Fundamentals exam 4
A patient has a pressure injury on the coccyx measuring 5 cm by 3 cm that is covered with eschar. How should the nurse classify the wound?
Unstageable
Hypokalemia
Usually from potassium loss, but may occur from inadequate intake -diarrhea, vomiting -gastric suction -diuretics -excessive IV fluid without potassium
When a nurse interacts with the client, which is the most effective statement by the nurse regaurding his new antidepressant medication?
Your meds will often make you feel better but its going to take a couple of weeks
metabolic alkalosis causes
severe vomiting, excessive GI suctioning, diuretics, excessive antacid use
Edema
"Accumulation of excess fluid in the interstitial space caused by increased capillary hydrostatic pressure"
An older client with a history of CHF was just admitted to the hospital for chest pain. The patient asks a nurse "why did the chest pain begin after I thought someone was trying to break into my house?" What is the nurse's best response?
"Fear causes an increase of the body's heart rate and blood pressure, which can place additional stress on your damaged heart and cause chest pain"
Which statements should be included in the assessment of a wound?
"Nickel-side area on left ankle" "cloudy drainage from the site" "high protein drinks requested" "4 cm tunneling around wound" "no pain at site"
The nurse is presenting a workshop on stress and adaptation to a group of teens. A teen approaches the nurse and says "sometimes I feel stressed when i have to take a test. I feel my heart is going faster and faster and I have a hard time focusing. I'm scared I'm going to fail. Do you think that is normal?" What is the most appropriate response by the nurse?
"You may need to develop some additional stress-reducing activities"
A nurse is planning care for a culturally diverse group of clients. What considerations are neededto best meet cultural and spiritual needs? Select all that apply.
-Deliver appropriate care that is not discriminating to any race, sex, or ethnic group. -Become familiar with any facet of the patient's culture that may have an impact on his or her care -Show respect for each individual to whom care is provided.
Spiritual assessment tools
-FICA: faith, importance, community, address in care -HOPE: hope sources, organized religion, personal spirituality, effects on medical care/ end of life
The community health nurse is conducting an assessment of a homeless family living in their carin an alley. What would be important to include in the family assessment? Select all that apply.
-Family composition -Health beliefs, values, and behaviors -Coping methods -Abuse and violence history
The nurse is teaching a client with newly diagnosed diabetes about dietary changes. The client says she is a strict vegetarian for religious reasons. The client may be a follower of which religion? Select all that apply.
-Hinduism -Buddhism -Seventh Day Adventism
Problems that occur when adaptation fails
-Inability to cope effectively in the workplace -anxiety and flashbacks about a traumatic event -physical symptoms with no known cause -preoccupation with physical illness -pain as the main focus of life without physical cause -perceived threat to self or others
Clients at risk for hypovolemia
-Motor vehicle accident with trauma -burns -hiker without water supply -vomiting from a viral infection -uterine rupture during childbirth
Pressure injury stage 1
-Nonblanchable erythema (doesn't turn white when you press down with finger) -damage to blood flow -in darker skin, look at surrounding skin and palpate for warmth
Concepts in Spiritual Health
-Spiritual: breath or wind, something that gives life -hope: something to live for -religion: roadmap/ state of doing -faith: global framework of belief, helps navigate challenges
Standardized spirituality interventions
-active listening -presence -caring touch -exploring meaning -reminiscence therapy -spiritual support -forgiveness facilitation -hope inspiration -prayer
Psychological effects of immobility
-apathy toward self care -depression -sleep disturbances -disorientation
Cultural specifics that affect health
-communication -space -time orientation -social organization -environmental control -biological variations -religion/ philosophy -education -technology -politics/ law -economy
Hyponatremia clinical manifestations
-confusion, lethargy, weakness, seizures, coma, (brain cells are swelling)
The nurse, Peter, knows that Mariam is at a higher risk for injury as a result of her immobility. Which assessment changes indicate a potential complication of immobility? Select all that apply.
