. What is the BEST response by the nurse? "Continue on a soft diet." "Decrease your fluid intake." "Eat at least 2 slices of whole wheat bread daily." "Increase your fiber intake with fruits, vegetables, beans, and unsalted nuts."

Pressure ulcer development (This client is at risk for developing pressure ulcers related to protein deficiency if he or she remains bedridden.Anemia and weight gain have no correlation with this client's protein deficiency. The client does not have an indicated wound.)

An older adult client who is bedridden has a documented history of protein deficiency. What does the nurse plan to monitor for? Anemia Decreased wound healing Pressure ulcer development Weight gain

Dry mouth Constipation Increased intraocular pressure (Oxybutynin is an anticholinergic/antispasmodic. Side effects include dry mouth, urinary retention, constipation, and risk for increased intraocular pressure with the potential to make glaucoma worse. Alpha-adrenergic agonists and beta blockers, which may be prescribed for urinary incontinence, may cause an increase in blood pressure. Phenazopyridine, a bladder analgesic used to decrease urinary pain, causes the urine to be a reddish-orange color.)

An older adult patient diagnosed with stress incontinence is prescribed the medication oxybutynin. Which side effects does the nurse tell the patient to expect? Select all that apply. Dry mouth Constipation Increased blood pressure Reddish-orange urine color Increased intraocular pressure

Schedule a visit by another resident who is diabetic. Demonstrate food choices using food photographs. Encourage the patient's family to participate in teaching sessions. Ask the patient about past experiences with lifestyle changes. (Strategies to promote learning in older adults include peer teaching, visual aids, family participation, and relating new learning to past experiences. Discussion of the patient's favorite foods is needed to determine how old favorites can be adapted to the new diet. Reminders about the damage already done will indicate that the changes are not worth the effort.)

Appropriate approaches used by the long-term care nurse to provide education for a 73 year old who has just been diagnosed with diabetes include which of the following? Select all that apply. Schedule a visit by another resident who is diabetic. Demonstrate food choices using food photographs. Avoid discussion of the patient's favorite foods. Remind the patient that a lot of damage has already occurred. Encourage the patient's family to participate in teaching sessions. Ask the patient about past experiences with lifestyle changes.

Second (Second-intention healing is characterized by a cavitylike defect frequently found in chronic pressure ulcers. This involves gradual filling in of the dead space with connective tissue in deeper tissue injuries or wounds with tissue loss.First-intention healing is characterized in a wound without tissue loss that can be easily closed and dead space eliminated. Third-intention healing is characterized by delayed primary closure. Wounds with a high risk for infection may be intentionally left open for several days while the wound is débrided and inflammation subsides. There is no such thing as mixed-intention healing.)

Deep tissue wounds, such as chronic pressure ulcers, take longer to heal because they heal by which intention? First Second Third Mixed

ncrease fiber intake. Increase water consumption (Increasing fiber assists in adding bulk to the stool. Increasing water assists in softening the stool and moving it through the large intestine. Decreasing exercise will have the opposite effect of slowing bowel movements. Refraining from alcohol and smoking have no direct effect on bowel movements.)

During an assessment, the patient states that his bowel movements cause discomfort because the stool is hard and difficult to pass. As the nurse, you make which of the following suggestions to assist the patient with improving the quality of his bowel movement? (Select all that apply.) Increase fiber intake. Increase water consumption. Decrease physical exercise. Refrain from alcohol. Refrain from smoking.

Clean and dry the client's skin. (Cleaning and drying the client to prevent skin breakdown is the first priority for skin protection.Applying a barrier cream, assessing the area, and placing the client in a side-lying position can all be done after the client has been cleaned.)

During morning rounds, the nurse discovers that an older adult client has been incontinent during the night. To protect the skin, what does the nurse do first? Apply a barrier cream to the area. Assess the area for skin breakdown. Clean and dry the client's skin. Place the client in a side-lying position.

b. It must not be handled by pregnant women. (Finasteride must not be handled by pregnant women because of its teratogenic effects. It is taken orally and without regard to meals. The other options are incorrect.)

During the administration of finasteride (Proscar), the nurse must remember which important precaution? a. It must be taken on an empty stomach. b. It must not be handled by pregnant women. c. It is given by deep intramuscular injection to avoid tissue irritation. d. The patient needs to be warned that alopecia is a common adverse effect.

functional incontinence

Inability of usually continent person to reach the toilet in time to avoid unintentional loss of urine. The person can either be unaware of the need to go, or unable to physically get to the toilet

overflow incontinence

Incontinence characterized by small frequent voidings due to leakage of small amounts of urine spilling from an overfilled bladder, or to a bladder with pathologically decreased volume. This condition can be caused by an obtruction (BPH) or from poor nerve/bladder communication.

urge incontinence (overactive bladder)

Involuntary passage of urine occurring soon after a strong sense of urgency to void. Drugs that inhibit the detrusor muscle of the bladder, such as oxybutynin, can be used as treatment.

incontinence

Loss of bladder control, varying from a slight loss of urine after sneezing, coughing, or laughing to complete inability to control urination.

stress incontinence

Sudden leakage of urine with activities that increase intra-abdominal pressure (laughing, coughing, sneezing, excerising). Worsens with decreased estrogen levels and childbirth. Kegel exercises can be effective in treating this condition.

