Intro to nursing final

The registered nurse is teaching about good skin health. Which instructions would the nurse give? Select all that apply. One, some, or all responses may be correct. "Eat foods rich in vitamin B." "Sleep for an adequate number of hours." "Use alkaline soaps for better hygiene." "Use sunscreen of sun protection factor (SPF) 30 daily." "Avoid sun exposure after taking ketoconazole."

"Eat foods rich in vitamin B." "Sleep for an adequate number of hours." "Avoid sun exposure after taking ketoconazole." (Deficiency of vitamin B4 (niacin) and B6 (pyridoxine) are manifested as erythema, bullae, and seborrhea-like lesions. Deficiency of biotin, a B-complex vitamin, may cause rashes and alopecia. Adequate rest increases tolerance to itching, thereby decreasing skin damage from scratching in pruritic skin diseases. Acidic activity of the skin protects against bacterial overgrowth. Alkaline soaps neutralize the skin thereby decreasing the protection. )

The nurse and the nutritionist are discussing the needs of a client who practices the Russian Orthodox faith. Which would the nurse and the nutritionist consider when planning meals for this client?

)No meat on wednesdays and fridays (A client who is Russian Orthodox may refrain from eating meat on Wednesdays and Fridays, and the nurse and the nutritionist would consider this when developing a nutrition plan for the client. A client who is Jewish might avoid pork and shellfish as part of a kosher diet. A client who practices the Jehovah's Witness faith might avoid blood-containing food. A client who is Hindu might follow a strict vegetarian diet.

Sebum softens and lubricates skin,

, slows water loss, and has bactericidal properties

Nursing dx actual

- Client problem exists at time of nursing assessment- Nursing care is focused on relief or resolution of the problem - Problem statement - r/t etiology (what's causing this) - AEB (objective and subjective data gathered)

Diagnosis

- Clinical judgement about an individual, family, or community to an actual or potential health problem or life processes - Analyze the data, synthesize and cluster data, and hypothesize about your client health status

Assessment

- Systematic gathering of information related to physiological, psychological, sociocultural, developmental, and spiritual status of an individual - Subjective data- Objective data - Primary and secondary sources - Documentation of data Special assessments:FocusSpecial needs

HELP

- Systematic observing H:Observe the first signs a patient may need help.Look for signs of distress .E:Environmental and equipment. Check to see that all equipment is working properly L:Look more closely. Examine patient thoroughly for appearance, breathing, condition of dressings etc. P:People. Who are the people in the room?

Sources of vitamin b1

-: Beef liver; beef; pork; trout, tuna, mussels; eggs, legumes and peas; nuts and seeds; whole grains such as white long grain rice; whole wheat macaroni; fortified grains and cereals; fortified English muffins

The nurse leader is planning to provide information about personal hygiene to a group of clients. Which communication methods would the nurse use to talk to the clients? Select all that apply. One, some, or all responses may be correct. -Giving abundant information -Being sensitive to nonverbal communication -Providing the opportunity for dialogue and feedback -Presenting information that addresses the listeners self-interest -Using primary written methods such as email and text messages

-Being sensitive to nonverbal communication -Providing the opportunity for dialogue and feedback -Presenting information that addresses the listeners self-interest

Denture care:

-Do not use plain toothpaste -Dilute any mouthwash -Do not soak in hotwater

Vitamine D sources

-Fatty fish such as salmon, sardines, swordfish, tuna, and mackeral -fish oils such as cod liver oil -fortified foods such as milk, cereal, and orange juice -Also found in egg yolks and beef liver

Vitamin A sources

-Green leafy vegetables -Orange yellow colorful fruits such as sweet potatoes, cantaloupes, apricots, mangos -Also inred pepper black eyed peas, whole milk, beef liver, and salmon

Vitamin K sources

-Green leafy vegetables such as spinach -kale, collard greens, turnip greens, broccoli -soybeans and soybean products such as natto and soybean oil -pumpkin; pomegranates, edmame; and carrot juice