-crackles in both lung bases -edema of the feet - reddened areas on the coccyx
Clients at risk for hypervolemia
-excess salt intake -excessive IV fluids -decreased cardiac output -liver failure -poor kidney functioning
Hypervolemia
-fluid volume excess -gain of water and sodium in equal proportions
Skin assessment
-focused nursing history ( risk factors, Braden scale) -focused skin assessment -color, integrity, temperature, texture, turgor, mobility, moisture -medical devices that could affect skin -check bony prominences
Traditional and Alternative Healing
-folk medicine: remedies that have been passed down -complementary medicine: needs to have a trained practitioner ( massage, acupuncture) -alternative: hasn't been validated through clinical testing ( aromatherapy)
Sodium main functions
-helps maintain blood volume -interacts with calcium to maintain muscle contraction -stimulates conduction of nerve impulses
Complications of wound healing
-hemorrhage -infection -dehiscence -evisceration -fistula formation
Symptoms of fluid overload
-hypertension -jugular venous distension -bounding pulses -tachycardia -tachypnea
Types of wounds
-incision wound -laceration wound -abrasion vs. Excoriation -puncture wound -penetration wound -contusion -hematoma
The nurse is caring for a client whose IV infusion ran quickly over a short amount of time, placing the client in fluid overload. What symptoms should the nurse anticipate?
-increased pulse rate -increased pulse strength -elevated blood pressure
Hypovolemia clinical manifestations
-low BP -rapid, weak, thready pulse -orthostatic hypotension -tachycardia -decrease urine output -dry mucous membranes -thirst -loss of body weigh and skin turgor
Which findings in the immobile client are complications related to immobility? Select all that apply
-lung fluid -decreased appetite -constipation -bladder infection
Functions of body fluids
-maintain blood volume and blood pressure -temperature regulation -transport gases and nutrients to/from cells -contributes in transforming food to energy -assist with digestion of food -waste removal
Potassium main functions
-maintains resting membrane potential of muscle cells -allows normal muscle functioning ( including cardiac muscle)
Hypernatremia
-osmolality deficit -body fluids become too concentrated -not enough water
Hyponatremia
-osmolality excess -excess water -body fluids become too diluted
Hypercalcemia causes
-prolonged immobilization -hyperparathyroidism -bone malignancy -excess calcium supplements
Fluid output
-skin, lungs, GI tract, kidneys -influenced by ADH, RAAS, ANP
Fluid assessment findings for fluid volume DEFICIT
-skin: dry and scaly, tenting skin turgor -mucous membranes: dry, cracked, dull -cardio: orthostatic changes, delayed cap refill, flat jugular or hand veins -respiratory: clear -neurological: confused, disoriented, headache -vital signs: hypertension, tachycardia
Fluid assessment findings for fluid volume EXCESS
-skin: edema, tight, oozing fluid -mucous membranes: moist -cardiovascular: jugular venous distention -respiratory: crackles, moist rales -neurological: confused, disoriented, headache -vital signs: hypertension, Tachycardia
Hypervolemia clinical manifestations
-weight gain -edema -elevated blood pressure -bounding pulse ( can see in DJV) -tachypnea/ dyspnea -crackles from pulmonary edema and fluid in the lungs
The nurse is concerned about fluid loss for the at-risk client. What should be included in the output measurement?
-wound drainage -emesis -urine
normal bicarbonate
22-26 mEq/L
Normal potassium level
3.5-5.0 mEq/L
Hypocalcemia causes
1. Decreased intake and absorption -diet/vitamin D deficiency -chronic diarrhea -laxative abuse 2. Increased calcium loss or a shift of calcium from serum into bone -loop diuretics -renal disease -hyperphosphatemia
Normal magnesium level
1.5-2.5 mEq/ L
Normal sodium level
135-145 mEq/L
The nurse is assigned to care for a group of clients. On review of the client's medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit?