The patient has lost 10 pounds (4.5 kg) during the last month. (A 10-pound weight loss in 1 month could indicate cancer or may be an indication of further progression of memory loss. Depression is also another common cause of weight loss. The use of a marked pillbox and planning by the family for 24-hour care are appropriate for this patient. It is not unusual that an older patient would have friends who have died.)

The home care nurse is assessing an older patient diagnosed with mild cognitive impairment (MCI) in the home setting. Which information is of concern? The patient's son uses a marked pillbox to set up the patient's medications weekly. The patient has lost 10 pounds (4.5 kg) during the last month. The patient is cared for by a daughter during the day and stays with a son at night. The patient tells the nurse that a close friend recently died.

"I should chew or crush the tablet/capsule form of this medication." (Oxybutynin is an antispasmodic agent that reduces incontinence by causing bladder muscle relaxation. The extended forms of these drugs have to be taken to minimize the possibility of side effects. Therefore, the patient's statement that he or she should chew or crush the tablet/capsule form of this medication requires correction. The statements about increasing fluid intake, using hard candy to moisten the mouth, and increasing intake of fiber-containing foods do not require any correction because they minimize dry mouth and constipation effects respectively.)

The nurse finds oxybutynin in the prescription of a patient with stress urinary incontinence and provides some instructions to the patient. Which statement of the patient requires correction? "I should increase my fluid intake." "I should use hard candy to moisten my mouth." "I should increase my intake of fiber-containing foods." "I should chew or crush the tablet/capsule form of this medication."

Assessing for blood pressure changes when lying, sitting, and arising from the bed Immediately reporting any change in the alanine aminotransferase laboratory test Asking the client to report any weakness, light-headedness, or dizziness (Both the 5-alpha-reductase inhibitor (5-ARI) and the alpha1-selective blocking agents can cause orthostatic (postural) hypotension and liver dysfunction. The 5-ARI agent (Proscar) can cause a decreased libido rather than an increased sexual drive. The alpha-blocking drug (Cardura) can cause tachycardia rather than bradycardia.)

The nurse is administering finasteride (Proscar) and doxazosin (Cardura) to a 67-year-old client with benign prostatic hyperplasia. What precautions are related to the side effects of these medications? (Select all that apply.) Assessing for blood pressure changes when lying, sitting, and arising from the bed Immediately reporting any change in the alanine aminotransferase laboratory test Teaching the client about the possibility of increased libido with these medications Taking the client's pulse rate for a minute in anticipation of bradycardia Asking the client to report any weakness, light-headedness, or dizziness

It asks the patient about the severity of urinary symptoms. (The I-PSS asks the patient a total of eight questions: seven are about the severity of urinary symptoms relating to the enlarged prostate, and one is related to the effect of symptoms on quality of life. None of the questions relate to sexual function. They deal with the symptoms of BPH only (frequency, urgency, and stream). The I-PSS does not ask any questions about pain with urination.)

The nurse is assessing a patient for benign prostatic hyperplasia (BPH) using the International Prostate Symptoms Score (I-PSS). What statement most accurately describes the I-PSS system? It assesses the impact of BPH on sexual function. It is based on six questions concerning urinary symptoms. It asks the patient about the severity of urinary symptoms. It includes questions about the level of pain during urination.

"You are considered obese and will need to consult with your doctor about a plan that includes exercises, not diet, to decrease weight." (This patient is at an increased risk for sarcopenia and should be instructed to increase activity that includes strength training to prevent muscle loss. Diet is not indicated. A BMI of 31 is considered obese; however, this patient does not qualify for surgical intervention until BMI reaches over 35.)

The nurse is assisting a 79-year-old patient with information about diet and weight loss. The patient has a body mass index (BMI) of 31. How should the nurse instruct this patient? "Your weight is within normal limits. Continue maintaining with current lifestyle choices." "You are a little overweight. Cut down on calories and increase your activity, and you should be fine." "You are morbidly obese, and we would like to schedule you an appointment to speak with a bariatric specialist about surgery." "You are considered obese and will need to consult with your doctor about a plan that includes exercises, not diet, to decrease weight."

