Exam 2 1340

sensory perception risk factors

-age, -amount of stimuli -environmental factors -cultural factors

Lipids function

-major source of energy -deficiency occurs when fat intake falls below 10% daily intake

Negative consequences of malnutrition

-obesity -physiological/psychological dysfunction -altered hydration staturs -low energy -growth/developmental delay

a nurse is teaching a group of older adult clients about dietary needs. which of the following recommendations should the nurse include in the teaching A. "You should consume1,200 mg of calcium daily." B. "consume 4% of your diet as fat" C. "You should drink 1,300 mL of fluid daily" D."Consume 40% of your diet as protein"

A. "You should consume1,200 mg of calcium daily."

A nurse is assessing a client for conductive hearing loss. When using the Rinne test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the left ear? A. Air conduction is less than bone conduction in the left ear. B. Air conduction is greater than bone conduction in the left ear. C. Sound is lateralizing to the right ear D. Sound is lateralizing to the left ear.

A. Air conduction is less than bone conduction in the left ear.

A nurse at an ophthalmology clinic is assessing a client referred by the provider for a potential cataract. Which of the following client reports should the nurse recognize is consistent with cataracts? A. Halos, when looking at lights, B. loss of peripheral vision, C. bright flashes of lights and floaters, D. eye strain and headache with close work.

A. Halos when looking at lights

A nurse is teaching a client who has iron-deficiency anemia. The nurse should encourage the client to increase her consumption of which of the following foods? A. Lentils B. Avocados C. Cabbage D. Broccoli

A. Lentils

A nurse in a providers office is reviewing the medical records of a group of clients. Which of the following clients is at risk for iron deficiency? select all that apply A . client who is postmenopausal B. A client who is a vegetarian C. A middle at age adult male D.A client who is pregnant E. A toddler who is overweight

B. A client who is a vegetarian D. A client who is pregnant E. A toddler who is overweight

Risks for glaucoma select all that apply A. damage to the hypothalamus B. Age C. hypertension D. Diabetes E. Stress

B. Age C. hypertension D. Diabetes

A nurse is developing a plan of care for a school age child who underwent a surgical procedure that resulted in a temporary loss of vision. Which of the following interventions should the nurse include in the plan of care? A. Assign an assistive personnel to feed the child. B. Explain sounds the child is hearing. C. Have the child use a cane when ambulating. D. Rotate nurses caring for the child.

B. Explain sounds the child is hearing.

A nurse is developing a plan of care for a school-age child who underwent a surgical procedure that resulted in a temporary loss of vision. Which of the following interventions should the nurse include in the plan of care? A. Assign an AP to feed the child B. Explain the sounds the child is hearing C. Have the child use a cane when ambulating D. Rotate nurses caring for the child

B. Explain the sounds the child is hearing

A nurse is assessing a client who has anorexia nervosa. The nurse should expect the client to display which of the following characteristics? A. refusal to participate in physical exercise activities. B. Feelings of decreased self-worth C.- preoccupied with concerns about personal health D. avoidance of discussions of food

B. Feelings of decreased self-worth

A nurse is caring for a client who has a temperature of 38.7 C (101.7 F). Which of the following actions should the nurse take? A. Apply an alcohol-water solution to the client's skin. B. Keep the client's bed linens dry. C. Apple ice packs to the groin. D. Limit the client's fluid intake to 1183ml of fluid per day.

B. Keep the client's bed linens dry.

A nurse is planning care for a child who has hyperthermia. Which of the following actions should the nurse take? A. administer antipyretics to the child every 4 to 6 hrs B. position the child on a cooling blanket and cover her with a sheet C. place the child in a tub filled with water cooled to 26.7 to 29.4 c D. Assess the child's temperature every 2 hrs during the cooling process

B. Position the child on a cooling blanket and cover her with a sheet

A nurse is teaching a middle-aged female client about disease prevention and health maintenance. Which of the following diagnostic tests should the nurse recommend as part of the client's routine? A. annual Papanicolaou (pap) B. mammogram every 2 years C. Eye examination every 2 years D. Anual colonoscopy

C. Eye examination every 2 years

A nurse is assessing a client who has a new diagnosis of acute angle-closure glaucoma. The nurse should anticipate the client to report which of the following manifestations? A.multiple floaters B. flashes of light in front of the eye C. severe eye pain D. double vision

C. Severe eye pain

A nurse is reinforcing teaching w/ the guardians of a school-age child who has hearing loss. Which of the following techniques should the nurse recommend to facilitate communication with the child?A. Exaggerate the pronunciation of each word. B.Keep hands still when speaking. C.Speak at the child's eye level. D. avoid using facial expressions when speaking.