A client with an ileostomy
A client is admitted to the mental health unit with a diagnosis of depression. The RN develops a plan of care for the client with which intervention?
A structured program of activities in which the client can participate
Blood pH normal range
7.35-7.45 (too low= acidosis; too high=alkalosis )
Normal calcium level
8.5-10.5 mg/dL
The nurse is planning care for a client requiring an extensive dressing change. The client tells thenurse that she does not want anyone else in the room while her spiritual adviser is visiting. Whatshould be the nurse's next action?
Assure the client that once the dressing change is completed, she may see herspiritual adviser.
BALI
B: be aware of own cultural heritage A: appreciate that every patient is unique L: learn about your patient's culture I: incorporate patient's cultural values
Potassium rich foods
Bananas, avocados, spinach, white beans, sweet potatoes, dried apricots, sun dried tomatoes, potatoes, squash, white mushrooms
Acidosis deals with the ________ system, and Alkalosis deals with the _________ system.
CNS, Musculoskeletal
Upon assessment, the nurse identified a positive Trousseau's sign. What electrolyte is of concern?
Calcium
A client has just been admitted with terminal cancer. Which is the best nursing statement inassessing the client's spirituality?
"I notice you have a Bible on your nightstand; is that a source of spiritual strengthto you?"
An older client suffered left sided paralysis from a stroke. Which are the best actions for this client? Select all that apply
-Assess the extremities for swelling/ muscle atrophy -teach the use of a two point crutch technique for ambulation
The nurse is admitting to the hospital an older adult client with a terminal illness and a large,extended family. Which situations are within the role of the bedside nurse? Select all that apply.
-Assisting family with conflict resolution -Counseling family members on effective coping skills
Hyperkalemia
Results from increased intake of potassium or decreased excretion -potassium containing salt subs -IV fluids -oliguria from renal disease -diuretics
Which of the following best describes an individual's self concept?
The overall view of oneself
The nurse is assessing a client after surgery who is dehydrated and experiencing hypotension, tachycardia, and decreased urine output. What additional assessment should the nurse perform?
Tongue and skin turgor
Besides clients and families who speak different languages, what else can create language barriers in healthcare?
Use of healthcare jargon (medical language)
Adaptive coping behaviors
Seeking advice, exercising, spending time alone, taking a class
Drew just celebrated his 12th birthday and has been an insulin-dependent diabetic for one year. He often thinks about how everything in his life revolves around his illness and everyone sees him as a diabetic, not a normal kid. Which psychosocial understanding is this an example of?
Self concept
The nurse's documentation of a wound states, "Round stasis ulcer on right ankle, no tunneling. Clear serous drainage present. Dry dressing applied." What additional documentation is needed? Select all that apply.
Skin around the wound, pain and nutritional status, size, condition of the wound bed
When does thirst occur/
When plasma osmolality increases, or blood volume decreases
Symptoms of dehydration
-Dry skin -decreased urine output -orthostatic hypotension -thirst -increased heart rate -increased blood pressure
The nurse is caring for a client with a hypotonic fluid ordered for infusion. What would be the reason for this type of fluid being used?
-Intracellular space is dry -extracellular spaces are swollen
Hypervolemia causes
-Oliguria associated with renal failure ( most common) -aldosterone excess from malabsorption of salt and water -medications/ IV fluids -excess oral fluid intake of salty foods or fluids -renal failure -excessive isotonic IVs
Which of the following statements are true?
-ethnicity is passed down through generations -race is groupings based on biological similarities -culture changes over time
Hypovolemia
-fluid volume deficit which causes a decreased blood volume and tissue perfusion -loss of water and sodium in equal proportions
Which is an appropriate intervention for a patient with hypovolemia?
-monitor I&O -encourage fluid intake -monitor electrolyte balance -measure daily weights
Peter develops an immobility plan care for Mariam. What should be included?