Orthostatic hypotension is a side effect of this treatment. (Orthostatic hypotension is a side effect of this treatment, so the patient must change positions carefully and slowly to avoid dizziness. It will take at least 6 months before improvement is noticed. Bedtime dosing decreases the risk for problems related to hypotension. Decreased libido and erectile dysfunction are side effects of this treatment.)

The nurse is caring for a patient who is being treated with a 5-alpha reductase inhibitor (5-ARI) as the first-line drug therapy for benign prostatic hyperplasia (BPH). What instruction does the nurse give to the patient about this therapy? Increased libido is a side effect of these drugs. Orthostatic hypotension is a side effect of this treatment. It will take at least 2 months before improvement is noticed. Bedtime dosing increases the risk for problems related to hypotension.

Cloudy urine (Cloudy urine could indicate infection due to possible urine retention and should be a priority action. Common symptoms of benign prostatic hyperplasia are urinary hesitancy, post-void dribbling, and a weak urinary stream due to the enlarged prostate causing bladder outlet obstruction.)

The nurse is conducting a history on a male client to determine the severity of symptoms associated with prostate enlargement. Which finding is cause for prompt action by the nurse? Cloudy urine Urinary hesitancy Post-void dribbling Weak urinary stream

Serum albumin (Albumin measures protein, which is necessary for healing. Increased serum albumin indicates successful collaboration with the dietitian.Calcium, hematocrit, and WBC readings do not relate to successful pressure ulcer management.)

The nurse is evaluating the effectiveness of interventions for pressure ulcer management. Which diagnostic test result with an increased level indicates client progress and effective health care team collaboration? Calcium Hematocrit Numbers of immature white blood cells (WBCs) Serum albumin

Emphasize it must not be touched or handled by pregnant women because of teratogenic effects. (Finasteride (Proscar) and dutasteride (Avodart) are indicated for BPH. Both drugs are contraindicated in patients who have shown hypersensitivity and in pregnant women and children. It is considered potentially dangerous for a pregnant woman even to handle crushed or broken tablets. Both drugs are classified as pregnancy Category X.)

The nurse is providing education to a patient and the patient's caregiver, who is pregnant, on the medication dutasteride (Avodart) for treatment of benign prostatic hyperplasia (BPH). What important teaching would the nurse provide to the patient and the patient's caregiver about this medication? Notify your health care provider for an erection that lasts 2 hours. Emphasize it must not be touched or handled by pregnant women because of teratogenic effects. Instruct to put the drug into a container with other medications. Take the medication with dairy containing products such as milk or yogurt.

a. Oral anticoagulants (Androgens, when used with oral anticoagulants, can significantly increase or decrease anticoagulant activity. The other options are incorrect.)

The nurse is reviewing the medication list of a patient who will be starting androgen therapy. Which drug classes, if taken with androgens, may have an interaction with them? a. Oral anticoagulants b. Nitrates c. Beta blockers d. Proton pump inhibitors

b. Undiagnosed abdominal pain c. Nausea and vomiting d. Fecal impaction f. Acute surgical abdomen (Cautious use of laxatives is recommended in the presence of these: acute surgical abdomen; appendicitis symptoms, such as abdominal pain, nausea, and vomiting; intestinal obstruction; and undiagnosed abdominal pain. Oral laxatives must not be used with fecal impaction; mineral oil enemas are indicated for fecal impaction. The other options are indications for laxative use.)

The nurse is reviewing the uses of oral laxatives. Which conditions are general contraindications to or cautions about the use of oral laxatives? (Select all that apply.) a. Irritable bowel syndrome b. Undiagnosed abdominal pain c. Nausea and vomiting d. Fecal impaction e. Ingestion of toxic substances f. Acute surgical abdomen

Drink 6 to 8 glasses of noncaffeinated fluids daily. Void when the urge is felt. (Drinking noncaffeinated drinks and voiding when the urge happens are the most appropriate measures for avoiding a urinary tract infection. Increasing fiber, exercising, and eating fruit do not prevent a urinary tract infection.)

The nurse is talking with a patient who was just diagnosed with a urinary tract infection. The patient asks the nurse how to prevent such infections in the future. The nurse should make which appropriate recommendations for the patient? Select all that apply. Drink 6 to 8 glasses of noncaffeinated fluids daily. Exercise daily. Increase fiber in the diet. Void when the urge is felt. Eat fruit twice daily.

"There should be no problem with a glass of wine with dinner each night." (This client did not associate wine with the avoidance of alcohol, and requires additional teaching. The nurse must teach a client with BPH to avoid alcohol, caffeine, and large quantities of fluid in a short amount of time to prevent overdistention of the bladder. Decongestants also need to be avoided to lower the chance for urinary retention.)