C. Speak at the child's eye level.

A nurse is caring for an 18-month-old infant who has chronic otitis media. The nurse should recognize that chronic otitis media will affect which of the following? A. fine motor skills B. visual acuity C. Speech patterns D. Hand-to-eye coordination

C. Speech patterns

a nurse is preparing to administer eye drops for a client who has glaucoma. when instilling the medication, which of the following actions should the nurse take? A. instruct the client to blink several times after instilling the medication. B. ask the client to look straight ahead during installation of the medication. C. apply pressure to the puncta after instilling the medication. D. place each drop od the medication directly onto the client's cornea

C. apply pressure to the puncta after instilling the medication.

A nurse in a clinic is providing teaching to an adolescent client who has recurrent external otitis. What instructions should the nurse include in the teaching? A. dry the ear canal with a cotton swab after swimming B. apply an ice pack to the ear to relieve pain C. instill a diluted alcohol solution into the ear after swimming D. irrigate the ear with cool tap water to clean

C. instill a diluted alcohol solution into the ear after swimming

A nurse is assessing a client who reports an acute visual disturbance that he describes as a "curtain" pulled over his visual field with occasional flashes of light. The nurse should notify the provider that this client might have which of the following disorders?A.Cataracts B. Angle-closure glaucoma C.Retinal detachment D. Macular degeneration

C.Retinal detachment

Macula degenerative disease definition and expected findings

Central loss of vision that affects the macula of the eye; common vision loss in older adults; no cure. -lack of depth perception (driving issues) -blurred vision -loss of central vision -blindness

BMI of 22.6 and expresses concern about weight gain during pregnancy. Which of following responses should nurse make? A. " You're eating for 2, so you should double your caloric intake." B. "you'll lose weight easily after the birth of your baby." C. "plan to gain a total of 15 to 20 pounds during pregnancy." D. "gaining weight will promote a healthy pregnancy."

D. "gaining weight will promote a healthy pregnancy."

A nurse is teaching a client who has a new diagnosis of primary open-angle glaucoma (POAG). Which of the following pieces of information should the nurse include in the teaching? (select all that apply) A. Lost vision can improve w eye drops. B. Administer eye drops as needed for vision loss. C. Glasses will be necessary to correct the accompanying presbyopia. D. Driving can be danerous d/t the loss of peripheral vision. E. Laser surgery can help reestablish in the flow of aqueous humor.

D. Driving can be danerous d/t the loss of peripheral vision. E. Laser surgery can help reestablish in the flow of aqueous humor.

A nurse is caring for a 5 year old child who has a fever and begins to have a seizure. Which of the following actions should the nurse take? A. give acetaminophen 240 mg PO immediately following the seizure B. sponge the child's skin with a mixture of cold water and rubbing alcohol c. administer rectal diazepam if the seizure lasts longer than 2 minutes D. Place the child in a side-lying position

D. Place the child in a side-lying position

A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance? A. 2-point discrimination test B. glasgow coma scale C. Babinski reflex D. Romberg test

D. Romberg test

a nurse is reviewing the medical record of a client who is experiencing tinnitus in both ears. which of the following pieces of information in the client's medical record should the nurse identify as a risk factor for tinnitus? A. use of hydrochlorothiazide B. Chronic use of acetaminophen C. allergic external otitis D. Sclerosis of the ossicles

D. Sclerosis of the ossicles

a nurse is caring for a client who is dehydrated. the nurse should expect htat insensible fluid loss of approximately 500 to 600 mL occurs each day through which of the following organs? A. kidneys B. lungs C. gastrointestinal tract D. skin

D. Skin

A nurse is caring for a client who has hearing loss. Which of the following actions should the nurse take when communicating with the client? A. speak in a loud voice B. avoid the use of nonverbal communication C. adjust the client's hearing aid to a high volume D. face the client when speaking

D. face the client when speaking

A client who has glaucoma of the right eye Self administer timolol eyedrops by looking at the ceiling, instilling a drop into the center of the conjunctival sac, and applying gentle pressure to the lower lid with a facial tissue. After observing this process, which of the following action should the nurse take? A. confirm that the client performed the procedure correctly. B. instruct the client to look at the floor while instilling the eye drop. C. remind the client to avoid using a facial tissue after instillation. D. instruct the client to apply pressure to the inside corner of the eye after instillation.

D. instruct the client to apply pressure to the inside corner of the eye after instillation.

sensorineural hearing loss definition

most prevalent type of hearing loss cause by damage to cranial nerve VIII. decreased ability to hear high frequency tones more than low-freq tones.

cachexia

muscle wasting with prolonged malnutrition

Vitamins

Water soluble: -C (serves as an antioxidant) collagen, wound healing, aids with iron, deficiency scurvy. -B complex (nervous system, metabolism Fat-soluble: -A (antioxidant) (vision, NB skin, bones) -D (stimulation of calcium and phosphorus) -E (antioxidant) -K make various proteins for blood clotting

sarcopenia

a condition of loss of muscle mass and strength

Define Primary obesity

excess calorie intake over energy expenditure fro body's metabolic demands.

hypoalbuminemia

too little protein in the blood

cataracts definition

- opacity of lens that impairs vision; blurred vision, reduced night vision, diplopia (double vision)

trace elements

-Iron: transports oxygen through the body -Magnesium: part of several enzymes -Copper: iron metabolism -zinc: normal growth, wound healing and immune -iodine: thyroid regulation -fluoride: bone and teeth development -Selenium: defense against oxidative damage

nutrition antecedents

-Normal alimentary tract and associated organs -adequate ingestion of Nutrients and water -normal temp -Normal pH

types of glaucomas and their expected pressure

-Primary open angle 22-32 mmHg (most common) -Acute Angle-closure >50 mmHg (emergency) (severe eye pain, and loss of vision)

A nurse on med surg unit is caring for client who has been coughing intermittently during meals. Attempting to clear her throat repeatedly and eating only small portion of each meal. The nurse should recommend a referral to which of the following members of the interprofessional team to evaluate the client for dysphagia? A. Speech-language pathologist B. Social worker C. Physical therapist D. Occupational Therapist

A. Speech-language pathologist

A nurse is caring for a client who has hearing loss. The nurse should plan which of the following interventions when communicating with the client? A. attract the client's attention before speaking B. accentuate vowels of words while speaking C. touch the client at intervals when communicating D. sit at a 90-degree angle to the client when speaking

A. attract the client's attention before speaking.

A nurse is caring for a client who has protein malnutrition. Which of the following foods should the nurse identify as a source of complete protein? A. Eggs B.Cereal C.Peanut butter D.Pasta

A. eggs

A nurse is teaching parents of a 10-year-old child who has iron-deficiency anemia. Which of the following statements by a parent indicates an understanding of the teaching? A. "I will give my child an iron tablet once each day at bedtime." B. "I will Administer the iron tablet with orange Juice." C. "I WiIll encourage my child to take an antacid with the iron tablet." D. "I will crush the iron tablet prior to giving it to my child."