-position to allow for lung expansion -encourage visitors -eat a healthy balanced diet -turn every 2 hours
Hypomagnesemia clinical manifestations
Stimulation of neuromuscular system -tachycardia -hypertension -dysrhythmias -Hyperactive reflexes -muscle cramping and twitching -tetany -seizures -positive Chvostek's sign
The nurse is caring for a patient with a medical dx of hypernatremia. The following prescriptions are written in the client's EMR. Which one should the nurse question?
Strict I&O monitoring
A nurse is caring for a 25 year old client who is quadriplegic. Which treatment would be a priority to decrease the risk of joint contracture and promote joint mobility?
Passive ROM
Which electrolyte are inversely related to each other?
Phosphorus and calcium
The nurse is caring for a client admitted with a bleeding duodenal ulcer. He states that he has difficulty concentrating, is often "short of breath," and "awakes at night thinking and cannot get back to sleep." He has been unable to work or care for his family for the past 3 months. What should be the nurse's next action?
Provide emotional support and reflective listening
The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The clients speech pattern is rapid and affect is belligerent. Which is the nurse's immediate priority of care?
Provide safety for the client and other clients on the unit
Signs of wound infection
Pus, redness, red streaks, warmth, pain
The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply -peas -raisins -potatoes -cantoloupe -cauliflower -strawberries
Raisins, potatoes, cantaloupe
Erythema
Redness of the skin after prolonged pressure
A client has been admitted to the hospital for anxiety and depression. Which strategy should a nurse teach to the client to help reduce the effects of anxiety
Reduce coffee to one cup in the morning
The formal practice of rituals and symbols based on a teaching and belief
Religion
unstageable pressure ulcer
Can't see how deep the wound goes. Usually has eschar and slough around the edges
Hyponatremia
Causes 1. Gain of more water than salt -excessive ADH -excessive hypotonic IV (D5W) -diuretics -GI fluid loss 2. Loss of more salt than water -replacing body fluid loss with water but no salt
Third spacing
Certain conditions cause fluid to move into an area that makes it physiologically unavailable -ascites -pericardial effusion -burns
Physiological stressors
Cold exposure, obesity, high fat diet, tobacco, bacteria etc
Pressure ulcers are directly caused by:
Compromised blood flow
Hypernatremia clinical manifestations
Confusion, irritability, lethargy ( early signs) seizures, coma (brain cells are shrinking)
Metabolic acidosis causes
DKA, severe diarrhea, renal failure, shock
At the end of a mediation session, which physical assessment finding would suggest that the relaxation technique was successful?
Decreased blood pressure
Dehiscence vs evisceration
Dehiscence is a separation of one or more layers of wound tissue and evisceration involves the protrusion of internal viscera from the incision site
Hypermagnesemia clinical manifestations
Depression of neuromuscular function -lethargy, hypoactive reflexes -bradycardia -hypotension -respiratory depression -cardiac arrest
Hypercalcemia manifestations
Depression of the neuromuscular system -lethargy -weakness -diminished reflexes -anorexia -N & V -constipation -decreased LOC -confusion -osteoperosis
Psychological responses to stress
Difficulty learning, irritability, depression, forgetfulness, rebellion, preoccupation, fear
The charge nurse of a unit tries, as a rule, to admit Hispanic clients to a room at the end of the hall so that "the noise from the family will not disturb others." This nurse is exhibiting:
Discrimination
The nurse suspects that a client receiving IV fluids is experiencing a fluid overload when the assessment reveals which one of the following?