The nurse is teaching a client with benign prostatic hyperplasia (BPH). What statement indicates a lack of understanding by the client? "There should be no problem with a glass of wine with dinner each night." "I am so glad that I weaned myself off of coffee about a year ago." "I need to inform my allergist that I cannot take my normal decongestant." "My normal routine of drinking a quart of water during exercise needs to change."

Press over the bladder area. (Credé method is a bladder compression technique in which the patient presses over the bladder area to increase its pressure. In the Valsalva maneuver, breathing techniques increase chest and abdominal pressure; this increased pressure is then directed toward the bladder during exhalation. Water is left running in the sink to help the patient undergoing bladder training to urinate at that time. The patient with cystitis should use a warm sitz bath for comfort.)

The nurse is teaching behavioral techniques to a patient with reflux urinary incontinence. What does the nurse teach the patient about the Credé method? Use a warm sitz bath. Press over the bladder area. Run water in the sink simultaneously. Breathe to increase abdominal pressure.

"The residual urine will be measured during the examination." (Residual urine may be measured with cystoscopy, not during a DRE of the prostate for BPH. During a DRE, the prostate gland is palpated and massaged to obtain a fluid sample to rule out prostatitis. The patient is assisted to a side-lying fetal position, or the patient bends over the examination table for the DRE. The patient may feel the urge to urinate when the prostate is palpated. BPH presents as a uniform, elastic, and non-tender enlargement.)

The nursing instructor is teaching a group of nursing students how to prepare a patient with benign prostatic hyperplasia (BPH) for a digital rectal examination (DRE). What statement by a student nurse indicates a need for further teaching? "The residual urine will be measured during the examination." "BPH presents as a uniform, elastic, and non-tender enlargement." "The patient may feel the urge to urinate when the prostate is palpated." "The patient should be assisted to a side-lying fetal position for examination."

Massages bony prominences (Massaging bony prominences should be avoided in older adult clients because they are at high risk for skin tears. The nursing instructor needs to make sure that the student is aware of this fact.Reddened areas should not be directly massaged because this can damage capillary beds and increase tissue necrosis. The client should be repositioned at least every 1 to 2 hours to prevent ulcer extension and the generation of additional pressure ulcers. Using a moisturizing lotion is appropriate.)

The nursing instructor reviews instructions with the nursing student about caring for an older adult client with a pressure ulcer. What action by the nursing student indicates a need for further instruction about proper skin care for this client? Massages bony prominences Avoids reddened areas Repositions the client every 1 to 2 hours Uses a moisturizing lotion

Drink 6 to 8 glasses of noncaffeinated fluids daily. (Drinking 6 to 8 glasses of noncaffeinated fluids daily helps with bladder health because urine is not stagnating in the bladder. Exercising and eating foods high in fiber help with bowel elimination but do not have an effect on urination. Visiting the urologist is good if there is a problem, but this is not the most important recommendation from the nurse.)

The patient talks with the nurse about bladder health. What is one of the most important recommendations the nurse can make for this patient? Eat foods high in fiber. Drink 6 to 8 glasses of noncaffeinated fluids daily. Exercise in the morning and evening. Visit the urologist once yearly.

Get up slowly from a sitting or lying position. (This medication is used to relieve impaired urinary flow in men with benign prostatic hyperplasia, but it also can cause orthostatic hypotension when changing positions from sitting or lying positions. Because of these effects, the blood pressure may become dramatically lowered, and lightheadedness may occur, increasing the risk of falling.)

The teaching for a patient who is taking tamsulosin (Flomax) to reduce urinary obstruction due to benign prostatic hyperplasia will include which of these? Fluids need to be restricted while on this medication. Take the medication with breakfast to promote the maximum effects of the drug. Get up slowly from a sitting or lying position. Blood pressure must be monitored because the medication may cause hypertension.

8 (Bulk-forming laxatives such as psyllium must be given with at least 8 oz of liquid plus additional liquid each day to prevent esophageal obstruction and fecal impaction.)

To avoid fecal impaction, psyllium (Metamucil) should be administered with at least how many ounces of fluid? 8 4 6 10

Promote mobility and/or frequent repositioning. (Frequent repositioning and/or promoting mobility is the best way to prevent further deterioration of this client's pressure ulcer.Reddened areas should never be massaged. Padding the ulcer may not be appropriate. An egg crate mattress may be suggested but is not the best option.)

What is the best way for the nurse to prevent a client's stage I pressure ulcer from advancing to stage II? Massage the reddened areas. Pad the ulcer. Promote mobility and/or frequent repositioning. Suggest an egg crate mattress.

It decreases peristalsis in the intestinal wall. (Diphenoxylate is an opiate antidiarrheal medication that acts on the smooth muscle of the intestinal tract to inhibit gastrointestinal (GI) motility and excessive propulsion of the GI tract (peristalsis).)