B. "I will Administer the iron tablet with orange Juice."

A nurse is caring for a client who has acute lymphocytic leukemia and reports a fever, chills, fatigue, and pallor over the past week. When checking the clients laboratory results, which of the following values should the nurse identify as contributing to the clients fatigue and pallor? A. Magnesium 2.0 Meq/L B. HGB 6.5 g/dL C. WBC 9.6/mm3 D. Creatinine .08 mg/dl

B. HGB 6.5 g/dL (anemia)

A nurse is reviewing the medical record of a client who has been taking a vitamin D supplement. Which of the following findings from the client's record should the nurse identify as a risk factor for developing vitamin D deficiency? A. Middle-age pregnancy B. Obesity C. Dark-colored eyes D. Light-pigmented skin

B. Obesity

What medications are given to treat N/V? select all that apply A. Ferrous sulfate B. Ondansetron C. Dimenhydrinate D. Metoclopramide E. Aspirine

B. Ondansetron C. Dimenhydrinate D. Metoclopramide

A nurse is assessing a client who has cataracts. Which of the following findings should the nurse expect? A. Pupils nonreactive to light B. Opacity visible behind the pupil C. White circle around the outside of the iris D. Increased intraocular pressure

B. Opacity visible behind the pupil

A nurse is caring for a 4-month old child who has acute otitis media and a fever of 38.3 C (101 F). Which of the following medications should the nurse administer? A. diaphenhydramine B.furosemide C. Amoxicillin D. Ibuprofen

C. Amoxicillin

A nurse is teaching a client who has iron-deficiency anemia. The nurse should encourage the client to increase consumption of which of the following foods? A. Beef liver B. Oranges C. Turnips D. Whole milk

A. Beef liver

Medications use to treat glaucoma (select all that apply) A. Beta blockers (timolol, betaxolol) B. Dantrolene C. Aspirin D. cholinergic agents (miotics, pilocarpine) E. systemic osmotic (mannitol)

A. Beta blockers (timolol, betaxolol) D. cholinergic agents (miotics, pilocarpine) E. systemic osmotic (mannitol)

A nurse asks a client to stand with her feet together and her eyes open. After a few seconds, the nurse asks the client to close her eyes. If the client begins to fall, the nurse should interpret this finding as a positive Romberg's test, indication what alteration? Cerebellar dysfunctionCerebellar dysfunction causes a loss of position sense (proprioception) which results in positive Romberg's sign. A. Cerebellar dysfunction. B. Occipital lobe dysfunction. C. Increased intraocular pressure. D. Macular degeneration.

A. Cerebellar dysfunction.

A nurse is administering brimonidine eye drops to a client who has glaucoma. Which of the following ocular effects should the nurse expect? A. Decrease intraocular pressure B. Blocked growth of new blood vessels C. Paralysis of accommodation D. Mydriasis

A. Decrease intraocular pressure

A nurse is assessing a client who has a head injury with a possible skull fracture. Which of the following findings should the nurse identify as an indication that the client might have a complication involving the eighth cranial nerve (CN VIII)? A. Dizziness and hearing loss B. Weakness of a side of the tongue C. Facial droop and asymmetrical smile D. Loss of the same visual field in both eyes

A. Dizziness and hearing loss

A nurse is assessing a client. Which of the following findings should the nurse identify as an indication of protein-calorie malnourishment? select all that apply A. Dry brittle hair B. Edema C. poor wound healing D. Spoon-shape nails E. Gingivitis

A. Dry brittle hair B. Edema C. poor wound healing

A nurse is assisting a client who has dysphagia at mealtimes. Which of the following actions should the nurse take? A. Assist the client into semi-sitting position B. Have the client lean slightly backward C. Advise the client to tuck his chin downward D. Instruct the client to tilt his head slightly backward

C. Advise the client to tuck his chin downward

secondary obesity

Results from various congenital anomalies, chromosomal anomalies, metabolic problems, CNS lesions, disorders or drugs

Symptoms of malnutrition

Skin - dry, scaly skin, brittle nails, hair loss mouth- crusty, ulcerations muscles- cachexia (muscle waisting) CNs- Confusion, irritability delayed wound healing due to decreased protein increased susceptibility to infection steatorrhea (fatty stools) due to malabsorption

Define myringotomy

Surgical incision into the eardrum, to relieve pressure or drain fluid and insertion of a small tube.

anasarca

a condition of massive fluid overload

Nutrition Attributes

-Adequate intake for development/energy/growth/tissue repair -ideal ht, wt, BMI -muscle tone, strength, agility, reflex, response -cognitive & mood response -Albumin with in normal limits -hemoglobin & Hematocrit WNL -electrolytes WNL