Assessment data sources

-Patient -Family caregivers and significant others -Health care team -Medical records -Other records and the scientific literature -Nurse's experience

In which position would the nurse place a client recovering from general anesthesia? -Supine -Side-Lying -High Fowler -Trendelenburg

-Side-Lying (Turning the client to the side promotes drainage of secretions and prevents aspiration, especially when the gag reflex is not intact. This position also brings the tongue forward, preventing it from occluding the airway when it is in the relaxed state. The risk for aspiration is increased when the supine position is assumed by a semi-alert client. A high Fowler position may cause the neck to flex in a client who is not alert, interfering with respirations. The Trendelenburg position is not used for a postoperative client because it interferes with breathing.)

Vitamin b12 sources:

-Sources: -Beef such as sirloin; clams; beef liver; -fish such as rainbow trout, tuna, and haddock; ham; poultry such as chicken; -whole eggs; dairy products such as milk, cheese, and yogurt; and fortified cereals.

b6 vitamin sources

-Sources: Poultry such as chicken breast and turkey; fish such as tuna and salmon; organ meats such as beef liver; potatoes, chick peas, bananas and fruits (except citrus fruits); and fortified cereals

How would the nurse position a dehydrated client who is hypotensive while waiting for an intravenous line to be started? -Prone -High Fowler -Supine with feet elevated 6 inches above the bed -W/E position is most comfortable for the client

-Supine with feet elevated 6 inches above the bed (Feet elevated while keeping head flat or elevated to no more than a 30-degree angle is the best position for dehydration. A prone position does not promote circulation. Although the high-Fowler position facilitates breathing, it does not assist blood flow to the head. Maintaining blood flow to vital centers, not comfort, is the priority.)

Bathing promotes

-increases circulation -Helps promote healing by dilating blood vessels near the skin surface allowing more blood flow to skin -helps maintain muscle tone and joint mobility (◦For acute care and surgical procedures: ◦Bathing should be done with the use of chlorhexidine scrubs or clothes ◦Rationale: decrease colonization rates of potentially harmful pathogens, especially in critical care settings .)

Folic acid sources

-s: Beef liver; Dungeness crab; spinach; legumes such as black-eyed peas and kidney beans; roasted peanuts; white rice; white bread; green vegetables such as asparagus, romaine lettuce; spinach, broccoli, mustard greens, and green peas; avocados; tomato juice; orange juice; and fortified cereals

Nursing Diagnosis Steps

1. Identify significant data 2. Cluster cues 3. Identify gaps and inconsistencies 4. Make inferences 5. Identify problem etiologies (what is causing it?)

Enema administration

1.Not sterile, gloves, privacy, warmed solution as ordered, adult 750-1000 ml 2.Assess for abdominal distention, bowel sounds *3.Left side, sim's position (follow natural curve of colon), insert lubricated tip, adult 3-4 inches 4.Open clamp and allow to flow slowly, raise to appropriate height, can cause cramping if flow rate too rapid 5.If order, "enemas until clear", repeat until fluid passed is clear, up to 3 total

ostomy pouches should be changed every

3-7 days

The nurse is assessing several clients. Which client will require parenteral nutrition? A client with brain neoplasm A client with anorexia nervosa A client with inflammatory bowel disease A client with severe malabsorption disorder

A client with severe malabsorption disorder

Fat soluble vitamins

A, D, E, K

The nurse is caring for a client admitted with cardiovascular disease. During the assessment of the client's lower extremities, the nurse notes that the client has thin, shiny skin; decreased hair growth; and thickened toenails. Which condition might this indicate? -Venous insufficiency -Arterial insufficiency -Phlebitis -Lymphedema

Arterial insufficiency (Clients experiencing arterial insufficiency present with extremities that become pale when elevated and dusky red when lowered. Lower extremities may also be cool to touch, pulses may be absent or mild, and skin may be shiny and thin with decreased hair growth and thickened nails. Clients with venous insufficiency often have normal-colored extremities, normal temperature, normal pulses, marked edema, and brown pigmentation around the ankles.)