Dyspnea, increased blood pressure, headache
Hypomagnesemia causes
Excessive GI loss, Thiazides or loop diuretics, CHRONIC ALCOHOLISM, DKA
Family focus is on examining life goals and accomplishments :
Families with middle aged adults (during middle age, families examine what's been accomplished )
Clinical dehydration
First symptom is thirst! Body fluids are decreased and too concentrated
what are the 3 processes that maintain fluid homeostasis
Fluid intake, distribution, and output
Shear
Friction + force of gravity -layer of tissue slides horizontally over another ( not visible) -blood flow is compromised ( leads to ischemia and necrosis)
Pressure injury stage 3
Full thickness skin loss -adipose tissue is visible and granulation tissue is often present -slough/ Escher may be visible -damage/ necrosis to subQ tissue
stage 4 pressure ulcer
Full thickness skin loss -exposed and directly palpable fascia, muscle, tendon, ligament, cartilage, or bone -slough and eschar may be visible
Which nursing intervention specifically helps reduce a patient's anxiety
Giving clear facts obtaining to the patient's circumstances
Isotonic solution
Has the same tonicity as normal blood
Factors that influence successful adaptation
Healthy lifestyle, hardiness, good coping skills, developmental level, age, church support group
Vic is in the final stages of cancer with metastatic bone disease. He is weak and constipated with anorexia, nausea, and vomiting. He is very thirsty and urinating often. Which electrolyte imbalance is causing the problem?
Hypercalcemia
The nurse is caring for a client with severe diabetic ketoacidosis. Which electrolyte imbalance will occur as a result of the acidosis state?
Hyperkalemia
Mark has chronic renal failure. He missed dialysis yesterday and today he feels weak with intestinal colic. His ECG shows dysrhythmias with tall T waves. Which electrolyte imbalance is causing the problem?
Hyperkalemia (excessive potassium)
Iliana has been dealing with adrenal insufficiency for 5 years. She has hypotension, feels warm to touch, and is lethargic. Her reflexes are hypoactive
Hypermagnesemia
Kimberly went on a hike with friends on a hot summer day. She did not take adequate amounts of water and is brought to the emergency department with a high fever, dry mouth, sticky mucous membranes, and hallucinations. Which electrolyte imbalance is causing the problem?
Hypernatremia ( excessive sodium )
Christina is on chemotherapy for breast cancer. She is experiencing tetany symptoms with tingling of the extremities. She has been started on aluminum hydroxide with meals. Which electrolyte imbalance is causing the problem?
Hyperphosphatemia
Maddie, an older adult, takes a loop diuretic twice a day for CHF. She tells her daughter that she's very tired and weak, feels nauseated, and notices heart palpitations. Which electrolyte imbalance is causing the problem?
Hypokalemia ( low potassium)
A patient with a history of alcoholism is disoriented and vacillates between being calm and disruptive and loud. Vital signs are BP 134/84; pulse regular and strong; respiratory rate 22 bpm; T 98.1 F. What electrolyte imbalance might the nurse suspect this patient is experiencing?
Hypomagnesemia
Erin has been an alcoholic for 10 years. He drinks daily and consumes the majority of his caloric intake this way. He is disoriented, irritable, and showing dysrhythmias on the cardiac monitor. Which electrolyte imbalance is causing the problem?
Hypomagnesemia
James is experiencing water intoxication as a result of psychogenic polydipsia, a condition compelling him to drink excessive amounts of water. He is weak,lethargic, and confused. The nurse is concerned about seizures. Which electrolyte imbalance is causing the problem?
Hyponatremia
Santos has been without food for almost 2 weeks as a result of digestive problems. He has been started on a meal and is eager to clean his plate. After eating, he experiences joint stiffness and parenthesis of the extremities. Which electrolyte imbalance is causing the problem?
Hypophosphatemia
An older patient has been vomiting for 2 days and has been unable to eat or drink anything during that time. Current VS are T 99.6 F orally; 110 weak, thready; BP 80/52. Skin and mucous membranes are dry, there is decreased skin turgor, and the patient is experiencing weakness. The most recent lab results are as follows: sodium 138mEq/L potassium 3.7 mEq/L calcium 9.2 mg/dL magnesisum 1.8 which health problem should the nurse realize the patient is experiencing ?