Types of sensorineural hearing loss

-Congenital hearing loss: hearing loss at birth or congenital. -conductive hearing loss: sounds cannot get throught the outer and middle ear caused by otitis media, impacted cerumen, otosclerosis.

sensory perception antecedents

-External stimuli -Intact neural system -Intact/functioning (visual, gustatory, auditory, integument, auditory)

a nurse is administering brimonidine eye drops to a client who has glaucoma. which of the following ocular effects should the nurse expect? A. Decreased intraocular pressure. B. Blocked growth of new blood vessels C. paralysis of accommodation. D. Mydriasis

A. Decreased intraocular pressure.

A nurse perfoms a neurologic assessment on a client with a brain tumor. Which of the following findings should indicate to the nurse cranial nerve involvement? A. Dysphagia B. Positive Babinski sign C. Decreased deep tendon reflexes D. Ataxia

A. Dysphagia

A nurse is reviewing a laboratory findings of a client who has protein-calorie malnutrition. What findings should the nurse expect? A. decreased albumin B. elevated hemoglobin C. Elevated lymphocytes D. Decreased cortisol

A. decreased albumin

A nurse is providing teaching to the partner of a client who has a new diagnosis of Parkinson's disease about degenerative complications. The nurse should include in the teaching that what manifestations is the priority? A. dysphagia B. emotional lability C. impaired speech D. self-care dependency

A. dysphagia

A nurse is caring for a client with anorexia nervousa who has light skin. Which of the following findings should the nurse expect? A. presence of lanugo B. flushed skin tone C. hyperactive bowel sounds D. Clubbing of the fingernails

A. presence of lanugo

A nurses is admitting an older adult client who fell at home 3 days ago, the client has a fractured hip, malnutrition and dehydration. which of the following laboratory values noted on admission should indicate to the nurse prolonged malnutrition?A) increased sodium B) decreased albumin C) increased bun D) decreased blood glucose.

B) decreased albumin

A nurse is providing discharge teaching about foot care to a client who has diabetic neuropathy. Which of the following statements by the client demonstrates an understanding of the teaching? A. " I can use a heating pad on my feet to keep them warm" B. "I can go barefoot as long as I stay inside the house." C. "I will wash my feet daily and apply lotion, except between my toes." D. "I will trim my toenails every morning by rounding the corners".

C. "I will wash my feet daily and apply lotion, except between my toes."

A nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching? A. Cream of rice B. Cottage cheese C. Gelatin D. Ice cream

C. Gelatin

A nurse is planning care for a client who reports abdominal pain. Am assessment by the nurse reveals the client has a temperature of 39.2 C (102.6F), heart rate of 105/min, a soft non tender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority? A. Heart rate 105/min B. Soft, non tender abdomen C. Temperature D. Overdue menses

C. Temperature

obesity assessment

body mass index >30 kg/m2 waist circumference: Male >40" Female>35" increase work of breathing hypertension tachycardia dysrhythmia knee, hip, low back pain. possible findings: elevated sugar cholesterol triglycerides liver function enlarged heart

types of macular degeneration

-Dry macula (most common) (blocked retinal capillary arteries. lack of blood to macula becoming ischemic and necrotic) -wet macula (less common) (new growth of blood vessels that have thin walls and leak blood and fluid)

sensory perception attributes

-Hearing (0-25 dB) -Vision (20/20) -Intact integument system -Gustatory sensations (sweet, salty, sour, bitterness) -Olfactory

marasmus definition

a type of protein-energy malnutrition that can affect anyone but is mainly seen in children. severe deficiency of nutrients like calories, proteins, carbohydrates, vitamins and minerals

Anorexia nervosa definition

characterized by a distorted body image, with an unwarranted fear of being overweight.

macrominerals

daily requirement >100 -calcium -phosphorus -magnesium -sodium -potassium -chloride -sulfur

Malnutrition definition and types

deficit, excess or imbalance of essential nutrients; with or without inflammation -starvation-related. malnutrition -anorexia nervosa -marasmus -kwashiorkor -Chronic related malnutrition -acute disease or injury related malnutrition

Sensory perception definition

the ability to receive sensory input and, through various physiological processes in the body, translate the stimulus or data into meaningful information

A nurse is reviewing recent lab values during a prenatal visit for a client who is pregnant. The nurse notes a hemoglobin level of 10g/dL. Which of the following actions should the nurse take? A. Review the medical record for a history of gastric bypass surgery B. Advise the client to start iron and vitamin C supplementation C. Review the medication list to determine if the client is taking an anticonvulsant D. Request an order for sickle cell anemia screening

B. Advise the client to start iron and vitamin C supplementation

A nurse is assessing a client who is experiencing an obstruction of the flow of the vitreous humor in the eye. This manifestation is consistent with which of the following eye disorders? A. Retinopathy B. Glaucoma C. Cataracts D. Macular degeneration

B. Glaucoma

a nurse is reviweing the medical record of a client who might have hearing loss. which of the following data from the clients medical record should the nurse identify as a risk factor for hearing loss? A. frequent use of steroids B. chronic use of salicylates C. intermittent use of antacids D. habitual use of laxatives

B. chronic use of salicylates

a nurse is providing teaching to a newly licensed nurse about metoclopramide. The nurse should include in the teaching that which of the following conditions is a contraindication to this medication? A. hyperthyroidism B. intestinal obstruction C. glaucoma D. low bp

B. intestinal obstruction

A nurse is reviewing the laboratory data of a client who has a fever and watery diarrhea. Which of the following results should the nurse report to the provider? A.) Calcium 9.5 mg/dL B.) Sodium 150 mEq/L C.) Potassium 4 mEq/L D.) Magnesium 1.5 mEq/L

B.) Sodium 150 mEq/L

Iron deficiency anemia

is caused by a deficiency in iron. It is microcytic anemia meaning it creates really small red blood cells.