ADPIE

AssessmentDiagnosis: (actual and potential) Planning: (SMART goals, interventions, EBP) ImplementationEvaluation: (five parts)

water soluble vitamins

B and C

The nurse is helping a client and her or his family to set and meet goals. Which professional role is the nurse displaying? Educator Advocate Manager Caregiver

Caregiver (As a caregiver, the nurse helps the client and her or his family set goals. The nurse also assists them in meeting these goals with a minimal financial cost, time, and energy. The educator role is used to explain concepts and facts about health, describe the reason for routine care activities, demonstrate procedures such as self-care activities, reinforce learning or client behavior, and evaluate the client's progress in learning. The advocator role helps protect the client's human and legal rights and provides assistance in asserting these rights if the need arises. In the manager role, the nurse coordinates the activities of members of the nursing staff and has personnel, policy, and budgetary responsibility for a specific nursing unit or agency.)

Which technique would the nurse use to maintain surgical asepsis? Change the sterile field after sterile water is spilled on it. 2 Put on sterile gloves and then open a container of sterile saline. 3 Place a sterile dressing no more than half an inch from the edge of the sterile field. 4 Clean the surgical area with a circular motion, moving from the outer edge toward the center.

Change the sterile field after sterile water is spilled on it (A sterile field is considered contaminated when it becomes wet. Moisture can act as a wick and allow microorganisms to contaminate the sterile field. The outsides of containers and packages are not considered sterile and sterile gloves are considered contaminated when touching either of these items. Items on the sterile field should be no less than 1 inch from the outer border or edge of the sterile field; any less is not considered sterile. Surgical areas or wounds should be cleaned from the inside edges to the outside edges to prevent recontamination.)

An older client who is usually cheerful and cooperative demonstrates irritability and restlessness during morning hygiene. Which assessments would the nurse perform first? Level of stress and ability to cope Changes in mental status and cognition Deviations from baseline mood and affect Feelings related to loss of independenc

Changes in mental status and cognition

After surgery, total parenteral nutrition (TPN) is instituted via a central venous infusion. During the fourth hour of the infusion the client complains of nausea, fatigue, and a headache. The hourly urine output is twice the amount of the previous hour. After contacting the primary health care provider, which action would the nurse take? Check the serum glucose level. Obtain an oxygen saturation level. Administer a prescribed analgesic. Elevate the head of the bed.

Check the serum glucose level

Process of learning key aspects of a group's culture, especially as it relates to health and health care practices Patients are best source of information about their culture

Cultural Knowledge (Learn basic general information about predominant cultural groups in your geographic area. Cultural pocket guides can be a good resource Assess patients for presence or absence of cultural traits based on an understanding of generalizations about a cultural group. • Do not make assumptions based on cultural background because the degree of acculturation varies among individuals Read research studies that describe cultural differences. Read ethnic newspaper articles and books View documentaries about cultural groups)

Ability to understand patients unique cultural needs

Cultural awareness (Identify your own cultural background, values, and beliefs, especially as related to health and health care • Examine your own cultural biases toward people whose cultures differ from your own culture)

Ability to collect relevant cultural data Performance of a cultural assessment

Cultural skill (Be alert for unexpected responses with patients, especially as related to cultural issues. • Become aware of cultural differences in predominant ethnic groups • Develop assessment skills to do a competent cultural assessment for anv patient.* Leam assessment skills for different cultural groups, including cultural beliefs and practices)

Which teaching point would the nurse provide to help an aging client prevent skin complications related to decreased sebum gland production? "Use soap with a high fat content." "Do not squeeze your nasal pores." "Lower the water heater temperature." "Avoid frequent bathing with hot water.