What is the mechanism of action of diphenoxylate (Lomotil)? It decreases peristalsis in the intestinal wall. It inhibits intestinal excretion of water and sodium. It increases intestinal secretion and motility. It prevents the reabsorption of water in the bowel.

Ejaculatory dysfunction (Possible adverse effects of finasteride include ejaculatory dysfunction, loss of libido, loss of erection, hypersensitivity reactions, gynecomastia, and severe myopathy. It is also used to treat male pattern baldness and thus would cause hair growth, not hair loss.)

What possible common adverse effect would the nurse include in the discharge teaching for a patient prescribed finasteride (Proscar)? Hair loss Muscle weakness Increased libido Ejaculatory dysfunction

a. fluid retention. (Fluid retention is an undesirable effect of androgens. The other options are incorrect.)

When a male patient is receiving androgen therapy, the nurse will monitor for signs of excessive androgens such as: a. fluid retention. b. dehydration. c. restlessness. d. visual changes.

c. These laxatives may cause esophageal obstruction if taken with insufficient water. (Bulk-forming drugs increase water absorption, which results in greater total volume (bulk) of the intestinal contents. Bulk-forming laxatives tend to produce normal, formed stools. Their action is limited to the gastrointestinal tract, so there are few, if any, systemic effects. However, they need to be taken with liberal amounts of water to prevent esophageal obstruction and fecal impaction.)

When administering a bulk-forming laxative, the nurse instructs the patient to drink the medication mixed in a full 8-ounce glass of water. Which statement best explains the rationale for this instruction? a. The water acts to stimulate bowel movements. b. The water will help to reduce the bulk of the intestinal contents. c. These laxatives may cause esophageal obstruction if taken with insufficient water. d. The water acts as a lubricant to produce bowel movements.

Recent changes in elimination patterns Changes in color, consistency, or odor of stool or urine Discomfort or pain with elimination List of medications taken by patient (Recent changes in elimination patterns, color, consistency, or odor are important for the nurse to know concerning elimination. Discomfort or pain during elimination is important for the nurse to know. A nurse should also know which medications the patient is on as this may affect elimination. Time of day is not important, nor is the patient's preferences for toileting. They are personal preferences and do not affect elimination.)

When conducting a health history assessment, the nurse would want to know what important information about the patient's elimination status? (Select all that apply.) Recent changes in elimination patterns Changes in color, consistency, or odor of stool or urine Time of day patient defecates Discomfort or pain with elimination List of medications taken by patient Patient's preferences for toileting

Apply a different pressure-relieving device. ("Bottoming out," as evidenced by deep imprints in the mattress overlay, indicates that this device is not appropriate for this client, and a different device or strategy should be implemented to prevent pressure ulcer formation.)

When transferring a client into a chair, a nurse notices that the pressure-relieving mattress overlay has deep imprints of the client's buttocks, heels, and scapulae. Which action should the nurse take next? Turn the mattress overlay to the opposite side. Do nothing because this is an expected occurrence. Apply a different pressure-relieving device. Reinforce the overlay with extra cushions.

Sepsis Kidney failure (Pressure injuries may lead to sepsis because there is a possibility of infection through the wound. Pressure injuries may also affect kidney function, leading to kidney failure. Diabetes can put a patient at higher risk for the formation of injuries, but it is not a complication of pressure injuries. Uremia and cirrhosis are not complications associated with pressure injuries.)

Which are common complications of pressure injuries? Select all that apply. Sepsis Uremia Diabetes Cirrhosis Kidney failure

Erythema (Erythema is a clinical manifestation that occurs during the inflammatory phase of wound healing. It is characterized by redness or swelling of the skin that exists from skin trauma due to an aseptic surgical incision or a pressure injury. Itching is a clinical feature that occurs in pruritus. Injuries on body surfaces such as the sacrum, hips, and ankles are a characteristic feature in pressure injuries. A rash of white edematous papules or plaques occurs in urticaria.)

Which clinical manifestation is observed during the inflammatory phase of wound healing? Itching Erythema Injuries on the body surface White edematous papules

Bladder distention with constant dribbling (The nurse would assess for palpable bladder distention and constant urine loss through dribbling in a patient with overflow incontinence. An abrupt and strong urge to void is seen with urge incontinence. Urine loss with physical exertion is associated with stress incontinence. A post-void residual urine measurement of less than or equal to 50 mL indicates effective bladder emptying.)

Which clinical manifestation would the nurse assess for in a patient with overflow incontinence? Abrupt and strong urge to void Urine loss with physical exertion Bladder distention with constant dribbling Post-void residual urine less than or equal to 50 mL

Weak pelvic muscles (Weak pelvic muscles and structural supports can cause stress urinary incontinence in a patient. Impaired cognition or neuromuscular limitations are related to functional urinary incontinence. Urge urinary incontinence is related to bladder spasms and decreased bladder capacity.)