Hypovolemia
When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. Which is the most appropriate maintenance goal? 1. Suppressing feelings of anxiety 2. Identifying anxiety-producing situations 3. Continued contact with a crisis counselor 4. Eliminating all anxiety from daily situations
Identifying anxiety producing situations
Blanchable erythema
If redness blanches, there is a still patent blood supply to skin ( good sign, skin is getting oxygen)
Stress management techniques
Imagery, humor, journaling, exercise, meditation, massage, biofeedback
A client experiences physical symptoms whil waiting for test results. Which autonomic symptoms does the nurse associate with moderate anxiety
Increased blood pressure, increased heart and respiratory rate, hand tremors
Filtration (hydrostatic pressure)
Increased capillary hydrostatic pressure pushes fluid into the interstitial space, causing edema
Trousseau's sign
Indication of hypocalcemia -when taking a blood pressure, flex ion and hyper extension to the wrist and fingers occur
Chvostek's sign
Indication of hypocalcemia or hypomagnesemia -twitching of the muscles and face when tapping on facial nerve
The nurse completes a skin assessment on the client and finds that the right heel has a reddened area that does not blanch. Which nursing diagnosis would be most appropriate?
Ineffective peripheral tissue perfusion
Calcium main functions
Influences excitability of nerve and muscle cells and is necessary for contractions
Magnesium main function
Influences function of neuromuscular/ enzyme cofactor
What are the body's 3 mechanisms of homeostasis for acid based balance
1. Acid buffering: first line of defense, releases more hydrogen ions into the blood within seconds 2. Respiratory control: carbonic acid regulation, lungs either retain or exhale CO2 and alters depth of breathing as needed, takes minutes 3. Renal control: kidneys regulate balance of bicarbonate, takes hours to days
In this religion, dietary restrictions include some types of meats, adherents should not eat dairy and meat at the same meal
Judaism
_______ are the principle regulator of a fluid and electrolyte imbalance
Kidneys
Wound assessment
Location, type, size, undermining, appearance, swelling, pain, nutritional status, redness, drainage
Existing wound assessment
Location: in anatomical terms size: length, width, depth appearance: open or closed? Sutures? Wound color? Condition of wound bed? Necrosis? Slough? Eschar? Skin around the wound? drainage: color, consistency, amount, odor weigh dressings: before and after removed odor: fistula or bacteria contamination
Slough
Moist devitalized host tissue ( needs to be debreided)
sanguineous drainage
bloody drainage
Stages of general adaption syndrome
alarm, resistance, exhaustion, recovery
Normal fluid intake for an adult
1500-2000 mL/day
Serous wound drainage
clear, watery plasma or straw colored
Serum Osmolality
concentration of particles in plasma -fluid deficit: serum osmolality rises -fluid excess: decreases
Arterial blood gas ABG
measurement of oxygen and carbon dioxide content of arterial blood by various methods ( test for body's acid base balance)
serosanguineous drainage
mixture of serum and red blood cells
Hypotonic solution
more fluid than particles, cell swells
purulent drainage
thick green, yellow, or brown drainage that contains pus
Hypertonic solution
More concentrated with particles, makes cell shrink
A 44 year ' old female client who was just admitted states " I must be under too much stress at work and home. I just do not feel well." Which physical findings are consistent with the client's statement? Select all that apply
Mucous membranes are dry, legs are continually moving in the bed, palms of her hands are sweaty, and BP is 178/96
Hyperkalemia manifestations
Muscle weakness, abdominal cramping, diarrhea, cardiac arrhythmias
Hypokalemia clinical manifestations
Muscle weakness, decreased bowel sounds, constipation, cardiac dysrhythmias
The nurse is assessing a patient with a stage 2 pressure injury. What sign is the nurse likely seeing?