Do not squeeze your nasal pores (Decreased sebum production may be associated with an increased size of nasal pores and large comedones. Skin trauma may occur due to squeezing of the pores or comedones. Soap with a high fat content is recommended for a client with decreased eccrine and apocrine activity. A lower water heater temperature is advised for a client with a reduction in the number and function of nerve endings to prevent scalds. Frequent bathing with hot water should be avoided when a client has an increased susceptibility to dry skin)

Which nursing interventions are required for hepatitis A? Private room with the door closed Gown, mask, and gloves for all persons entering the room Gown and gloves when handling articles contaminated by urine or feces Gowns and gloves only when handling the client's soiled linen, dishes, or utensils

Gown and gloves when handling articles contaminated by urine or feces (Hepatitis A is transmitted via the fecal-oral route; contact precautions must be used when there are articles that have potential fecal or urine contamination. Neither a private room nor a closed door is required; these are necessary only for respiratory (airborne) precautions. Hepatitis A is not transmitted via the airborne route and a mask is not necessary; a gown and gloves are required only when handling articles that may be contaminated. Wearing gowns and gloves only when handling the client's soiled linen, dishes, or utensils is too limited; a gown and gloves also should be worn when handling other fecally contaminated articles, such as a bedpan or rectal thermometer)

The nurse is preparing to change a client's dressing. For which reason would the nurse use surgical asepsis? Keeps the area free of microorganisms Confines microorganisms to the surgical site Protects self from microorganisms in the wound Reduces the risk for growing opportunistic microorganisms

Keeps the area free of microorganisms

•Needed for proper nerve and muscle function; steady heart rhythm; maintain bone strength; and helps body create proteins and energy -Sources: Salmon; avocados; peanut butter; whole grains; leafy green vegetables; almonds and brazil nuts; and soybeans

Magnesium

Which action would the nurse implement when a client is receiving total parenteral nutrition (TPN)? Select all that apply. One, some, or all responses may be correct. Monitoring hydration Monitoring weight daily Monitoring vital signs every 4 hours Discarding any solution after 24 hours Checking the expiration date of the solution before administration

Monitoring hydration Monitoring weight daily Monitoring vital signs every 4 hours Discarding any solution after 24 hours Checking the expiration date of the solution before administration

A deficiency of B12, HCL acid, or intrinsic factor (produced by the cells in the stomach) results in:

Pernicious anemia

When caring for a client with peripheral arterial insufficiency, how would the nurse position the client's feet and legs?

Place them slightly lower than the head and chest (Gravity will assist the flow of blood to the dependent legs and feet (placed lower than the head and chest). Elevating the heels on pillows will decrease blood flow to the feet. Bending the knees with the use of the knee gatch will decrease blood flow to the feet. Elevating the foot of the bed will decrease blood flow to the feet.)

Factors affecting hygiene

Social practices Personal preferences Body image Socioeconomic status Health beliefs and motivation Cultural Beliefs (Box 40-1) Developmental stage Physical condition/illness Mental health Cognitive ability

The nurse is preparing to assess the heart of a client during a routine health checkup. Which positioning of the client would be appropriate to assess the murmurs of the heart?

The client should lie in the lateral recumbent position so that the nurse can effectively detect heart murmurs (The supine position provides easy access to the pulse sites (shown in Figure 1). The client should be placed in the dorsal recumbent position (Figure 3) for abdominal assessment. Sims position (Figure 4) is used so that the nurse can assess the rectum and vagina.)

Vitamin E sources

Vegetable oils, whole grains, green vegetables, almonds, kiwi fruit

A health care provider prescribes an intermittent enteral tube feeding for a client with a nasogastric tube. Place the nursing interventions in the order in which they should be implemented.

Verify the health care provider's prescription. Elevate the head of the bed to at least 30 degrees. Check the volume of residual against the parameters prescribed. .Administer the volume of feeding as per the prescription. Flush the tube with 30 mL of water after the feeding.

•Antioxidant (prevents/delays cell damage); needed for vision, bone growth, reproduction, cell function, immune system

Vitamin A

•- Helps body cells change carbs to energy; needed for muscle contraction and nerve conduction

Vitamin B1

•Required for formation of collagen (wound healing) and chemical messengers in the brain.

