NS 125 Quiz 4

urine exits the bladder through the

urethra

what type of diet, Nutrition recommendations by the American Diabetes Association: focus on total energy, nutrient and food distribution; include a balanced intake of carbohydrates, fats, and proteins; varied caloric recommendations to accommodate patient's metabolic demands

diabetic

How fast the medication reaches its site depends on the vascularity of tissue/organ

distribution

what was a special note on the study guide

do not rub an injection site after administration of a med

refers to the removal, clearance, or separation of matter

elimination

Medication exits the body, Main organ for this is the kidney, however the Liver, bowel, lungs, and exocrine glands also do this to medication

excretion

what type of diet, As for clear liquid, with addition of smooth-textured dairy products (e.g., ice cream), strained or blended cream soups, custards, refined cooked cereals, vegetable juice, pureed vegetables, all fruit juices, sherbets, puddings, frozen yogurt

full liquid

type of urinary incontinence which is a loss of urine by an outside factor, like can't reach the bathroom in time

functional incontinence

what is considered a motor function of the brain

functioning with tongue, nose, and mouth

What will Health History problems of the neurological system most likely include

headache, dizziness, seizures, loss of consciousness, changes in movement (tremors, weakness, or incoordination), changes in sensations (numbness or tingling), difficulty swallowing, or difficulty communicating such as inability to understand speech or inability to speak.

what type of diet, Addition of fresh uncooked fruits, steamed vegetables, bran, oatmeal, and dried fruits

high fiber

loud and very frequent bowel sounds in thirty seconds is known as

hyperactive bowel sounds

less than 5 bowel sounds in a 30 second period is known as

hypoactive bowel sounds

Cranial Nerve XII

hypoglossal; Tongue movement for speech sound articulation (l, t, n) and swallowing

what are the four functions of the GI tract

ingestion (food), digestion (food), absorption (nutrient, electrolytes, and water), and excretion (waste)

what type of route of administration is characterized by when a med goes through nasal or oral passage, goes through an ET tube or tracheostomy, reach the deeper respiratory passage ways

inhalation

what are some examination techniques for the GI tract

inspection, auscultation, palpation (ALWAYS AUSCULTATE BEFORE PALPATING)

defined as the science or optimal cellular metabolism and its impact on health and disease

nutrition

term for LOC meaning patient sleep most of the time and is difficult to arouse

obtunded

who would have a sweet or fruity odor to their urine

occurs from acetone or acetoacetic acid (by-products of incomplete fat metabolism) seen with diabetes mellitus or starvation

Cranial Nerve III

ocular motor; Raise eyelids, most extraocular movements, Pupillary constriction, change lens shape

Cranial Nerve I

olfactory; Smell reception and interpretation

what are the rules for enema's

only take 3 enemas. If patient is administering on their own then make sure they know not to take more than 3. generally enemas are taken until clear. If still not clear after 3 enemas then notify a health care provider

Cranial Nerve II

optic; Visual acuity and visual fields

occurs when a bladder is overly full and bladder pressure exceeds sphincter pressure, resulting in involuntary leakage of urine.

overflow incontinence

a form of specialized nutrition support in which nutrients are provided intravenously

parenteral nutritoin

what type of diet, As for clear and full liquid, with addition of scrambled eggs; pureed meats, vegetables, and fruits; mashed potatoes and gravy

pureed

what are topical routes of administration

Applying, Inserting, Instilling, Irrigating, spraying

what is considered a light palpation? deep palpation?

1-2 cm; 4-6 pm

questions to ask regarding mental assessment

1. are client's answers appropriate? 2. Is their behavior and facial expressions appropriate? 3. is speech pattern of normal tone, rate, rhythm, and volume? 4. are the answers complete? 5. is the client's appearance neat or untidy? appropriate for age and weather conditions 6. is client cooperative? 7. experiencing hallucinations or delusions? 8. is posture or hygiene appropriate? 9. is the client drowsy?

Normal findings for a neuro assessment

1. patient should respond to name with something appropriate and should be oriented to name, place, and time. 2. voice should be clear and understood and response should show understanding of what was said 3. posture should be upright and gait is maintained

how many bowel sounds should you hear in one minute when auscultating

5-30

Cranial Nerve VI

Abducens; Lateral eye movement

Cranial Nerve VIII

Acoustic or vestibulocochlear; hearing and equilibrium

what are guidelines for administering medication into the eye

Apply medication to conjunctival sac by pulling down on lower lid of the eye, Avoid touching the structures of the eye (eye lashes, eye lid, or lid itself) want to keep bottle sterile, Nurse needs to administer but client can self-administer if they are able to, Can be refrigerated at time. This is not a temperature issue

This is permanent and develops over a long period of time. It is characterized by multiple cognitive deficits, memory impairment, cognitive disturbances, and impairment in occupational or social functioning. You can remember what you did as a kid but not what you did five minutes ago. Alzheimer is an example.