Which factor does the nurse attribute to stress urinary incontinence in a patient? Impaired cognition Spasmodic bladder Weak pelvic muscles Decreased bladder capacity

Serenoa repens (Serenoa repens (saw palmetto), a plant extract, is often used by men with early to moderate BPH. They believe that this agent relieves their symptoms and prefer this treatment over prescription drugs or surgery. However, studies on the effectiveness of Serenoa repens have not shown that it is effective. The nurse must remind clients wanting to use complementary and integrative health therapies to check with their primary health care provider before using them.Acupuncture, calcium supplements, and yoga are not common alternative therapies for BPH.)

Which method is a common integrative health therapy for benign prostatic hyperplasia (BPH)? Acupuncture Calcium supplements Serenoa repens Yoga

Functional urinary incontinence (The functional urinary incontinence is the nursing diagnosis observed in a patient related to impaired cognition and neuromuscular limitations. Urge urinary incontinence is related to decreased bladder capacity, bladder spasms, diet, and neurological impairment. Stress urinary incontinence is related to weak pelvic muscles and structural supports. Reflex urinary incontinence is related to neurological impairment.)

Which nursing diagnosis observed in a patient with urinary incontinence is related to impaired cognition and neuromuscular limitations? Urge urinary incontinence Stress urinary incontinence Reflex urinary incontinence Functional urinary incontinence

Every 2 hours, reposition a client who has had a stroke and is incontinent. (The nurse can delegate repositioning a client to a nursing assistant. A nursing assistant has the education and scope of practice to perform such a task.Using the Braden Scale, changing a sterile dressing, and client admissions are actions that should be done by licensed nursing staff who have broader education and scope of practice.)

Which nursing interventions can the nurse working in a long-term care facility delegate to a nursing assistant? Use the Braden Scale to determine pressure ulcer risk for a newly admitted client. Complete daily sterile dressing changes for a client with a venous leg ulcer. Every 2 hours, reposition a client who has had a stroke and is incontinent. Admit a newly transferred client who had pedicle flap surgery 1 week ago.

Atopic dermatitis (Atopic dermatitis is the skin inflammation that is characterized by extreme itching. Moderate itching is associated with drug eruption. Contact dermatitis can cause mild itching. Moderate and extreme itching are not associated with nonspecific eczematous dermatitis.)

Which skin inflammation is characterized by extreme itching? Drug eruption Atopic dermatitis Contact dermatitis Nonspecific eczematous dermatitis

Deep tissue

Which stage of pressure injury? An area of deep maroon discolored skin is located over the left heel. The area looks bruised. Skin surface is intact.

Unstageable

Which stage of pressure injury? Areas of tissue loss from pressure are completely covered by slough/eschar. The wound base is not visible.

Stage 2

Which stage of pressure injury? Mr. H. is a 73 year old male who is chairbound. A pressure injury is observed on the right ischial tuberosity. The wound is shallow with a red wound bed. No slough is observed. Tissue loss extends into the dermis.

Stage 4

Which stage of pressure injury? Pressure injury over the left ischial tuberosity is 3.5 cm by 2.5 cm in size. Tissue damage extends to muscle with undermining noted along the right wound margin. The base of the wound is not completely visualized.

Stage 1

Which stage of pressure injury? Reddened area over the left sacral area does not blanch with lightly applied pressure. Epidermal skin is intact.

Stage 3

Which stage of pressure injury? The circled pressure injury is approximately 11 cm in length and 3 cm in width. Subcutaneous fat is visible in the wound bed. No tendon, bone or muscle is visualized. Slough is present at the left proximal wound edge. The slough does not obscure the depth of tissue loss.

Stage 4

Which stage of pressure injury? The pressure injury on the left ear of this male patient is from a medical device. Cartilage can be seen in the wound base.

Bladder calculi Urinary tract infections Increased residual urine Chronic urinary retention Overflow urinary incontinence (The most common symptoms of prostate enlargement include bladder calculi, urinary tract infections, increased residual urine, chronic urinary retention, and overflow urinary incontinence. While some men with benign prostate enlargement experience microscopic hematuria if they have an infection, it is unlikely that enough blood will be lost to result in severe anemia.)

Which symptoms are most likely to occur with benign enlargement of the prostate? Select all that apply. Severe anemia Bladder calculi Urinary tract infections Increased residual urine Chronic urinary retention Overflow urinary incontinence

Urinalysis (The first step in the assessment of incontinence in patients of any age includes urinalysis; this helps to rule out infection. Digital rectal examination (DRE) helps to detect impaction of stool which is a cause of transient urinary incontinence. To assess the size, shape, support, and function of the urinary tract system, a voiding cystourethrogram (VCUG) is recommended. Electromyography (EMG) of the pelvic muscles is a part of the urodynamic studies.)