Chronic related malnutrition

occurs with conditions with sustained mild to moderate inflammation. when dietary intake does not meet tissue needs although in normal circumstances, it would. eg. organ failure, cancer, rheumatoid arthritis, obesity, metabolic syndrome.

oral dysphagia

- difficulty in passage from the mouth to the esophagus. -More common type -Stroke is most common cause

treatment for pediculosis

-1% permithrin shampoo -nit comb -repeat after 7 days -avoid home remedies -bag items that can not be laundered into a tightly sealed bag for 14 days. -boil combs, Brushes 10 min or soak in lice killing for 1 hr

factors that affect wound healing

-Age -wound stress -immunocompromised and/or malnourised -infection -medication -tissue perfusion -obesity

proliferation

-Angiogenesis (the formation of new blood vessels) -re-epithelialization

cases for anemia

-Decreased intake of Iron (bad diet) -increased demand for iron (growing) -decreased absorption of iron (need acid to absorb) -Increased loss of iron (blood loss)

signs symptoms of dysphagia

-Drooling increases oral secretion -difficulty swallowing -heartburn, chest pain -coughing or choking at meals -difficulty chewing or swallowing -hoarseness or increased throat-clearing -gurgling voice -increased throat clearing.

antecedents of tissue integrity

-Good nutrition. -Lack of external trauma. -Adequate perfusion. -Limited pressure on site. -Affected by life cycle ( birth to death).

Complete CBC includes and ranges

-Hemoglobin: range 12-17 g/dl -hematocrits: range 34-50% varies between males and females -mean corpuscular volume: measures average size of red blood cells. - mean corpuscular hemoglobin average mass of hemoglobin per red blood cell. -Mean corpuscular hemoglobin concentration: measures average concentration of hemoglobin inside a single red blood cell -platelets: shows blood clotting or lack of

types of dysphagia

-Oral -Pharyngeal -Esophageal

symptoms of anemia

-Palor -fatigue -glossitis (inflammation of the tongue.) -cheilitis (inflammation of the lips) -headaches -paresthesias -burning sensation of tongue -fatigue

full liquid diet

-all forms of milk, protein shakes -strained soups -strained fruits and vegetables -plain ice cream and sherbert -yogurt and pudding -boost, ensure, liquid supplements

tissue integrity negative consequence that I didn't know

-altered body image -decubite (pressure ulcers) -loss of perfusion -infections and infestations -burn, radiation, chemical burn -lesions -Wart, growth, skin tag, tumors.

diagnostic tests for anemia

-complete CBC -Serum Iron (transferrin and ferritin) -Fecal occult blood test

esophageal dysphagia

-food passage is disorderly through the esophagus -most commonly due to actual blockage -structural disorder.

stages of wound healing

-hemostasis, -inflammation, -proliferation, -remodeling

attributes of tissue integrity

-integument structurally intact and functioning -normal healing process

impetigo interevention

-meticulous hygiene -warm compress (aluminum acetate solution to remove crusting) -topical antibiotics

topical treatments for Psoriasis

-moisturizers and emollients - steroids: topical or oral to decrease immune response -uv light

Candida manifestation

-mouth: white cheesy plaque on tongue -vagina: red, edematous, painful vaginal wall, white patches, discharge and pain, -skin: erythematous rash with pinpoint satellite lesions around edges of affected area.

hemorrhage wound healing

-normally occurs immediately after initial trauma - Detect internal bleeding -look for swelling, drop in bp, distention. -the risk of hemorrhage is greater after surgery for the first 24 to 48 hrs.

dysphagia interventions

-provide rest before feeding. -avoid straws with patients with dysphagia -sit the person 90 degrees -avoid rush feeding -alternate solids and liquids -placed food on non impaired side of mouth -have suction equipment ready at all times avoid sedatives and hypnotics that my impair the cough reflex and swallowing.

Pureed diet

-pudding -mashed potatoes -yogurt -juices without pulp -baby food -pureed meats -broths -ice cream

impetigo prevention

-skin clean and dry - cleaning minor cuts and scrapes with soap and water -if infection- don't share personal items -after touching infected skin wash ahnds ith soap and water -contact precautions

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take first after discovering that the client's wound has eviscerated? A. Cover the incision with moist sterile dressing B. Have the client lie on his back with his knees flexed C. call the client's surgeon D. Reassure the client

A. Cover the incision with moist sterile dressing

a nurse is caring for a client who has a stage II pressure ulcer. Which of the following wound dressings should the nurse apply to the ulcer? A. Hydrocolloid B. Collagen C. Calcium Alginate D. Proteolytic Enzyme

A. Hydrocolloid

A patient's leg wound is not healing as quickly as expected. What should the nurse do to determine the reason for the patient's poor healing? Select all that apply. A. Obtain a referral for a dietician B. Elevate the extremity on a pillow C. Increase the frequency of dressing changes D. Encourage increased independent movement E. Obtain an order for prealbumin and albumin levels