Dementia

Cranial Nerve VII

Facial; Movement of facial expression muscles except jaw, close eyes, labial speech sounds (b, m, w, and rounded vowels), Taste—anterior two thirds of tongue, sensation to pharynx, Secretion of saliva and tears

what are some problem based health history questions for GI regarding family history

GERD

Cranial Nerve IX

Glossopharyngeal; Voluntary muscles for swallowing and phonation, Sensation of nasopharynx, gag reflex, taste—posterior one third of tongue, Secretion of salivary glands, carotid reflex

type of medication action that is characterized by Unpredictable effects, Client may overreact, be extremely sensitive, or opposite effect happen to them from medication.

Idiosyncratic Reactions

what are parenteral routes of administration

Intradermal, Subcutaneous, Intramuscular, intravenous

what are some problem based Health History Questions

O - Onset L - Location D - Duration C - Characteristics A - Aggravating and Alleviating factors R - Related Symptoms T - Treatment S - Severity

who is a candidate for parenteral nutrition?

Patients who are unable to use GI tract. Patients in highly stressed physiological states such as sepsis, head injury, or burns.

The study of how medications enter the body, reach their site of action, are metabolized, and exit the body

Pharmacokinetics (Absorption, Distribution, Metabolism, Excretion)

what are guidelines for administering a vaginal suppository

Self-administration, These meds are going to interact with mucus membrane. Suppository will melt and be distributed and absorbed. Creams are given for infections and there may be a lot of drainage or fowl order. Make sure they receive hygiene or extra time in the bathroom to clean themselves

Cranial Nerve XI

Spinal Accessory; Turn head, shrug shoulders, some actions for phonation

Cranial Nerve V

Trigeminal; Jaw opening and clenching, chewing and mastication, Sensation to cornea, iris, lacrimal glands, conjunctiva, eyelids, forehead, nose, nasal and mouth mucosa, teeth, tongue, ear, facial skin

Cranial Nerve IV

Trochlear; Downward, inward eye movement

this type of urinary incontinence is more common in young women and can be brought on my local irritation such as an UTI. Individuals sense they need to urinate but cannot keep from urinating long enough to reach a toilet so you better get there quickly

Urge or urgency incontinence

Cranial Nerve X

Vagus; Voluntary muscles of phonation (guttural speech sounds) and swallowing, Sensation behind ear and part of external ear canal, Secretion of digestive enzymes; peristalsis; carotid reflex; involuntary action of heart, lungs, and digestive tract

The passage of medication molecules into the blood from its site of administration

absoprtion

type of medication action that that has severe responses and would require to discontinue the med

adverse effect

different terms for LOC

alert, lethargic or somnolent, obtunded, stupor or semi-coma, coma

type of medication action that Can happen not any time, not always first time. Get more severe with each time client is exposed to medication, Can be mild, (itching, hives) Up to severe where clients stop breathing

allergic reaction

body expels feces and flatus from the rectum through this

anus

how can you assess mental status?

appearance, behavior, cognitive function, thought process, and minimental exam

muscular organ that stores and excretes urine

bladder

what are oral routes of administration

buccal and sublingual

what are the different names that have the same meanings for a medication

chemical name (chemical makeup of medication), generic name (name first given to medication when it was developed), and trade name (name given to medication that it is marketed under)

what are some problem based health history questions for GI regarding present health status

chronic illness? medications metabolized in GI tract? Alcohol use? Peptic ulcer disease? pancreatitis? cirrhosis? smoke? bowel habits?

What type of diet, Clear fat-free broth, bouillon, coffee, tea, carbonated beverages, clear fruit juices, gelatin, fruit ices, popsicles

clear liquid

what would be normal urine findings

clear to amber in color with no sediment. Appears transparent at voiding. The more concentrated (darker) the urine is the stronger the odor

term of LOC meaning patient has no response to stimulous

coma

acute onset and is not permanent. It is characterized by a disturbance or consciousness, change in cognition, and develops over a short period of time. It is due to general medical condition or substance induced.

delerium

what type of route of administration is characterized by rare route of administration, when a med is placed on a contact lens and then the lens is placed in the eye

intraocular

what are some problem based health history questions for GI regarding past medical history

issues with digestive system? abdomen surgery?