Which test does the primary health care provider recommend as the first step in assessment of incontinence in patients of any age? Urinalysis Digital rectal examination (DRE) Voiding cystourethrogram (VCUG) Electromyography (EMG) of the pelvic muscles

Stress (Pelvic floor (Kegel) exercise therapy for women with stress incontinence strengthens the muscles of the pelvic floor, thereby helping decrease the occurrence of incontinence. Functional incontinence is not caused by a weakened pelvic floor; rather it is due to structural problems often resulting from injury or trauma. Overflow incontinence is caused by too much urine being stored in the bladder. Urge incontinence is caused by a problem (i.e., neurologic) with the patient's urge to urinate.)

Which type of incontinence benefits from pelvic floor muscle (Kegel) exercise? Urge Stress Overflow Functional

Urge (Urge incontinence is also known as an overactive bladder (OAB). Overactivity may be the result of abnormal detrusor contractions. Mixed, overflow, and functional incontinence are not known as an OAB. Mixed incontinence is the presence of more than one type of incontinence. Overflow incontinence is also known as reflex incontinence or underactive bladder. Functional incontinence is the incontinence occurring as a result of factors other than the abnormal function of the bladder and urethra.)

Which type of incontinence is also known as an overactive bladder (OAB)? Urge Mixed Overflow Functional

Stress (Stress incontinence is associated with the involuntary loss of urine during activities that increase abdominal or detrusor pressure. Urge incontinence is the involuntary loss of urine associated with a strong desire to urinate. Overflow incontinence is the involuntary loss of urine associated with overdistention of the bladder when the bladder's capacity has reached its maximum. Functional incontinence is the leakage of urine caused by factors other than disease of the lower urinary tract.)

Which type of incontinence is characterized by the involuntary loss of urine during activities that increase abdominal or detrusor pressure? Urge Stress Overflow Functional

c. Long-term use of laxatives often results in decreased bowel tone and may lead to dependency. (Long-term use of laxatives may lead to dependency. Patients need to be taught that daily bowel movements are not necessary for bowel health.)

While recovering from surgery, a 74-year-old woman started taking a stimulant laxative, senna (Senokot), to relieve constipation caused by the pain medications. Two weeks later, at her follow-up appointment, she tells the nurse that she likes how "regular" her bowel movements are now that she is taking the laxative. Which teaching principle is appropriate for this patient? a. She needs to be sure to take this medication with plenty of fluids. b. It is important to have a daily bowel movement to promote bowel health. c. Long-term use of laxatives often results in decreased bowel tone and may lead to dependency. d. She needs to switch to glycerin suppositories to continue having daily bowel movements.

Kennedy terminal ulcer

a bedsore that forms and progresses quickly, and often appears during the end-of-life stages. Due to the quick progression, wound care focuses mainly on pain management and comfort. they form due to poor blood circulation on the pressure area and are usually located at the base of the spine.

constipation

a condition of abnormally infrequent and difficult passage of stool through the lower GI tract

PSA (prostate-specific antigen)

a glycoprotein produced by the prostate. an analysis of this protein is used as a screening test for prostate cancer

pressure injury (ulcer)

a loss of tissue integirty caused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for an extended period

reepithelialization

a process of healing in which new epithelial cells move into a wound and grow

GFTT (geriatric failure to thrive)

a syndrome which affects older adults, includes under nutrition, impaired physical functioning, depression, and cognitive impairment

TURP (transurethral resection of the prostate)

a urological operation used to treat benign prostatic hyperplasia. it is performed by visualizing the prostate through the urethra and removing tissue by electrocautery or sharp dissection

skin tear

a wound caused by shear, friction, and/or blunt force resulting in separation of skin layers. treatment goal: realign skin and secure with steri-strips, and maintain moist clean environment. avoid triple antibiotic ointment (damages new cells)

partial thickness wound

a wound in which all or a portion of the dermis is intact. heals within 5-7 days

mepilex

an absorbent foam pad used for treatment of pressure injuries (ulcers)

cellulitis

an acute, rapidly spreading infection within the skin and subcutaneous tissue that is characterized by malaise, swelling, warmth, and red streaks. usually caused by a wound infection

hyperplasia

an increase in the number of cells

dutasteride (avodart) finasteride (proscar)

androgen hormone inhibitors (2) management of the symptoms of benign prostatic hyperplasia (BPH) ADRs: decreased libido, gynecomastia, ejaculatory dysfunction Misc: monitor urinary pattern, no blood donations during tx or <6 mo after, pregnant women should not handle, onset 3-6 mo.