Vitamin C

•Promotes calcium absorption; needed for bone growth, modulation of cell growth, neuro-muscular and immune function; reduction of inflammation

Vitamin D

Needed for synthesis of proteins for blood clotting

Vitamin K

•Needed for nerve and blood cells; makes DNA. Must have HCL acid and intrinsic factor to produce red blood cells.

Vitamin b12

Two stages of assessment Collection of information from: The interpretation and validation of data to determine whether more data are needed or the database is complete.

a primary source (a patient) and secondary sources

Healing by secondary intention

a wound will be left open (rather than being stitched together) and left to heal by itself, filling in and closing up naturally.

What is back channeling?

active listening prompts such as "all right," "go on," or "uh-huh."

The collection, review, and analysis of data make up the process of

assessment

healthy fats

avocado, nuts, salmon, olive oil, seeds (Fats - essential for cellular transport, regulation of cell activity, insulation, and protection of vital organs)

Good Sources of Protein

beef steak, skinless chicken breast, fresh salmon, smoked salmon, amaranth, tuna, quinoa, eggs, buckwheat, lentils, chickpeas, kidney neans, kale

Which physical assessment situation is appropriate for use of alcohol-based hand sanitizer for hand hygiene? Before and after palpating a pulse Assessing a client with norovirus If the hand brushes a seeping dressing When the hands have contacted sputum

before and after palpating a pulse (Alcohol-based hand sanitizer is appropriate when the hands are not visibly soiled or have not contacted any body fluid, so use of alcohol-based hand sanitizer before and after palpating a pulse is appropriate. Norovirus is not killed by alcohol-based hand sanitizer, so hand hygiene should be followed with soap and water. A seeping dressing and sputum involve contact with body fluid, so hand hygiene should be followed with soap and water.)

Older adults have __________ _________ _____________ functionand less moisture causing dry feet; common problems include corns, calluses, bunions, hammertoe, and fungal infections (especially of the toe nails)

decreased sebaceous gland

Vitamin C sources

fruits and vegetables (-Citrus fruits; kiwi fruit; green and red pepper; cantaloupe; tomato juice; cabbage and cauliflower; potatoes; green leafy vegetables such as broccoli; strawberries.)

Which positioning would be avoided while assessing a client with a history of asthma?

lateral recumbent (The lateral recumbent position is used to assess heart function. A client with asthma or other respiratory problems may not tolerate the lateral recumbent position.) (The sitting position is used to assess the heart, thorax, and lungs; this position should be avoided in physically weakened clients. The supine position is used to assess the heart, abdomen, extremities, and pulses. The dorsal recumbent position is used for an abdominal assessment and to assess the head, neck, and lungs.)

fungal infection of toenail) is manifested as scaliness under distal nail plate. Nails appear brittle, thickened, broken, or crumbling with yellowish discoloration

onchomychosis

Maslow's Heirarchy of Needs (bottom to top)

physiological, safety, love/belonging, esteem, self-actualization

Older adult considerations for skin

rate of epidermal cell replacement slows, skin thins and loses resiliency; decreased moisture causes itching; increased risk for bruising and injury

Older adults considerations for the mouth

reduced saliva production which results in dry mouth, or xerostomia, and reduction of vascularity and tissue elasticity accompanied by chronic disease can result in loss of teeth

Antioxidant; needed for immune function; helps maintain health of blood vessels

vitamin E

- Needed for enzyme reactions (i.e. metabolism), immune function; and brain development during pregnancy and infancy

vitamin b6

What does healing by primary intention mean?

when a clean laceration or a surgical incision is closed primarily with sutures, Steri-Strips, or skin adhesive.

Ear care:

•Do not put anything in the ear to clean it •Turn off hearing aids before inserting in ear

Epidermis (outerlayer)

◦Prevents water loss and injury ◦Prevent entry of pathogens ◦Colonized by normal flora ◦Generates new cells