filter waste products of metabolism that collect in the blood

kidneys

what is some anatomy of the GI/GU tract

kidneys, ureters, bladder, urethra, mouth, esophagus, stomach, small intestine, large intestine, anus

term for LOC meaning patient drifts off to sleep when not stimulated

lethargic or somnolent

what type of diet, 300 mg/day cholesterol, in keeping with American Heart Association guidelines for serum lipid reduction

low cholesterol

what type of diet, 4-g (no added salt), 2-g, 1-g, or 500-mg sodium diets; vary from no added salt to severe sodium restriction (500-mg sodium diet), which requires selective food purchases

low sodium

what type of diet, As for clear and full liquid and pureed, with addition of all cream soups, ground or finely diced meats, flaked fish, cottage cheese, cheese, rice, potatoes, pancakes, light breads, cooked vegetables, cooked or canned fruits, bananas, soups, peanut butter, eggs (not fried)

mechanical soft

what are the 6 rights of medication administration

medication, dose, client, route, time, documentation

Drug changed to less active or inactive form that is more easily excreted, Mostly occurs in the liver, can also occur in the Lungs, kidneys, blood, and intestines

metabolism

type or urinary incontinence that is both stress and urgency incontinence

mixed incontinence

digestion starts here, mechanically and chemically breaks down nutrients into a usable size and form

mouth

Damage to the spinal cord above the sacral region causes________. This causes loss of voluntary urination.

reflex incontinence

type of urinary incontinence which involves a loss of urine without feeling like you have to urinate

reflex incontinence

what type of diet, No restrictions, unless specified

regular

Type of medication action that is Unintended, (secondary effects) it is Predictable, can cause harm but for most part are harmless, need to teach patient how to avoid this

side effect

what are normal findings for inspection

skin color is even according to race, surface characteristics, contour - stomach should be flat and don't want to see bulges or masses. Should see no surface movement. Inspect ileostomy/colostomy

what are the guidelines for administering a topical medication

skin must be intact, clean, and dry. must wear gloves for the medication can have an effect on the person administering it, apply evenly by smearing but DO NOT RUB

digestion ends here

small intestine

what is considered sensory functions of the brain

smelling, hearing tasting

what type of diet, Addition of low-fiber, easily digested foods such as pastas, casseroles, moist tender meats, and canned cooked fruits and vegetables; desserts, cakes, and cookies without nuts or coconut

soft/low residue

who would have an "ammonia odor" to their urine

stagnant urine which is common is people who are repeatedly incontinent

stores swallowed food and liquid; mixing food, liquid, and digestive juices; and emptying its contents into the small intestine. It produces and secretes hydrochloric acid (HCl), mucus, the enzyme pepsin, and the intrinsic factor.

stomach

type of urinary incontinence which occurs more often in older women when intraabdominal pressure exceeds urethral resistance. Muscles around the urethra become weak (loss of tone); thus even a small amount of urine may leak spontaneously. Urine may leak when sneezing, coughing, or laughing due to the lack or muscle tone

stress incontinence

term of LOC meaning patient responds only to persistent vigorous shake or pain

stupor or semi-coma

how would you teach a client how to use a metered dose inhaler

tell patient to press down and release the medication while taking a big, deep breath in. Instruct them to keep breathing in for a couple seconds and then hold before exhaling.

how must insulin be administered and why

the parenteral route, it would be broken down if it was injected into the GI tract

Type of medication action that we want to happen, it is Expected or predictable physiological response

therapeutic affect

types of medication action

therapeutic affect, side effect, adverse effect, toxic effect, Idiosyncratic Reactions, and alergic reactions

type of medication action that is characterized by Prolonged intake or accumulation in blood, When medication is not metabolized or secreted by body in the appropriate matter, These could be lethal because you are increasing dose each time you give it to patient, Want to avoid medication that cause this, Big issue is looking at patients who have chronic illness of liver or kidney since those are the two main issues of excretion

toxic effect

who would be considered candidates for parenteral nutrition

unable to use GI tract (someone with pancreatitis)

drains urine into the bladder

ureter

an accumulation of urine resulting from an inability of the bladder to empty properly

urinary retention

how would you administer an enema

warm enema to room temp. advice patient to empty bladder (may reduce discomfort). you need gloves, incontinence pad, lubrication, water, bed pan or a commode. Identify allergies. Assess pt privacy and dignity. check enema for expiry and intactness. position pt on left side lying with knees drawn to abdomen. assess and perform a digital rectal exam. break enema seal and lubricate nozzel. gently expel the contents into the rectum tolling the container from the bottom up to reduce back flow (maximum of 3 enemasO

what are some problem based health history questions for GI tract

what is the problem? distention of abdomen? stool appearance? jaundice?

what are normal findings for palation

you are looking for tenderness or if it is firm. Normal findings would be a relaxed abdomen with no tenderness