probiotic (lactobacillus acidophilus)

anti-diarrhea treatment used to reestablished normal flora in GI tract

oxybutynin (ditropan) tolterodine (detrol)

anticholinergic meds (2) used to treat overactive bladder with symptoms of urge incontinence, urgency, and frequency ADRs: dizziness, drowsiness, blurred vision, dry mouth, increased IOP Contraindications: angle-closure glaucoma, asthma, myasthenia gravis, cardiovascular instability, BPH Misc: caution in elderly, delirium may develop

gynecomastia

breast tenderness and growth in males. an ADR in androgen hormone inhibitors (finasterade and dutasteride)

psylium (metamucil)

bulk-forming laxative used to absorb water in the intestines, which stimulates peristalsis. mix with 8 oz water, then drink 8 oz more

docusate sodium/senna

combination of stool softener and intestinal stimulant

sarcopenia

decline of skeletal muscle tissue with age

full thickness wound

deep wound, which extends through the dermis to the subcutaneous layer and may extend farther. healing process results in scar tissue

MAD (moisture associated dermatitis)

dermatitis caused by a combination of urine and stool in contact with skin for an extended period of time

atopic dermatitis

dermatitis consisting of a chronic systemic rash, which is often genetic in nature. treat with steroids, antihistamines, and comfort measures (cold moist compress, lukewarm bath)

nonspecific eczematous dermatitis

dermatitis of an unknown origin. treat with steroids, antihistamines, and comfort measures (cold moist compress, lukewarm bath)

contact dermatitis

dermatitis resulting in direct contact with a foreign object (e.g., earrings, watch, eye makeup) treat with steroids, antihistamines, and comfort measures (cold moist compress, lukewarm bath)

decongestants

drug class which should be avoided in pts with overflow incontinence because it can relax the bladder (risk of urinary retention)

laxatives

drugs that promote bowel evacuation, such as by increasing the bulk of the feces, softening the stool, or lubricating the intestinal wall

aquacell

exudate absorber used for treatment of pressure ulcers

adaptic xeroform

gauze used for moisture maintenance in treatment of pressure injuries (ulcers) (2)

pruritus

itching of the skin

bisacodyl (dulcolax) sennosides (exlax)

laxative used to stimulate intestinal motility. used for tx of opioid-induced constipation. ADR: urine discoloration (harmless) (2)

androgens

male sex hormones responsible for mediating the development and maintenance of male sex characteristics (e.g., testosterone)

doxazosin (cardura) prazosin (minipress) terazosin (hytrin)

non-site specific alpha adrenergic blockers (3) used to treat signs/symptoms of benign prostatic hyperplasia (BPH). ADRs: dizziness, palpitations, headache, hypotension, weakness, constipation, tachycardia Misc: change positions slowly (orthostatic hypotension), monitor changes in urine flow, monitor BP

BPH (benign prostatic hyperplasia/hypertrophy)

nonmalignant (noncancerous) enlargement of the prostate gland

diphenoxylate w/ atropine loperamide

opiate agonists used to treat diarrhea by inhibiting peristalsis. acts as an opiate but has no painkiller effects, rather has the constipating effect of an opioid. contraindicated in c. diff or e. coli (2)

polyethylene glycol (miralax)

osmotic laxative resulting in softening/swelling of fecal mass, thereby distending the intestine and increasing peristalsis

stage 4

pressure injury (ulcer) in which cartilage or bone is visible

deep tissue

pressure injury (ulcer) in which skin is deep red or purple and is intact

unstageable

pressure injury (ulcer) in which the base is obscured by slough and eschar. if removed, stage 3 or 4 is revealed

stage 1

pressure injury (ulcer) which consists of nonblanchable erythema of intact skin. mgmt: resposition q 2 hr, mepilex

stage 2

pressure injury (ulcer) which consists of partial thickness wound. consists of viable, pink, red, moist wound bed. not to be confused with a skin tear mgmt: keep moist (patroleum)

stage 3

pressure injury (ulcer) which is full thickness, fat is visible and has rolled edges.

sanguineous

red, bloody drainage

libido

sexual desire. a decrease is an ADR in androgen hormone inhibitors (finasterade and dutasteride)

alfuzosin (uroxatral) silodosin (rapaflo) tamsulosin (flomax)

site specific alpha adrenergic blockers (3) used to treat signs/symptoms of benign prostatic hyperplasia (BPH). ADRs: dizziness, palpitations, headache, weakness, constipation Misc: change positions slowly (orthostatic hypotension), monitor changes in urine flow

docusate sodium (colace)

stool softening laxative which adds water and lipids to stool to soften it

diarrhea

the abnormally frequent passage of loose stool

granulation

the formation of new vascular connective tissue

testosterone

the main androgenic hormone

debridement

the removal of slough or eschar from a pressure injury

serous

thin and clear wound drainage

calcium vitamin A C D

vitamins and minerals needed in increased amounts in older adults (4)