A. Obtain a referral for a dietician E. Obtain an order for prealbumin and albumin levels

A nurse is performing an admission skin assessment on a client and notes that the client has a stage 3 pressure injury to the coccyx. How should the nurse document the appearance of the pressure injury? A. Stage 3 pressure injury to the coccyx observed with full-thickness skin loss and visible adipose tissue B. Stage 3 pressure injury to the coccyx observed with a non-blanchable area of erythema C. Stage 3 pressure injury to the coccyx observed partial-thickness skin loss, wound bed pink and moist D. Stage 3 pressure injury to the coccyx observed with full-thickness skin loss, muscle and bone visible

A. Stage 3 pressure injury to the coccyx observed with full-thickness skin loss and visible adipose tissue

A nurse is providing teaching to a client who is in a wheelchair about measures to avoid skin breakdown. Which of the following instructions by the nurse is related to preventing skin breakdown? A. You should shift your weight off your buttocks at intervals throughout the day B. You should be sure your legs are placed on the floor prior to transferring C. Position yourself in the back of the wheelchair after transferring D. Lock your brakes when you are sitting in the wheelchair

A. You should shift your weight off your buttocks at intervals throughout the day

A nurse completed the Braden scale on four clients who are at risk for alterations in skin integrity. Which of the following clients should the nurse recognize as having the greatest risk for altered skin integrity? A. a client who has a Braden Scale score of 9 B. a client who has a Braden Scale score of 23 C. a client who has a Braden Scale score of 12 D. a client who has a Braden Scale score of 15

A. a client who has a Braden Scale score of 9

An older adult client has been lying in a supine position for the past 3 hours. The nurse who is repositioning this client would be most concerned with examining which bony prominences of this client? Select all that apply. A. heels B. ankles C. elbows D. sacrum E. back of the head F. greater trochanter

A. heels C. elbows D. sacrum E. back of the head

A nurse is teaching the parents of an infant about treatment options for profound sensorineural hearing loss. The nurse should include which of the following pieces of information about the function of cochlear implants? A. they provide direct stimulation of auditory nerve fiber B. they conduct sound waves through the mastoid bone to the cochlea C. they process digital sound to amplify several sound frequencies D. they convert vibrations in ear's structures to electrical sound

A. they provide direct stimulation of auditory nerve fiber

A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet? A. vitamin C and zinc B. vitamin D C. vitamin K and iron D. calcium

A. vitamin C and zinc

A nurse is caring for a client who has acute diverticulitis. While the client has active inflammation, the nurse should instruct the client to include which of the following foods in her soft diet? A. white bread and plain yogurt B. shredded wheat cereal and blueberries C. broccoli and kidney beans D. Oatmeal and fresh pears

A. white bread and plain yogurt

a nurse on an eating disorders acute care unit is assessing a client and observes the presence of lanugo on her skin. the nurse should identify that this finding is consistent with which of the following eating disorders? A.anorexia nervosa B.bulimia nervosa C.binge eating disorder D. pica

A.anorexia nervosa

medications used to treat psoriasis

Adalimumab linfliximab enteracept biologics to suppress immune system

Define psoriasis

Autoimmune disease, rapid desquamation of the skin, red, thickened, scaly patches. - usually develops before age 40 -over production of skin cells -produces silver plaques, often on scalp, elbows, knees, palms, soles and finger nails

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription reads: clear liquids; advance diet as tolerated. Which of the following responses should the nurse make? A. "lunch trays should be here within the hour" B. "I am going to listen to your abdomen" C. I'll get you some water to drink D. "I would wait a bit, or you could feel sick"

B. "I am going to listen to your abdomen"

A nurse is teaching a client who has a pressure injury on their leg about proper nutrition to facilitate wound healing. Which of the following client statements indicates an understanding of the teaching? A. "I should consume a diet high in carbohydrates" B. "I should increase my protein intake" C. "I should include fruit and vegetables with every meal" D. I should avoid meat products"

B. "I should increase my protein intake"

A nurse is preparing to obtain a wound culture from a client who has a suspected wound infection. Which of the following actions should the nurse take? A. Obtain the culture using a clean cotton applicator B. Clean the wound with 0.9% sodium chloride C. Collect drainage from the area surrounding the wound D. Place the applicator in a dry vial until cultures are complete

B. Clean the wound with 0.9% sodium chloride

A nurse is performing a physical assessment of a client. The nurse should recognize that which of the following findings places the client at risk of impaired skin integrity? A. 3+ Achilles reflex B. Faint pedal pulses C. Feet warm to the touch bilaterally D. Capillary refill of <2 sec

B. Faint pedal pulses

A nurse is cleaning a client's wound by swabbing from the area of least contamination to an area of greater contamination. Which of the following rationales should the nurse identify for using this technique? A. Preventing the transfer of microorganisms to the nurse B. Keeping microorganisms from entering the wound C. Applying minimal pressure to the wound D. Keeping excess moisture from entering the wound

B. Keeping microorganisms from entering the wound

A nurse in an outpatient clinic is assessing the incision site of a client who is 7 days postoperative. Which of the following findings should the nurse expect? A. a red incision site with a small amount of exudate B. a bright pink incision site that is absent of exudate C. a pale pink incision site with moderate amounts of exudate D. a white to silver incision site absent of exudate

B. a bright pink incision site that is absent of exudate

A nurse is caring for a client who is 2 days postoperative. Which of the following findings indicates the client is developing an infection? A. temperature 37.8C (100F) B. erythema at the incision site C. WBC count 9,000/mm^3 D. pain reported as a 6/10