Open, shallow wound with red pink wound bed, partial thickness loss of dermis
Normal PaCO2
35-45 mmHg
Respiratory Acidosis causes
• Depression of the respiratory center. (1) Head injuries. (2) Oversedation with sedatives and/or narcotics. • Conditions affecting pulmonary function. (1) COPD (2) Pneumonia. (3) Atelectasis. • Conditions that interfere with chest wall excursion. (1) Thoracic trauma: flail chest. (2) Diseases affecting innervation of thoracic muscle (Guillain-Barré syndrome, myasthenia gravis, polio). (3) Mechanical hypoventilation.
respiratory alkalosis causes
• Primary stimulation of CNS: hyperventilation. Can be due to emotional origin (anxiety, fear, pain) • Reflex stimulation of CNS. Hypoxia stimulates hyperventilation (heart failure, pneumonia, pulmonary emboli). Can also be stimulated by fever/ sepsis • Mechanical hyperventilation, resulting in "over breathing."
The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspnic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present?
An increase in blood pressure and increased respirations
Respiratory Acidosis lab findings
Arterial blood gas alterations: -pH < 7.35, ( decreased pH) -PaCO2 > 45 mm Hg ( increased CO2) -bicarbonate level normal
Respiratory alkalosis lab findings
Arterial blood gas alterations: -pH > 7.45 ( increased pH) -PaCO2 < 35 mm Hg ( decreased CO2) - bicarbonate level normal
Metabolic alkalosis lab findings
Arterial blood gas alterations: -pH > 7.45 ( increased) -PaCO2 normal -bicarbonate level > 26 mEq/L ( increased)
Metabolic acidosis lab findings
Arterial blood gas alterations: pH < 7.35 ( decreased ) PaCO2 normal bicarbonate level < 22 mEq/L ( decreased)
Which intervention in the immobile client's plan of care best helps develop muscle strength?
AROM each hour
Hormones controlling fluid balance
Aldosterone, ADH, renin-angiotensin, brain natriuretic peptide, thyroid hormone, C-type natriuretic peptide, Atrial natriuretic peptide
Shannon is a nursing student in her second semester. She finds herself waking up in the middle of the night with a knot in her stomach thinking about school. During the day, she is often tense with frequent headaches. Her heart races, and she feels shaky. Shannon has a hard time focusing on her school work and reading
Anxiety
Braden scale
Assesses patient's risk for pressure injury( lower score=higher risk) 1. Sensory perception 2. Moisture 3. Activity 4.mobility 5. Nutrition 6. Friction/shear
Purosanguineous drainage
Blood and pus
A client has been hospitalized for 4 weeks with aggressive therapy for lung cancer. She has become very withdrawn, refuses visitors, and does not participate in personal grooming. Which activity should be encouraged?
Contacting a support group
Cations vs anions
Cations are positively charged and anions are negatively charged
Hypernatremia (water deficit)
Causes: 1. Loss of more water than salt -hyperventilation -profuse sweating -heat stroke -prolonged fever 2. Gain of more salt than water -decreased thirst in elderly -hyperglycemia -eating a high volume of salty foods without increasing fluid intake
Eschar
Dead tissue found in full thickness wounds ( black tissue )
What is an appropriate nursing diagnosis for the above patient?
Deficient fluid volume r/t abnormal fluid loss
The nurse is caring for a mother with three small children who has been admitted with a newly diagnosed chronic ill'ness. The nurse would like to encourage communication between the parents about sharing household responsibilities and child care. What is the intention of this strategy for the client?
Facilitate role enhancement
A patient has a stage 1 pressure injury on their left heel. What's the initial treatment?
Elevation of heels off bed
The nurse notes that the client's grandmother is looked to for input whenever questions arise about the client's care choices. Which cultural specific will guide the nurse's plan of care?
Environmental control
Hypermagnesemia causes
Excessive use of mg laxatives or antacids, overload of IV mg, end of stage renal disease (kidneys won't be able to excrete magnesium, pt will need dialysis )
Physiological responses to stress
Hyperventilation, headaches, dysrhythmias, dilated pupils, eczema
The nurse gathers the following data: BP 150/94; neck veins distended; T 98.6 F. What disorder should the nurse expect?
Hypervolemia
Anna is recovering from a thyroidectomy in which her parathyroid gland was also removed. She tells the nurse she has muscle cramping as well as numbness and tingling in her fingers and toes. The nurse assesses a positive Chvostek's sign. Which electrolyte imbalance is causing the problem?
Hypocalcemia
Osmosis vs diffusion
Osmosis moves water, diffusion moves particles
Race
Identity with a group of people descended from a common ancestor that have biological similarities (skin color, blood type, etc)
Ethnicity
Identity with a group of people that share distinct physical and mental traits as a product of common heredity and cultural traditions.
Causes of hypovolemia
Inadequate intake of isotonic fluids, or an excessive loss of isotonic fluids -hemmorrhage -burns -increased GI losses -massive sweating without water or salt intake -increased renal output from diuretics
Which is an appropriate goal for a patient with the nursing diagnosis of deficient fluid volume?
Maintain fluid balance, AEB moist mucous membranes and urinating q4hr
Which is the principle system for regulation of fluid and electrolyte imbalance?
Renal
The nurse reviews the client's record and determines that the client is at risk for developing a potassium deficit because of which situation?
Requires NG suction
Nursing interventions for pressure ulcers
PREVENTION IS KEY!! -nutrition ( malnutrition doubles risk) increase patient'S protein and calories -repositioning -special mattresses
Pressure injury stage 2
Partial thickness skin loss with exposed dermis -wound is viable, pink or red, and moist -may have intact or ruptured serum filled blister
R.O.M.E
Respiratory :Opposite , Metabolic: Equal ( respiratory presents with an increase and decrease; metabolic presents with an increase and an increase or a decrease and a decrease)
A 35-year-old patient diagnosed with Hodgkin's lymphoma is undergoing chemotherapy, which leaves her unable to help care for her three young children. As a result, her husband has missed work often to care for her and the children. This leaves her feeling that she is not doing her part for the family. Which best describes this situation?
Role performance
The adherents of this religion prefer a holt sacrament when seriously ill
Roman Catholic
Subculture
People of a larger social system who have some characteristics that are different from the larger group
Nancy is a middle aged woman who struggles with male relationships. She's been married four times and has never had what she calls a successful relationship. During her therapy sessions, she discusses how her father and primary caregiver was abusive, often calling her ugly stupid and worthless. Psychosocial aspect?
Self concept
Ethan is a confident college student. He is the start of his school's football team and expected to play football professionally after college. During a game, he suffered an injury and was told he can never play again. He now feels worthless and as if his life isn't worth living. Which psychosocial understanding is this an example of?
Self esteem
A nurse understands which behavior is a characteristic of a client who is coping with anxiety?
Sets aside 30 min a day to exercise
Deep Tissue Injury (DTI)
Severe pressure ulcer with necrosis of underlying tissue. Is often intact, dark or purple in color, and has a mushy feeling
An older adult is tearful, shaky, withdrawn, tachycardia, and sleepless. She tells you that she is worrying herself to death about losing her aging husband and being all alone. Which statement can be made about this anxiety reaction?
She lacks adaptive coping mechanisms, it concerns anticipation of danger rather than a present danger, there is a psychological rather than physical threat, and it concerns future of anticipated events
The nurse is addressing a patient for depression. Which behavior symptoms of depression would they have?
Tearfulness, withdrawal, presence of substance abuse
Hypocalcemia manifestations
Neuromuscular -hypersensitivity to muscles and nerves -numbness and tingling of extremities -hyperactive deep tendon reflexes -tremors, cramps -cardiac dysrhythmias -confusion -anxiety -tetany -chvostek's sign -trousseaus sign
Phases of wound healing
1. Inflammatory stage 2. Proliferative stage ( granulation/ healing ) 3. Maturation/remodeling ( epithelization