B. erythema at the incision site

A nurse is assisting with the plan of care for a community health screening for a group of clients who are at risk for type 2 diabetes mellitus. which of the following clients should the nurse include in the screening? A. men who smoke B. men and women who are obese C. Women who have hepatitis D. men and women who consume high-protein and low-carbohydrate foods

B. men and women who are obese

A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime? A. encourage the client to drink fluids before swallowing food B. offer the client tart or sour foods first C. tilt the client's head backward when swallowing D. turn on the television

B. offer the client tart or sour foods first

The nurse assess a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? A. red, hard skin B. serous drainage C. purulent drainage D. warm, tender skin

B. serous drainage

A Nurse is caring for an older adult client who has moderate hearing loss. Which of the following action should the nurse take to enhance communication? A. speak with exaggerated lip movements B. speak at a moderate rate c. speak in a louder voice D. speak using higher pitch

B. speak at a moderate rate

A nurse is teaching a newly licensed nurse about wound healing by secondary intention. Which of the following statements by the new nurse indicates an understanding of healing by secondary intention? A. this type of healing carries a lower risk of infection than others B. this type of healing begins in the wound bed with the generation of granulations tissue C. these wounds heal faster than those that heal by other processes D. these wounds require a dry wound bed in order for healing to occur

B. this type of healing begins in the wound bed with the generation of granulations tissue

A nurse is planning care for an older adult client who is bedridden. Which of the following should the nurse include in the plan to prevent skin breakdown? A. firmly massage lotion into the client's skin B. tilt the client on their side at 30 degrees C. Slide the client to the edge of the bed to transfer D. Keep the head of the bed at 45 degrees when in the supine position

B. tilt the client on their side at 30 degrees

A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. On assessment, the nurse notes that the client's wound has eviscerated. Which of the following actions should the nurses take? Select all that apply A. Carefully reinsert the intestine through the opening in the wound B.Place the client in a supine position with the hips and knees flexed C.Leave the room to call the surgeon D.Cover the wound and intestine with a sterile, moistened dressing E.Monitor the client for manifestations of shock

B.Place the client in a supine position with the hips and knees flexed D.Cover the wound and intestine with a sterile, moistened dressing E.Monitor the client for manifestations of shock

Dehiscence wound healing

Bursting open of a wound, especially a surgical abdominal wound most likely to occur 4 to 5 days post op

A nurse is assisting a client who has dysphagia with eating meals. Which of the following actions should the nurse take? A. Add water to soup for a thinner consistency B. Encourage using water to clear the client's mouth C. Ask the client to think of a food that produces salivation D. Remind the client to rest after meals

C. Ask the client to think of a food that produces salivation

A nurse is preparing to administer timolol eye drops to a client sho has primary open-angle glaucoma (POAG). Prior to administering the medication, the nurse should recognize that which of the following conditions in the client's medical history is a contraindication to receiving this medication? A. Hypertension B. Peripheral vision loss C. Asthma D. Increased intraocular pressure

C. Asthma

A nurse is caring for a client who has a stage III pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first? A. Obtain the prescribed irrigation solution B. Don Personal protective equipment C. Check the client's pain level D. Place a waterproof pad under the client's extremity

C. Check the client's pain level

A nurse is caring for a client who has sustained a gunshot wound to the abdomen and is 6hr postoperative. The nurse notices protrusion of the client's organs from the incision site and calls for help. Which of the following actions should the nurse take? A. Ask the client to bear down and cough B. Ask another nurse to bring ice packs to apply to the wound C. Cover the client's wound with a sterile saline dressing D. Place the client in high-Fowler's position.

C. Cover the client's wound with a sterile saline dressing

A nurse on a surgical unit is caring for four clients who have healing wounds. Which of the following wounds should the nurse expect to heal by primary intention? A. partial-thickness burn B. stage III pressure ulcer C. Surgical incision D. dehisced sternal wound

C. Surgical incision

A nurse is preparing to irrigate a client's wound which of the following actions should the nurse take? A. Use a 10 mL Syringe B. Attach a 22 gauge catheter to the syringe C. Warm the irrigating solution to 37 C (98.6 F) D. Administer an analgesic 10 min before the irrigation

C. Warm the irrigating solution to 37 C (98.6 F)

A nurse is caring for a client who has a dime-sized stage one pressure injury located on the sacrum. Which of the following dressing types should the nurse use? A. a hydrogel dressing B. a wet gauze dressing C. a transparent film D. an alginate dressing

C. a transparent film

A nurse is caring for a client who has a portable wound bulb suction device and notes that the drainage is three-fourths full. Which of the following actions should the nurse take? A. decrease the drainage suction force B. place the bulb on a flat surface and measure the amount of drainage C. empty and measure the drainage D. kink the tubing to prevent further drainage

C. empty and measure the drainage

A nurse is providing discharge teaching to the caregiver for a client who has a stage 1 pressure injury to the sacrum. Which of the following instructions should be included to the caregiver to prevent further skin breakdown? A. be sure to keep the skin moist B. do not use pillows to support extremities C. flex the client's knees while in bed D. provide a firm mattress for the client

C. flex the client's knees while in bed

A nurse is caring for a client who has a deep foot wound with minimal exudate and necrotized tissue. For which of the following dressing types should the nurse anticipate a prescription to cover the wound? A. hydrofiber B. alginate C. hydrogel D. transparent film

C. hydrogel

A nurse is using the Braden scale to predict the pressure ulcer risk of a client in a long-term care facility. Using this scale, which of the following parameters should the nurse evaluate? A. Incontinence B. Mental state C. Nutrition D. General physical condition

C. nutrition

A nurse is instructing a nursing assistant on how to prevent pressure ulcers for frail elderly clients. Which actions by the nursing assistant indicate understanding of the instructions? Select all that apply. A. maintains a cooler environment when bathing B. bathes and dries vigorously to stimulate circulation C. offers nutritional supplements and frequent snacks D. keeps the head of the bed elevated at 45 degrees E. turns the patient at least every 2 hours

C. offers nutritional supplements and frequent snacks E. turns the patient at least every 2 hours

The nurse notes that a patient has several lacerations over the coccyx area. Which finding most likely caused these lesions? A. heat B. pressure C. shearing D. moisture

C. shearing

A nurse is assessing the skin of a client who has frostbite. The client has small blisters that contain blood and the skin of the affected area does not blanch. The nurse should classify this injury as which of the following? A. first-degree frostbite B. second degree frostbite C. third degree frostbite D. fourth degree frostbite

C. third degree frostbite

A nurse is assessing a toddler who has AIDS. The nurse should identify which of the following findings as an indication of an opportunistic infection? A. koplik spots B. Peripheral neuropathy C. chancre D. Candidiasis

D. Candidiasis

A nurse is assessing a client who is bedridden and was admitted from home. The nurse notes a shallow crater in the epidermis of the client's sacral area. The nurse should document that the client has a pressure ulcer at which of the following stages? A. IV B. I C. III D. II

D. II

A patient has a blood-filled blister surrounded by tissue that is painful, mushy, and warm to the touch. How should the nurse classify this skin presentation? A. Stage 3 ulcer B. Stage 4 ulcer C. Unstageable D. Suspected tissue injury

D. Suspected tissue injury

A nurse is caring for a client who requires a dressing change. Which of the following actions should the nurse take?A. clean the incision from bottom to top B. apply sterile gloves prior to opening dressing packages C. remove the tape by pulling away from the wound D. clean the drain site from center outward

D. clean the drain site from center outward

The nurse notes that a patient's wound is weeping and edematous. In which phase of healing is the wound? A. maturation B. hemostasis C. proliferative D. inflammatory

D. inflammatory

inflammation

Removal of bacteria and cellular debris chemotaxis (WBC)

Defined Candida

a fungal opportunistic infection. candida spreads in warm moist areas (groin, oral mucosa).

Candida Treatment

anti-fungals Skin: medicated powders/ cream Oral: nystatin mouth wash or oral lozenge Vaginal: vaginal suppository

Acure or injury related malnutrition

associated with acure disease or injury states with marked inflammatory response. Eg. major infection, burns, trauma, surgery

a nurse is providing teaching to a parent of a school-aged child who has pediculosis. which of the following instructions should the nurse include? A. machine-wash clothing in cold water b. Dry clothing in a hot dryer for at least 20 min C. soak combs and brushes for 5 min in boiling water d. Seal nonwashable items in a bag for 7 days

b. Dry clothing in a hot dryer for at least 20 min

pharyngeal dysphagia

caused by problems in the mouth

Clear liquid diet

clear and liquid at room temperature: primarily consists of water and carbohydrates. diet includes: -water -tea -coffe (limited upset stomach) -fat-free broth -clear juice -ginger ale -gelatin - sports drink

Define Glaucoma

decreased fluid drainage or increased fluid secretion increases IOP (intraocular pressure) build up of aqueous humor increases IOP causing damage to optic nerve. results in gradual loss of peripheral vision

dysphagia

difficulty or inability to swallow

Impetigo contagiosa

epidermal bacterial blistering -highly contagious- spreads by direct contact -most common on kids 2-5 yrs old -secretion dry forming honey colored crust

hemostasis

formation of platelets pus and formation of stable fibrin clot.

define peripheral neuropathy and expected findings

gradual thickening of the arteries- progressive stiffening and narrowing of the lumen (decreases blood supply to affected tissue usually occurs in lower extremities. cramping, burning, pain during exercise

infection wound healing

infected if purulent material drains from it even if the culture has negative results. -trauma wounds usually show infection in 2-3 days. -post op usually 4th, 5th day.

Kwashiorkor definition

is a form of severe protein malnutrition characterized by edema and an enlarged liver with fatty infiltration. sufficient calories but insufficient protein consumption (or bad quality protein)

soft, bland, low fiber diet

low in fiber, lightly seasoned and easily digested. for acute infections, chewing limitations, gastrointestinal disorders.

evisceration in wound healing

organs out, emergency surgery. Do not put organs back in. keep npo. possition client suppine with hips and knees bent. observe for shock

Define pediculosis

spread of obligate parasites that suck blood, leave excrement and eggs on skin and hair. they spread by direct contact. can live up to 48 hr with out human host

pressure ulcer staging

stage 1-epidermis (red but unbroken) stage 2-deeper into the epidermis (exposed dermis. pink, red moist) stage 3- dermis and subcutaneous tissue (adipose tissue visible, slough and eschar may be visible) stage 4- muscle, bone (skin and tissue loss exposes muscle, tendon or bone and may show slough) unstageable: no determination of stage because eschar or slough obscures the wound. Stage III or IV may present after removing slough or eschar

define tissue integrity

the ability of the body tissue to regenerate and/or repair to maintain normal physiological processes

remodeling

type 1 collagen predominates- collagen cross-linking